Transcript Drs. C Rivet, A Wilkinson, M Nassim - Academic Day

ESSENTIAL DERMATOLOGY
PROCEDURES
IN FAMILY MEDICINE
Dr Christine Rivet,
Dr Anna Wilkinson,
Dr Mark Nassim,
Academic Day February 5th, 2016
Objectives: at the end of this workshop
you will be able to:
• 1-describe the indications, contraindications,
risks and alternatives to liquid nitrogen, shave
biopsy, punch biopsy and elliptical excisions.
• 2-choose appropriate local anesthetic and
describe proper local anesthetic technique.
• 3-demonstrate digital block technique.
• 4-perform skin biopsies including shave,
punch and excisional biopsies on skin models.
• 5-describe aftercare instructions for the
patient.
Procedures are fun to do and generally
easy…
• The difficult part is deciding which procedure is
best for the lesion and knowing when it is best
NOT to do a specific procedure because of
potential complications.
Common OFFICE PROCEDURES
Cryotherapy
Shave biopsy
Punch biopsy
Elliptical excision
If you are comfortable with the above procedures you will
save your patients a lot of referrals, and will probably
have a lower threshold for removing skin lesions.
agenda
• Quiz
• Review of elliptical excision
• Break
• Review of shave biopsy indications and contraindications
• Review of punch biopsy
• Review of cryotherapy indications and contraindications
and proper technique
• Review of local anesthetics
A warm-up quiz
Question 1-After doing a shave biopsy on a 54 year old woman’s back, you
manage hemostasis best with:
• 1-Monsel solution (ferric subsulfate)
• 2-aluminum chloride 20%
• 3-silver nitrate
• 4-hydrogen peroxide
Question 1-After doing a shave biopsy on a 54 year old woman’s back, you
manage hemostasis best with:
• 1-Monsel solution (ferric subsulfate)
• 2-aluminum chloride 20%
• 3-silver nitrate
• 4-hydrogen peroxide
ANSWER: 2-aluminum chloride 20% (Drysol). Silver
nitrate and Monsel solution cause staining and can
leave a tattoo in the wound. Hydrogen peroxide is
not a coagulant.
Question 2: After the shave biopsy, you recommend this
wound care to the patient:
• 1-keep clean and dry until healed in approximately one week
• 2-use antibiotic ointment for 3 days then keep dry till healed
• 3-use antibiotic ointment for 7 days then leave uncovered
• 4-use petrolatum and keep moist and covered at least one
week
Question 2: After the shave biopsy, you recommend this
wound care to the patient:
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1-keep clean and dry until healed in approximately one week
2-use antibiotic ointment for 3 days then keep dry till healed
3-use antibiotic ointment for 7 days then leave uncovered
4-use petrolatum and keep moist and covered at least one week
ANSWER: 4-use petrolatum and keep moist and covered at
least one week. Keeping the wound moist minimizes scarring
and allows better healing by secondary intention than keeping
the wound dry. Petrolatum does not cause allergic reaction
that occurs with topical antibiotics such as polysporin or
bacitracin.
• Smack,DP,Allan C,et al Infection and allergy incidence in ambulatory surgery
patients using white petrolatum vs Bacitracin Ointment : RCT JAMA
1996;276:972-977
Question 3: You see a 30 year old man who has a 9mm dark macule
on his back that is suspicious for melanoma. What is your plan?
• 1-shave biopsy of the entire macule with 5 mm
margins
• 2-4 mm punch biopsy initially of the darkest part of
the macule
• 3-elliptical excision of the entire macule with 2 mm
margins
• 4-refer to a plastic surgeon since the lesion needs
initial wide excision
Question 3: You see a 30 year old man who has a 9mm dark macule
on his back that is suspicious for melanoma. What is your plan?
• 1-shave biopsy of the entire macule with 5 mm
margins
• 2-4 mm punch biopsy initially of the darkest part of
the macule
• 3-elliptical excision of the entire macule with 2
mm margins
• 4-refer to a plastic surgeon since the lesion needs
initial wide excision
ANSWER: 3-elliptical excision of the entire macule with 2 mm margins.
• A shave biopsy may be too shallow to show accurate depth, and
depth(Breslow microstage) is the best measure of melanoma prognosis.
