Transcript WE267-Lewis

Primary Care Dermatology
Update
Christina Lewis N.P.
Director of Nursing
UCLA Arthur Ashe Student Health and Wellness
Center
ACHA 2009
[email protected]
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Warts, Hair Loss, and Skin Tags
Differential Diagnoses and Evidenced-Based
Treatment
Warts
(flat, common, plantar, filiform)
Hair Loss, Nonscaring (telogen
effluvium, androgenic alopecia)
Skin Tags (acrocordon)
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Warts
Spontaneous Regression
30% in months
78% in 2 years (British Journal of Dermatology,
2001)
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Warts: Risk factors
• Trauma
• Communal showers - 146 adolescents, 27% of
those who used the communal shower area had
warts vs. 1.3% who used the locker changing room
only (UBJ Clinical Handbook, 2008).
• Immunosuppressed - Renal transplant recipients,
after 5 years, 90% had warts (UBJ Clinical
Handbook, 2008).
• Diet - Low in carotenoids (spinach and other greens,
sweet potatoes, and carrots) and high in refined
sugar (Rakel, 2007).
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Thrombosed capillaries in a hyperkeratotic plaque (Fitzpatrick)
Dilated capillaries in the
wart may bleed
during/after shaving.
Identified by
changes in
the skin
lines.
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Differential Diagnosis
• Callus direct pressure hurts (warts hurt with
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side pressure)
Corn a central hyperkeratotic core
Pitted keratolysis
Seborrheic keratoses flatter, darker, velvety
Pigmented verrucous nevi projections are
not dry and rough
Lichen planus
Molluscum contagiosum
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Corn
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Pitted keratolysis dermnet.com
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Lichen planus
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Differential Diagnosis (cont)
• Verrucous carcinoma -- a low-grade
squamous cell carcinoma
• Scar tissue
• Skin tag
• Actinic keratosis
• Lichenoid keratosis
• Black heel
-warts may be associated with:
• Bowenoid papulosis (premalignant state)
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Black heel
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Bowenoid papulosis (premalignant state) dermnet.com
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Non-Prescription Treatment for Warts
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Duct tape-- Vs. cryotherapy. Resolution: 85% with duct tape, 60% with cryotherapy (Cutis,
1978).
Hypnosis--Small studies, no controls. When comparing hypnosis, placebo, and salicylic acid
treatments; results indicated that the hypnotic subjects lost more warts than the treatment
controls, but subjects treated with salicylic acid lost the highest percent (Spanos, 1990).
Interactive guided imagery
Garlic extracts--One placebo-controlled study (International Journal of Dermatology, 2005).
Potato, onion, or fresh garlic--Directly to the wart. No data to support, but possible that some
direct irritant effect may stimulate the immune response.
Vitamin A, Vit C, Vit E or folic acid--Studies are inconclusive (Rakel, 2007).
Distant healing--A single randomized trial of distant healing for peripheral warts showed no
effect (Harkness, 2000).
Acupuncture --Insertion of a needle directly into the wart using a complex “open door”
technique has been reported to be beneficial (Rakel, 2007).
Oral zinc sulfate--Increased cure rates compared to placebo--few high quality studies.
Catharidin--from the blister beetle, Cantharis vesicatoria. No longer available in the US.
Folk--Rub a dusty dry toad on warts, and they will disappear.
Folk--Tom Sawyer ”back up against the stump and jam your hand in and say ‘Barley-corn,
Barley corn, injun-meal shorts, Spunk water, spunk water, swaller these warts”.
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Most Effective Treatment Option:
Salicylic acid
 Soak, emery board, acid, occlusion.
 Not on face r/t possible irritation and scarring.
 13 trials using concentrations of 15-26% with or
without lactic acid. Data pooled from 6 placebocontrolled trials demonstrated a cure rate of 75% and
48% in placebo arm.
 Monotherapy with 5 FU, cryotherapy, podophyllin
proved no more effective than salicylic acid (Cochrane,
2003).
 Topical salicylic acid may be as effective as cryotherapy
(Cochrane, 2003).
 After 6 weeks of treatment, 50% of warts resolve
(Berger, 1990).
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Second Line Therapy: Cryotherapy
Contraindicated in Reynaud's if treating hand/foot
warts.
