Transcript Dermatological Assessment and Procedures

Dermatological
Assessment and
Procedures
Bucky Boaz, ARNP-C
What is Skin Cancer?
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Skin cancer happens
when some of the
cells of the epidermis
begin to grow out of
control
Types of Skin Cancer
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Basal Cell Carcinoma
Melanoma
Squamous Cell Carcinoma
Basal Cell Carcinoma
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The cancer that
affects the cells at the
lowest level of the
epidermis, called the
basal cells.
Basal means ‘at the
bottom’.
Melanoma
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The cells affected are
in the melanocytes,
the cells between the
basal cells.
Melanocytes produce
melanin, skin color
Most serious, least
common
Squamous Cell Carcinoma
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The cancer is found
within the layer of
flat cells just above
the basal cells.
Squamous means
‘like scales’
What Causes Skin Cancer?
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Most skin cancers are
caused by a particular
kind of ray from the sun
called ultraviolet
radiation (UVR).
This is not the light you
can see (visible light).
Not the light you can feel
(infra-red radiation).
You cannot see or feel
UVR.
Who is at Risk?
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Increased sun
exposure.
Sun burns
Age
Lots of moles or
freckles
Location
How is Skin Cancer Diagnosed?
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Skin exam
Biopsy
If concerned about
possible cancer
spread:
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Blood tests
X-rays
CT scans
Assessing the Skin
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Normal Mole
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Round or oval, and
even colored.
Many moles indicate
an increased risk of
melanoma skin
cancer
Assessing the Skin
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Atypical Mole
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Mix of brown,
smudged border, and
is often bigger than
5mm.
Increased risk of
melanoma skin
cancer
Assessing the Skin
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Melanoma:
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Most serious
Fastest growing
US cases have
almost doubled in
past two decades
Assessing the Skin
Assessing the Skin
Assessing the Skin
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Melanoma
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Cure Rate
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Melanoma can spread
to other parts of the
body quickly, but
when detected in its
earliest stages, it can
be curable.
If not caught early, it
is often fatal.
Assessing the Skin
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Melanoma
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Begins as an
uncontrollable
growth of pigmentproducing cells in
the skin.
This growth leads to
the formation of
dark-pigmented
malignant moles or
tumors
Assessing the Skin
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Melanoma
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May appear without
warning, but may
also develop from or
near a mole.
Assessing the Skin
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Melanoma: what to
watch for:
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Changes in size or color
of a mole
Dark or irregular
pigmented growth
Scaliness or Oozing
Bleeding
Change in appearance of
bump or nodule
Pigment spread
Itchiness, tenderness, or
pain
Assessing the Skin
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Basal Cell Carcinoma
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Small, fleshy bumps
or nodules on the
head and neck.
Found among fair
skin people.
Does not grow
quickly, rarely
spreads.
Assessing the Skin
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Squamous Cell
Carcinoma
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Nodules or red-scaly
patches.
Second most common
skin cancer in fairskinned people.
Rarely found in darkskinned people.
Can develop into large
masses, can spread
Assessing the Skin
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Actinic Keratosis
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Sun-induced skin
growths occur on
body areas exposed
to sun.
Face, hands, V of
neck susceptible
Pre-malignant
Look for raised,
reddish, rough
textured growths.
Mind Your ABCD’s
Asymmetry
Border
Color
Diameter
Options for Lesion Removal
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Cryosurgery
Skin Biopsy
Cryosurgery
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1st performed in late 19th century
Advantages:
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Easy to perform
Heals quickly
Post-op care simple
No surgery
High risk patients
Cryosurgery
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Liquid nitrogen most
commonly used
cryogen
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Inexpensive
Readily available
Boiling point 196°C
Stored in insulated
container
Refilled regularly
Cryosurgery Techniques
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Direct cryogen
application
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Cotton-tipped
applicator
10 second freeze
Include small rim of
normal tissue
Thaw 20-45 seconds
Cryosurgery Techniques
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Spray technique
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Constant flow of
liquid nitrogen onto
lesion, rapid freeze.