• A 4 mm punch could give a false neg path report if only part of the
lesion is a melanoma ie the part that was not sampled.
• Initial wide excision is not recommended since this may not be
necessary if not a melanoma. If this is a melanoma, wide margins may
disrupt cutaneous lymphatic flow and affect the ability to identify the
sentinel node.
Question 4: a 5 year old boy is brought in because of plantar warts. He says they are
not painful; his parents would like to get rid of them. You see 3 small warts on the
sole of his foot. What treatment should you avoid?
• 1-observation
• 2-salicylic acid
• 3-occlusive tape
• 4-liquid nitrogen
Question 4: a 5 year old boy is brought in because of plantar warts. He says they are
not painful; his parents would like to get rid of them. You see 3 small warts on the
sole of his foot. What treatment should you avoid?
• 1-observation
• 2-salicylic acid
• 3-occlusive tape
• 4-liquid nitrogen
ANSWER: Avoid 4-liquid nitrogen which is painful in a
young child and can cause scarring if too aggressive;
warts are harmless and are not painful in this child so do
not require treatment. Salicylic acid if used correctly
should not cause pain. Occlusive tape is not effective but
will not do any harm.
A 67 y o man with rough spots on his forehead for the
past few months.
What is this and how would you treat it?
Actinic Keratoses
• SCC in situ
• Some will regress
spontaneously
• A small number will
progress to SCC
• Liquid nitrogen treats
effectively—5-10
seconds of spraying
only once.
47 year old woman with a mass on her
cheek
• It has been present for
a few months
• It is growing slightly
but then appears to
partly heal. It bleeds
from time to time.
• What is your diagnosis
and treatment
recommendations?
47 y o woman with a BCC on R cheek
• This is a classic
nodular BCC.
• This is in a danger
zone where the
temporal branch of the
facial nerve crosses
the zygomatic arch.
• Do superficial shave
rather than ellipse.
A 68 y o woman
• A non-healing lesion
just below the clavicle
for the past 2 years
which has been slowly
growing.
• It is itchy at times.
• What is your diagnosis
and what do you do?
Superficial Basal cell carcinoma(BCC)
• Too large to excise
completely
• Options: shave or 4 mm
punch biopsy (may be best
because closed with
suture) of the thickest part
which gives a pathology
diagnosis.
• Then referral to plastic
surgeon for excision and
graft.
• Excellent prognosis: by
type (superficial BCC)and
location (trunk).
A 24 y o man with a spot
• His girlfriend noticed
this spot on the back of
his arm and thought it
should be checked.
• The patient is not
aware of the spot and
has no symptoms.
• What is your diagnosis
and what do you do?
A 24 y old man with a spot
• This is a superficial
spreading melanoma
• Do elliptical excision with
2-3 mm borders.
• Depending on path report
re thickness, this will guide
further surgical
management: eg if ‘in-situ:
5 mm margins.
• Do not do shave biopsy
since does not give
thickness of lesion which is
what determines
prognosis.
ELLIPTICAL EXCISION
WHEN WOULD YOU
USE AN ELLIPTICAL
EXCISION?
BEST INDICATIONS FOR ELLIPTICAL
EXCISION
• Pigmented melanocytic nevi ie when a melanoma
is suspected.
• Basal Cell Carcinoma (large, recurrent, or high
risk area).
• Squamous Cell Carcinoma.
• Removal of subcutaneous lesions.
• In some locations for better cosmetic results.
Advantages and Disadvantages
ADVANTAGES
DISADVANTAGES
• One-stage diagnostic and
• Risk of infection
therapeutic intervention
• Large tissue sample
• Deep margins
• Scarring
• Time consuming
• Be careful in danger
areas on face and neck
Keys to a good cosmetic result
• Follow Langer’s lines (exception forearm where
best to have scar parallel to forearm).
• Corners at angles≤30 degrees.
• Length 3 times the width.
• Undermining to reduce tension.
• Proper suturing technique (edges everted, deep
symmetric suturing with proper spacing).
• Appropriate post-care instructions.
Undermining diagram Cardiff university module
SUTURING diagram Cardiff university module
Square knots with instrument tie
diagram Cardiff university module
Wound care
• Clean area after homeostasis achieved.