Aggressive use over superficial nerves on the volar
or lateral aspects of the proximal phalanges of the
fingers has caused neuropathy.
White halo for 5-20 sec. improves effectiveness
(British Journ of Derm, 2001).
Permanent nail changes may occur if the nail
matrix is frozen.
Hypopigmentation is a possible complication.
OTC (Verruca-Freeze) freezes tissue to only -70
degrees, so less effective.
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Second Line Therapy: Cryotherapy
(cont)
 Tx every two weeks with cotton swab vs spray gun X 3 months is
47% and 44% respectively, not significant (Baumbach, 2001).
 Warts present 6 mo or less cleared at 84%, those longer than 6 mo,
39%.
 Freeze thaw technique, no significant different in cure rates at 3 mo
for hand warts but was for plantar warts. Possibly due to the callus
being a thermal insulator.
 Frequency of treatment not related to cure, but number of
treatments are. Improvement after 4 treatments not statistically
significant (Cochrane database).
 Cryotherapy may be less effective than photodynamic treatment or
occlusive treatment with duct tape.
 70%-80% of patients with hand warts cured with nonblistering
liquid nitrogen cryosurgery within 12 weeks (Bunney, 1976).
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Other Treatment Options
• Aldara 5% cream (imiquimod)--Immune modulator. Nightly to three times
a week--expensive.
• Antigen injection, C. albicans--No randomized controlled studies. Minimal
pain and no scarring. 1:1 mixture of C. albicans skin test antigen solution
and 1% lidocaine injected intradermally into and at the margins of each
wart (genital and facial warts excluded) up to a total of 1.0 ml. Repeat
every 4 weeks up to three injections. 72% clearance within 8 weeks of the
last injection, without subsequent recurrence (Habif, 2004).
• Bleomycin--No controlled studies. Dermajet 1/10cc with each injection
(hematoma), nonmed corn pad, debride in 3 weeks X 2-3 treatments,
painful. 87% cleared (Salk & Douglas, 2006).
• Cautery--Success of 65-85% but scarring and recurrence in up to 30%.
• Cimetidine--Studies mixed. Immune modulator, probably blocking type 2
histamine receptors on suppressor T cells.
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Other Treatment Options (cont)
• Dinitrochlorobenzene (DCNB)--Causes allergic
reaction and inflammatory response; studies
are conflicting regarding wart clearance
compared to placebo. Application qd to bid X
4 months.
• 5 ALA (aminolevulinic acid) 20% followed by
photodynamic therapy.
• 5-FU--Immunotherapeutic. Possible
hyperpigmentation. Not FDA-approved.
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Other Treatment Options (cont)
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Formalin--pare, soak daily for 30 minutes in 4% formalin solution. Risk of inducing
sensitization to formalin (Habif, 2004).
Hot water--45-48 degrees centigrade.
Lasers--2-4 treatments every 2-4 weeks. Careful of plume, hypertrophic scarring.
 Pulsed Erbium Laser (Er:Yag) Cleared 75% of patients with one treatment
with a 25% relapse. 14% are non-responders. Healing in 7-10 days, but
erythema up to 2 months. Shortened wavelength (2940) is absorbed 12-18
times more efficiently by water-containing superficial cutaneous tissues than
the CO2 laser. There is a smaller zone of thermal damage so less scarring.
 Carbon Dioxide Laser Older therapy. Longer wave length, nonselective
thermal tissue destruction, 64-71% cure rate.
Podophyllin--cured 81% in 12 weeks.
Punch excision--60% cure rate.
Retinoic acid 0.1% cream or .25% gel--bid X 4-6 weeks cleared 50% flat warts
(Berger, 1990).
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Other Treatment Options (cont)
• Squaric acid dibutylester (SADBE)--Contact immunotherapy. Sensitization
by applying 1% or 2% SADBE with or without occlusion to normal skin
overnight then washed off. Ninety percent of patients were successfully
sensitized after one application of SADBE. Sensitization determined when
a second or third dose was applied to a different area causing erythema
and pruritus. After sensitization, 0.5% to 5% SADBE applied to the warts
every 2-4 weeks. SADBE is not usually used on the face. Clearing in 69%
of patients. Mean duration of 4.4 months with a mean of 5.9 treatments.
