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Dermatologic procedures

RecognitionAnatomy/physiology

Treatment method/workshops

Warts

Common warts/Verruca VulgarisFlat warts/Verruca PlanaPlantar warts/Verruca Plantaris

Common warts

HPV type 2Age: 5-20Natural hx:

–½ resolve in 1 yr, 2/3 in 2 yrs.Location

–Hands (fingers/palms) periungualDistinguishing characteristics:

–Tiny black dots (dilated caps)

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Common wart

Periungual wart

Flat warts

Primarily HPV type 32-4mm flat topped papulesGenerally multiple and grouped on

face, neck, dorsum of hand, wrist, knees

Highest spontaneous remission

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Flat warts

Plantar warts

Primarily HPV 1Generally at pressure pts of footCan be confused with a callousSoft bulky core and black bleeding

pts when pared

Plantar wart

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Treatment of Warts

Discuss with pt:– Indications–Contraindications–Prognosis

2-3 months is a reasonable trial

Treatment of Flat warts

Frequently resolve, so tx should be mild

CryocauterySalicylic acidTopical tretenoin (high conc. bid)

–For extensive lesionsFailures:

–5FU or pulse dye laser

Treatment common and plantar warts

Destruction–Plantar warts: may use same tx

modalities but are tougher to tx–Surgical tx may lead to painful scar,

especially on wt bearing area Immunotherapy

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Cryocautery for warts

Utilize one tx or a freeze thaw => blister

Spray, cotton tip or derm tip–Repeat q 2-3 wks

Complications–Hypopigmention, scaring, nerve damage

Caution in certain pts:–Raynauds, PVD, cryoglobulinemias

Salicylic acid for warts

As effective as cryo

Pt applied

Soak, apply, dry, cover

Debride

Canthorone for warts

.7% canthiridin (Bleomycin used in same way)

Apply, dry, cover 24hrs–q 2-3 wks

Worse blister than cryoHigher incidence of donut wartsEffective for hard to tx

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Surgical treatment of warts

Curettage and electrodessication–Needs anesthesia–Scarring–Reserve for refractory warts

CO2 laser or pulse dye laser

Acrochoran/Skin tags

Small, fleshy, dark brown colorPin sized or largerSessile and pedunculated papillomasCommon to neck, axilla, eyelids

–Less on trunk and groin10-50 y/o60% of people have them by age 69

Skin tag

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Skin tag removal

AsepticClip @ baseSmall ones require no anesthesiaAluminum chloride for hemostasisLarger ones:

–Anesthetize and clip–Electrodessication–Cryo

Dermatofibroma characteristics

Single, round, ovoid papule/nodule ~ 1 cm, reddish brown to yellow hue

Elevated or depressed, primarily on lower extremity

Adherent to epidermisMiddle aged, injuriesMay appear similar to other tumors

Dermatofibroma treatment

When over 2-3 cm:–Excisional Biopsy/Punch–Excise entire lesion

May involute if left alone

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Dermatofibroma

Seborrheic keratosis characteristics

Multiple, oval, slightly raised, lt brown to black

Rarely > 3 cmPrimarily on chest and backAge of onset: 4th – 5th decadeCrumbly with raw moist base

Seborrheic keratosis

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Seborrheic keratosis: Treatment

BIOPSY any atypicalsLiquid nitrogen and curettageLiquid nitrogenCurettage with anesthesia/shaveUtilize aseptic techniques

Seborrheic keratosisDifferential diagnosis

Usually not a problemAtypical (black) may be at timesMore verrocous (not smooth or

infiltratingActinic keratosis usually

erythematous, rough scaly–Treat with cryo–Seen on upper ext. Consider to be

premalignant

Actinic keratosis

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Lipoma Characteristics

Palpable under skinNon tender, freely movable, soft,

irregularExcise if rapidly growing or painfulExcisional biopsy done

Sebaceous cyst/Epidermal cystCharacteristics

Round tense, keratinizing cystFreely movable and superficial

central poreExcise totally or Incisional

Keratocanthoma

Appears on sun or chemically damaged areas or sites of trauma

Skin colored or pink smooth lesion with RAPID growth

Volcano shaped with protruding masses of keratin (lava)

Regresses spontaneously but atypical ones may be Squamous cell

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Keratocanthoma

keratocanthoma

Common locations: hands, face, arms, legs and scalp

Basal cell cancer

Waxy semitranslucent nodules around central depression

Rolled bordersTelangiectasesBleeds easily (as grows, ulcerates)Rarely metsPrimarily on face, head, neck (85%)

–Upper trunk also (dorsum of hand: akand sc)

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Basal Cell

EAR

Basal cell

Basal cell

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Basal cell

Utilizing a dermatoscope

Basal CellTreatment

Depends on the area involvedShave biopsy (to diagnose)Excisional biopsy/Mohs surgery

–3mm margins (to treat)Shave, electrodessication and

curettage (to treat)Radiation

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Squamous Cell CancerCharacteristics

Occurs on skin and mucous membranes

Frequently sun exposed areasSuperficial, hard, arising from

indurated round baseDull red with telangiectasesFew mos. -> larger, nodular,

ulceratedEarly movable, later fixed

Squamous cell cancer

Squamous cell cancer

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Squamous cell

Squamous cellEtiology

UVBThermal injury/ chemical injuryChronic radiationHPVScars

Squamous Cell

Differential diagnosis–Actinic keratosis–Keratoacanthoma

Metastasis–Depending on the cause and treatment

modality may be up to 5.2%

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Squamous CellTreatment

Incisional

Excisional with margin control–5mm margins

Mohs (especially for recurrent)

Radiation (select)

Squamous cellPrevention

*Sunscreen–Especially the first 18 years–Would reduce the incidence of non

melanoma skin cancer by 78%

Malignant melanomaCharacteristics

Prolonged horizontal growth phase– Grow asymmetrically

Develops into tumor nodule– Vertical growth phase

Invasion -> metastatic disease A B C D

– Asymmetry– Border irreg– Color variegation– diameter

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Malignant MelanomaEtiology

Light complexion, eyes, hairBlistering sun burnsHeavy frecklingPoor tanners/sun burn easily20-50% develop in pre-existing

lesions

Dysplastic nevi

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Melanoma Primary Histopathologic Types

Lentigo melanoma

Superficial spreading

Acral lentigenous

Nodular

Lentigo melanoma

Face

Superficial/ tan

Thin vertical spread

Superficial spreading melenoma

70% of melenomas

5th decade

Upper back/shins

Horizontal 1-5 yrs then vertical

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Acral lentigenous melanoma

50 y.o

Blacks

Foot common

Acral lentigenous melanoma

Feet, hands, toenails, fingernails or mucous membranes. May appear originally as a bruise or nail streak.

Nodular melanoma

15% of melanoma Pigmented papule for

a few mos. Arise without clinically

appearing radial growth phase

2:1 male to female Primarily sun exposed

areas Variety of forms

including amelonotic

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Malignant Melanoma

Staging:–Clark and Breslow

Based on:–size– invasion–depth

Malignant melanoma

BIOPSY CORRECTLY!

–Surgical excision1 cm margins depending on depth

– Incisional or PunchThickest and most atypical area

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Things to think about as you progress through your residency regarding

Procedures

Skill set: Learn everything you can while in your residency

Cost of equipmentTrained medical assistantCost of supplies

–Amount needed to order–Expiration dates–Can you do enough procedures to pay

for it?

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Conclusion

Know your lesion before you biopsy or excise

Use the correct procedure

Follow-up on pathology accordingly!

References

See workbook