• Cover with petrolatum and sterile dressing.
• Clearly discuss signs of infection.
• Keep area covered and dry for 24 hrs.
Timing of suture removal (days)
• Arms
• Face
• Hands/feet
• Legs
• Palms/soles
• Scalp
• Trunk
Timing of suture removal (Days)
• Arms 7-10
• Face 3-5
• Hands/feet 10-14
• Legs 10-14
• Palms/soles 14-21
• Scalp 7-10
• Trunk 10-14
Pickett H, O’Callaghan F. Shave and Punch Biopsy for Skin Lesions. Am Fam Physician. 2011 Nov 1; 84(9):995-1002
Danger areas of the face mayo clinic proceedings
Danger areas of the face mayo clinic proceedings
• (1) The temporal branch of the facial nerve,
which innervates the frontalis and orbicularis
oculi muscles, runs closest to the surface near
the zygomatic arch. Damage to this nerve can
impair the ability to raise the eyebrow.
• (2) The marginal mandibular branch of the
facial nerve innervates depressor anguli oris,
and damage to this nerve leads to inability to
properly smile or depress the lip.
• (3) The approximate location of Erb's point,
where the spinal accessory nerve (cranial
nerve XI) enters the posterior triangle.
Damage to the spinal accessory nerve results
in paralysis of the trapezius muscle with
resultant muscle wasting.
TIME TO PRACTISE ELLIPTICAL
EXCISION ON A SYNTHETIC
MODEL
Shave biopsy
What are the benefits of a shave
biopsy?
Benefits of shave biopsy
• Quick to perform.
• Simple wound care.
• Good cosmesis generally.
• Clean not sterile procedure: takes less time and less
equipment.
What are the indications for a
shave biopsy?
Indications
• For lesions that are epidermal without extension into
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dermis.
Examples: skin tags.
Superficial basal cell carcinoma.
Squamous cell carcinoma if small and thin.
Seborrheic keratosis.
Actinic keratosis if raised.
Contraindications
• Not appropriate for suspicious pigmented lesions
(possible melanoma).
• Caution on the lower leg if poor circulation since takes
weeks to heal by secondary intention.
(A)
A 2-mm margin is marked around the lesion. (B) Injection of anesthetic created a
dermal wheal that elevated the lesion, making it easier to shave.
Am Fam Physician 2011;84(9):995-1002
A double-edged blade is held parallel to the skin for a
superficial shave biopsy Am Fam Physician 2011;84(9):995-1002
A thin disk of tissue is removed in a superficial shave biopsy
Am Fam Physician 2011;84(9):995-1002
DEMO: Technique for shave biopsy
• Obtain consent.
• Clean skin.
• Measure 1-2 mm margin and ink borders.
• Anesthetize skin.
• Hold blade between thumb and 3rd finger parallel
to skin with 2nd finger bending blade slightly.
• With a sawing motion, remove lesion of
combined epidermis and upper dermis (less than
1 mm thick).
Technique of shave biopsy continued
• If the lesion is a suspected BCC or SCC use a skin
curette to scrape the base of the lesion to remove any
possible remaining cancer cells (DEMO) and document
use of curette.
• Use a hemostatic agent such as aluminum chloride
20%(Drysol).
What do you do for a dressing and
what do you tell the patient about caring
for shave biopsy site?
Dressing and care of biopsy site
• Dress with petrolatum (Vaseline).
• Avoid polysporin.
• Ask pt. to keep area moist with petrolatum and covered
for at least one wk to minimize scarring and help healing.
• Advise patient that wound will take about 2 weeks to heal
on the trunk and up to 4-6 weeks on the lower legs.
Am Fam Physician 2011;84(9):995-1002
TIME TO PRACTISE SHAVE
BIOPSY
Punch biopsy
What are the indications for a
punch biopsy?
Indications for a punch biopsy• Useful for lesions that require dermal or
subcutaneous tissue for diagnosis ie full
thickness.
• Can remove a whole lesion (excisionial punch) or
part of a lesion (incisional) if it is too large to
remove completely.
• Examples: possible dysplastic nevi, scalp lesions,
small SCC, a diffuse rash to obtain a diagnosis.