• Trichloroacetic, bichloroacetic, and monochloroacetic acids--A thin
coating of petrolatum should be applied to the surrounding normal skin.
Repeat after 7 to 10 days.
• Surgical excision --Recurrence rates as high as 30% (filiform warts).
• Silver nitrate sticks--Chemically cauterize, caution with burns and staining.
Clinical efficacy is moderate, clearance 43%, placebo 11%.
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Summary: Treatments That Have
Replicated Studies
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Cryotherapy
Duct tape or moleskin
Topical salicylic acid
5 FU with occlusive dressing
Photodynamic therapy with 5-aminolevulinic
acid
(Fox, G and Brier, M., Nov 2008)
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Treatment With Limited or No Clinical
Data
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Imiquimod
• Cimetidine
Retinoids
• Levamisole
Cantharidin
• Hypnotic and “suggestion” therapies,
including use of “wart tape”
Bichloroacetic acid
• Formaldehyde
Dinitrochlorobenzene solution
• Glutaldehyde
Silver nitrate solution
• Homeopathy
Alpha-Lactalbumin plus oleic acid
• Pulsed dye laser
Formic acid
Diphencyprone (diphenylcyclopropenone) • Surgical procedures
Ciclopirox-containing laquer
Intralesional injection of skin test antigens
Bleomycin
Combination of 5-fluorouracil, lidocaine, and
epinephrine
(Fox, G and Brier, M., Nov 2008)
Laser tx
Oral zinc sulfate
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References
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UBJ Clinical Handbook, Fall 2008.
Rakel. Integrative Medicine, 2nd ed. Saunders, An Imprint of Elsevier, 2007. available at:
www.psychosomaticmedicine.org. Accessed May 20, 2009.
Fitzpatrick, TB et al. Color Atlas and Synopsis of Clinical Dermatology Common and Serious Diseases.
www.dermnet.com. Accessed May 20, 2009.
Spanos N.H., Williams V, Gwynn M.I. Effects of hypnotic, placebo, and salicylic acid treatments on wart
regression. Psychosomatic Med. 1990;52:109-114.
Harkness EF, Abbot NC, Ernst E. A randomized trial of distant healing for skin warts. Am J Med 2000;108:448452.
Cochrane Database Systems Review. Available at:
http://search.cochrane.org/search?restrict=review_abstracts&scso_cochrane_org=this+site&scso_review_abstr
acts=review+abstracts&scso_registered_titles=registered+titles&scso_evidence_aid=evidence+aid&scso_colloq
uia_abstracts=colloquia+abstracts&scso_newsletters=newsletters&ie=&site=my_collection&output=xml_no_dtd
&client=my_collection&lr=&proxystylesheet=http%3A%2F%2Fwww.cochrane.org%2Fsearch%2Fgoogle_mini_x
sl%2Fcochrane_org.xsl&oe=&filter=0&sub_site_name=Cochrane+Reviews+search&q=&btnG=Search+Reviews
. Accessed May 2009.
Berger, T. and Elias, P. Manual of Therapy for Skin Diseases. Livingstone :Wintroub,B.Churchill ;1990.
Dermatologic drug therapy . Baumbach, 2001
Bunney, Nolan and Williams. An Assessment of Methods of Treating Viral Warts by Comparative Treatment
Trials Based on a Standard Design. Br. J. Dermatol. 94:667-679, 1976.
Habif , Clinical Dermatology 4th Ed. 2004. Available at: http://www.mdconsult.com/das/book/body/1385815984/0/1195/85.html. Accessed May 20, 2009.
Fox, G and Brier, M. Stat Consult, Verrucea Vulgaris. The Clinical Advisor, p.95-96, Nov 2008.
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Hair Loss: Telogen Effluvium
Telogen Effluvium Simultaneous passage of a large number of follicles from
antagen (growth) to telogen (resting) phase. Hair loss appears after about 3
months, corresponding to duration of telogen. Most club hairs are retained
within the follicle during telogen and shed with new antigen hair.
•Scalp paresthesia or pain (trichondynia) 5-30% of pts, esp females.
•Hair pull test is diagnostic (often more than 10 hairs).
•Shedding of hairs higher than 100, generally 200-300/day.
•Pt can remember precisely when hair loss started.