3 patterns
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Ever-enlarging circle
Side to side
Central point
Two freeze-thaw
cycles required
Cryosurgery
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Most common side
effects:
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Immediate erythema
and edema at
treatment site.
Throbbing sensation
for several minutes
to half an hour.
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Healing Pattern
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Within 24 hrs =
blister.
Followed by scab for
2-3 weeks.
Postinflammatory
hypopigmentation
Skin Biopsy
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Snip excision
Shave biopsy
Punch biopsy
Incisional Biopsy
Elliptic excision biopsy
Choosing a Technique
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1st factor = purpose of procedure
2nd factor = differential diagnosis of the
skin lesion
3rd factor = physical determinants
4th factor = spatial characteristics of the
lesion
5th factor = cosmesis
Snip Excision
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Easiest technique
Ideal for lesions with
pedunculated base
Lesion is lifted with
forceps to visualize
the base, and the base
is transected with
sharp iris or gradle
scissors.
Snip Excision
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Lesions such as
acrochordons,
filiform verruca, or
seborrheic keratosis.
Reasons: cosmesis,
itching, irritation,
catching on clothing
Shave Biopsy
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Simple, practical
method of removing a
lesion or obtaining a
skin biopsy
A blade is used to
slice very thin
sections of skin
Shave Biopsy
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Indications
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Exophytic lesions
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Seborrhea keratosis
Verruca
Skin tags
Small nevi
Useless
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Deep dermis
Subcutaneous fat
Shave Biopsy
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The Procedure
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Consent
Prep skin
Intradermal injection of
local anesthetic
Pinch skin to elevate
#15 blade cut
longitudinally
Swinging motion
Aluminum Chloride
Antibiotic ointment
Punch Biopsy
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Uses a punch or
trephine
Ideal for histologic
diagnosis
Size is important
The Punch Biopsy
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The Procedure
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Circular instrument
2mm to 10mm dia.
Anesthesia and prep
Stretch skin
perpendicular to natural
wrinkle lines
Punch perpendicular and
vertical pressure
Gently grasp with
forceps
Suture
The Incisional Biopsy
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Indications
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Inflammatory disorders
Suspected fungal
Suspected bacterial
The Incisional Biopsy
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Procedure
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Anesthesia and prep
Incision
perpendicular
Counter traction on
skin, full thickness
incision
Second cut parallel
Elliptical result
Suture
The Excisional Biopsy
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Fusiform or elliptic
Procedure of choice
for melanoma
Length:width = 3:1
Long axis parallel to
skin tension or
wrinkle lines
The Excisional Biopsy
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Procedure
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Mark excision margins
Three point traction
Begin at one pole
Incise vertically, full
thickness, into subQ fat
Stay vertical as excision
continues
Repeat on opposite side
Grasp with forceps and
cut through fat as lifting
Electrocautery
Surgical Margins
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Margins fit lesions
Benign lesions = narrow 1-2mm
Malignant
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Basal cells 3-4mm
Squamous cell 5mm
Melanoma = narrow margin with axis toward
draining lymph node. If positive, refer to
surgeon.
Undermining
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If edges invert when
pushed together,
undermining is necessary
Used to avoid wound
tension and dehiscence
Done with blunt scissors
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Scalp = midfat or
fatgalea junction
Face = subq fat
Small torso or extremity
= upper subq
Large = deep fascia
Danger Zones in Undermining
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Motor nerves lie superficially
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Later zygoma – temporal branch of facial
nerve
Posterior triangle of neck
Lateral popliteal space
Processing the Biopsy Sample
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For light microscopy, each specimen
should be placed in a separate bottle of
10% buffered formalin solution.
Specimens smaller than 1cm in 30ml sol.
Bacterial of fungal cultures in sterile
container with NS.
Viral specimens in viral sol.
Questions?