WHAT IS AN IMPORTANT LIMITATION
OF A PUNCH BIOPSY?
Important limitation of punch biopsy
• It may not provide a wide enough sample if
the lesion is a suspected melanoma ie your
specimen may not capture the melanoma
part of a large mixed lesion.
DEMO:
Technique of performing a punch biopsy
• Obtain consent.
• Determine skin line(Langer lines) orientation: pull skin
perpendicular to skin lines to do punch; this will produce an
oval (instead of a circle) which is easier to suture.
• Determine the punch size with 1-3 mm margin around lesion.
• Prepare skin: clean; local anesthetic; this is a sterile technique
(controversial: some consider it a clean technique).
• While you pull skin perpendicular to Langer lines, place punch
over lesion and rotate through skin until there is a decrease in
tension on the tissue; this indicates full-thickness sample into
fat (usually to the hilt of the instrument).
Technique of punch biopsy continued
• Remove tissue gently with tooth forceps or needle to
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minimize crush artifact.
If sample is less than 4 mm there is no need for sutures
and can apply aluminum chloride 20% for hemostasis.
If 4 mm punch or larger, close with 1-2 sutures.
Punches exist in 2mm to 8 mm size.
Avoid using 2 mm in most cases since does not give
sufficient material for pathologist to analyse.
If sutures are used, keep covered and dry for 24 hours.
If no sutures, use petrolatum and keep moist for at least 1
week
Procedure for punch biopsy
. ((AM Fam Physician
2011;84(9):995-1002)
TIME TO PRACTISE
PUNCH BIOPSY
Cryotherapy
WHAT ARE SOME IDEAL
LESIONS FOR LN2
TREATMENT?
Spot treatment for actinic keratosis 5-10
seconds (Diploma in Practical Dermatology Cryosurgery Module, Cardiff University
Best indications for treatment with LN2
• Actinic keratoses: 5-10 seconds**; one freeze per visit.
• Solar lentigos: 7 seconds**: usually only one treatment
needed.
• Warts: 15 seconds**(approx) one freeze per visit.
• Seborrheic keratosis 10 seconds** one freeze per visit.
**these are FREEZE times; some articles refer to freeze-thaw total time;
freeze time refers to spray time which is about 1/3 of total freeze-thaw time
WHAT ARE THE
BENEFITS AND RISKS
OF LN2?
Benefits and risks of LN2
benefits
• Postop infection rare
• Final healing is excellent
with no scarring(usually)
• Minimal physician time
and multiple lesions
treated quickly
• Easy to learn
• Ideal if light skin colour
risks
• Painful so not ideal for
children under 10 or 12
• Limited in patients with
darker skin since causes
permanent
hypopigmentation.
• Not recommended where
hair growth (eg eyebrows)
since destroys hair follicles.
• No tissue available for path
dx.: avoid in pigmented
lesion if ddx melanoma
WHERE WOULD YOU AVOID
USING LIQUID NITROGEN?
Areas NOT recommended for cryotherapy
• Areas where hair loss is critical to the patient.
• Areas where pigment changes are critical to the patient.
• Flat pigmented nevi if differential includes melanoma.
• Any potential skin cancer since no tissue available for
diagnosis.
“Small” BCC left nasofacial sulcus, surgery is a better option at
this high risk site
(Diploma in Practical Dermatology Cryosurgery Module, Cardiff University
ALTERNATIVES TO
LN2?
Alternatives to LN2
• Warts: No treatment or observation or salicylic acid
preparations
• Solar lentigos: observation/reassurance
• Seborrheic keratosis: reassurance and no treatment;
shave excision
• Actinic keratosis: Topical chemotherapy if extensive (5Fluorouracil, Imiquimod, Ingenol Mebutate)
WHAT IS THE TECHNIQUE
FOR USING LIQUID
NITROGEN?
Different methods of application of liquid nitrogen
Thermos gun technique
• Select ‘C’ or ‘D’ nozzle size.
• Keep thermos upright.
• Hold the unit 1-2 cm from the
target.
• Anchor yourself to the patient
so that there is no movement.
• Spray continuously until lesion
is white + 1-2 mm around the
periphery; then spray
intermittently and quickly(pulse)
for the desired time.