•Genetic predisposition and androgen on the follicles.
•Finer texture hair, shorter in length and reduced diameter (Tosti and Piraccini,
2006).
•Considered normal in middle aged women if lasts greater than 6 months.
Frontotemporal thinning worsens with time. Diffuse thinning is uncommon.
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Telogen Effluvium
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Hair Loss: Androgenic Alopecia
Androgenic Alopecia Most common form of
hair loss affecting up to 80% of men and
50% of women.
Typically after puberty and evident by age
30, about half the population expresses
this trait before the age of 50 (Habif,
2004).
Acquired progressive kinking of the hair.
Whisker hair
Variation in the hair shaft diameter
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Androgenic Alopecia
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Tests (Habif, 2004)
Hair Pull Test
Tightly grasp 20 to 40 hairs firmly between the thumb and forefinger above ear. Exert a
slow, constant traction to slightly tent the scalp, and slide the fingers up the hair
shafts. Normal if fewer than six club hairs extracted. Repeat the count on the
opposite side of the head and in two other areas.
Daily Hair Counts
The patient collects hair lost for 14 days. The patient counts the hairs and records the
number for each day. Daily hair shed counts are not necessary if the pull test is
positive. It is normal to lose up to 100 hairs daily and 200 to 250 hairs on the day of
shampooing. If the hair is shampooed daily, the counts should be less than 100.
Part Width
Part the hair with a comb over vertex, occipital, and temporal scalp. Compare the part
diameters in the different anatomic scalp areas. The hair is less dense in the vertex in
both sexes, and thinning increases with age.
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Lab Tests (Habif, 2004)
FemaleLaboratory
pattern
parameter
alopecia
Female-pattern
alopecia with
hirsutism
DHEA-S * Normal or
elevated
Normal or elevated Elevated
T
Normal
Normal or elevated Elevated
TeBG
Normal
Decreased or
normal
Elevated
T/TeBG
Normal
Prolactin †
Male-pattern alopecia
(frontotemporal
recession)
Decreased or normal
Elevated
DHEA-S, dehydroepiandrosterone sulphate; T, total serum testosterone; TeBG, testosterone-estradiol–binding
globulin; T/TeBG, androgenic index.
† If elevated, suspect pituitary disease (e.g., pituitary prolactin secreting adenoma).
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Differential Diagnosis for NonScarring Hair Loss
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Iron deficiency anemia
Thyroid
Excessive circulating androgens. PCOS accounts for 30% of women with hair loss
(Tosti, 2006).
Secondary syphilis
SLE
ANA
Genetic disorders
Immune disregulation
Medications (birth control pills)
Chemotherapy
Weight loss (crash diets=inadequate protein) food supplements such as tryptophan,
vegetarianism, zinc deficiency
Excessive Vit A
Acute blood loss
Childbirth
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Differential Diagnosis (cont)
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Drugs: retinoids, bromocriptine, aminosalicylic acid,
Enalapril, amphetamines, levodopa, Captopril, lithium,
carbamazepine, metoprolol, cimetidine, propanolol,
Coumadin and others
Stress: emotional, surgery
Weight loss
UV exposure
Cigarette smoking
Diabetes
Pneumonia
TB
Fever
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Diffuse loss (non-scarring) diagnose 97% of cases of alopecia (Habif, 2004)
Disease
Telogen effluvium
Scalp
Normal
Pattern
Diffuse
Pull test
Increased
telogen
Laboratory Treatment
Disease
Disease specific
specific
Diffuse alopecia areata Normal
Irregularly Increased
diffuse
telogen
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Topical
immunotherapy
Androgenic alopecia
(men)
Hamilton Negative
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Minoxidil
Finasteride 1 mg
Ludwig
Surgery
Testosterone Minoxidil
DHEAs
Oral contraceptives
Androgenic alopecia
(women)
Normal
Normal
Negative
Spironolactone
Systemic disease
(thyroid, iron
deficiency, systemic
lupus erythematosus,
dermatomyositis)
Normal in Diffuse
most
Normal or
increased
telogen
Thyroid
function
Iron/IBC
ANA
Disease specific
DHEA-S, dehydroepiandrosterone sulfate; T, total serum testosterone; TeBG, testosterone-estradiol–binding
globulin; T/TeBG, androgenic index.
