A 73-year-old man presented with recurrent primary perianal extramammary Paget disease. The patient declined both surgery and topical imiquimod and preferred cryotherapy from the other available noninvasive therapeutic options. At the 1-month follow-up visit, a complete response to treatment was suspected both on clinical and dermoscopic examination. This response was confirmed by line-field confocal optical coherence tomography (LC-OCT), which demonstrated the efficacy of the treatment by the absence of Paget cells. For patients seeking less-invasive treatment options, LC-OCT-controlled cryotherapy not only reduces invasiveness but also allows for accurate real-time monitoring.