TIME TO PRACTISE USING
LIQUID NITROGEN ON A SKIN
MODEL
TIP: remember to freeze hard and fast to
destroy cells
LOCAL ANESTHETICS
Frequent questions
• How can we make injection of local anesthetics more
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comfortable?
What are safe amounts of local anesthetics?
Should we avoid epinephrine on ears, nose, fingers, toes?
How do we do effective digital blocks?
What if the patient says he is allergic to local anesthetics?
HOW CAN WE MAKE INJECTION
OF LOCAL ANESTHETICS MORE
COMFORTABLE?
How to make injection of local anesthetics
more comfortable?
• Keep local anesthetic at room temperature.
• Choose a fine gauge needle: 27 or 30 gauge.
• Stretch or pinch the skin just before injecting.
• Inject at dermis/fat junction.
• Inject slowly.
• Use low concentration lidocaine (1% as effective as 2%).
• Adrenalin causes slightly more discomfort.
• Use buffered lidocaine.
Ref: Basic skin surgery module, Diploma in Practical Dermatology, Cardiff University
WHAT ARE SAFE AMOUNTS
OF LOCAL ANESTHETICS?
Safe amounts of local anesthetics
• Lidocaine without epinephrine: 4.5 mg/kg not to exceed
300 mg (30 ml in adult of 1% lidocaine).
• Lidocaine with epinephrine: 7 mg/kg not to exceed 500
mg (50 ml in adult).
• Remember that lidocaine 1% has 10 mg/ml and lidocaine
2% has 20 mg/ml.
Ref: Pfenninger &Fowler Procedures in Primary Care 2nd edition 2003
SHOULD WE AVOID EPINEPHRINE
ON EARS, NOSE, FINGERS, TOES?
Should we avoid epinephrine on ears, nose, fingers,
toes?
• This is an old myth from early 1900s before commercial
mixtures of lidocaine and epinephrine.
Advantages of epinephrine:
• reduced bleeding.
• more rapid onset of analgesia.
• longer duration of postop pain control.
• Reduced use of tourniquet.
• Smaller amount of anesthetic required to control
pain
Ref: J AM Acad Dermatol 2004;51:755-9
But a note of caution about epinephrine
• Avoid epinephrine in extremities of patients
with vasospastic, or thrombotic conditions.
EFFECTIVE DIGITAL
BLOCKS
Cross-section of digit shows 4 digital
nerves: 2 dorsal and 2 ventral
Digital block
Digital block
Digital block for ingrown toenail
• There are 4 digital nerves on each digit.
• Insert the 25-30 g needle in the web space
toward the bone and inject .5 ml of 1% lidocaine.
• Direct the needle superiorly and inject 1.5 ml.
• Then direct the needle inferiorly and inject 1.5 ml.
• Repeat the same technique on the contralateral
side.
• Wait at least 15 minutes for block to take effect.
• How many mg of lidocaine have you injected?
Ref: Pfenninger &Fowler Procedures in Primary Care 2nd edition 2003
WHAT DO YOU DO IF THE PATIENT
SAYS HE/SHE IS ALLERGIC TO
LOCAL ANESTHETICS?
If the patient says he/she is allergic to
local anesthetics?
• This comes up rarely and the patient often
doesn’t know which agent caused reaction.
• Use ethyl chloride if you only need 1 second of
anesthesia (incision and drainage of abscess).
• Use single-dose vial (no parabens preservative
that may induce an allergic reaction).
• Use saline to produce swelling of skin.
• Use diphenhydramine(Benadryl):50mg/ml mixed
with 4ml normal saline; inject 10-50 mg.
Ref: Pfenninger &Fowler Procedures in Primary Care 2nd edition 2003
QUESTIONS?
Selected references
• Zimmerman, E, Crawford P. Cutaneous Cryosurgery. Am
Fam Physician. 2012;86(12):1118-1124.
• Pickett H, O’Callaghan F. Shave and Punch Biopsy for
Skin Lesions. Am Fam Physician. 2011 Nov 1;
84(9):995-1002
• Pfenninger &Fowler Procedures in Primary Care 2nd
edition 2003
THANK YOU!