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Common Treatment OptionsAndrogenic Alopecia
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Finasteride--Increases about 100 hairs in 1 inch area of vertex. Inhibits 5alpha reductase, the enzyme that converts testosterone to
dihydrotestosterone (DHT). DHT is responsible for male pattern hair loss,
prostate enlargement and male acne (Fitzpatrick). Prevents progression in
99% of patients and clinical improvement in 66% after 2 years of tx.
Effective in frontotemporal and vertex. Side effects in less than 2%:
decreased libido, erectile dysfunction, and diminished ejaculate volume
(Tosti, 2006). Solely for use in men.
Minoxidil 5% bid for men. 40% of men show visible improvement after 2
years (Berger, 1990). Side effects include scalp irritation and allergic
contact dermatitis. Improvement not seen until 4-6 mo after tx. Minoxidil
works better on vertex than bitemporal areas. Mechanism of action
unknown.
Minoxidil 2% bid for women, improvement in up to 80% of cases. Side
effects include irritation, contact dermatitis, and hypertrichosis (increase
facial hair). May be more effective in lower BMI.
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Common Tx Options Androgenic
Alopecia (cont)
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Spironolactone; binds to androgen receptors
and blocks action of dihydrotestosterone
(Fitzpatrick)
Hair transplants
Avoid sun exposure
Avoid sun bed tanning
Avoid smoking
Avoid restrictive diets
Avoid drugs that induce hair loss
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Common Tx Options
Androgenic Alopecia (cont)
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Hair Transplants--Have been used successfully to permanently restore hair. Age is not a
determining factor. Androgen-independent hairs from the lateral and posterior areas of the scalp
are used. The surgeon must have a sense of aesthetics to properly design the anterior hairline.
There are many techniques used for harvesting and implanting the graphs. The techniques are
constantly changing and improving.
Scalp Reduction and Flaps--An anterior-posterior elliptic excision of bald vertex scalp with primary
closure can provide an instant hair effect. The procedure can be repeated every 4 weeks until hair
margins converge or scalp tissue becomes too thin. Grafts or flaps may be used later to fill any
remaining void.
Hair Weaves--Create a matrix of crisscrossing, transparent fibers, fitted and shaped to the client's
thinning area.
Cosmetic measures (hairstyle adjustments, wigs, extensions, hair pieces, hats, scarves)
Cessation of wearing tight braids, buns, pins
In chemical/allergic causes, avoidance of the identified sources
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References
• Tosti, A. and Piraccini, B. Diagnosis and treatment of
Hair disorders an Evidence Based Atlas. Taylor and
Francis Group, New York. 2006.
• Berger, T. Elias, P. Manual of Therapy for Skin Diseases.
Livingstone, England. 1990.
• Fitzpatrick, TB et al. Color Atlas and Synopsis of Clinical
Dermatology: Common and Serious Diseases.
• Habif , Clinical Dermatology 4th Ed. 2004. Available at:
http://www.mdconsult.com/das/book/body/1385815984/0/1195/85.html. Accessed May 20, 2009.
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SKIN TAGS
Acrochordons
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Skin Tags
• Obesity, pregnancy, menopause, and endocrine
disorders increase skin tags.
• Low but detectable levels of HPV are found in
80% of skin tags, subtype 6 and 11 found 98%
of the time (Arndt and Bowers, 2002).
• If many skin tags develop over a short period of
time, consider colonoscopy r/t possible increase
in colonic polyps.
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Differential
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Pedunculated seborrheic keratosis
Dermal or compound melanocytic nevus
Neurofibroma
Molluscum contagiosum
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Seborrheic keratosis
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Compound melanocytic nevus
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Molluscum contagiosum
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Skin Tag Treatment
• Electrodessication
• Grasp with forceps, sever base with sharp scissors or
scalpel. Hemostasis by pressure, Monsels solution, 20%
aluminum chloride or 30% TCA or cautery.
• Grasp base of skin tag with forceps and direct liquid
nitrogen spray at lesion until frozen, grabbing minimizes
the spread and hyper or hypopigmentation .
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Neurofibroma
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References
• Arndt, K. and Bowers, K. Manual of
Dermatologic Therapeutics, sixth edition.
Lippincott Williams and Wilkins. 2002.
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