Dermatologic Procedures

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Dermatologic Procedures

• Core Skills for the Family Physician
• Michael Tuggy, MD

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Objectives

• Review the diagnosis and management of common
  skin lesions seen in everyday practice
• Review the procedure options
• Walk through selected procedures you must know
  how to do well.

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Common Skin Lesions in Clinic

• Nevi junctional, halo, melanocytic, dermal
• Seborrheic keratosis
• Actinic keratosis
• Basal cell carcinoma
• Squamous cell carcinoma
• Pre-melanotic lesions
• Melanoma

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Lesion 1
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Diagnosis 1

• Junctional nevus
• Features uniform pigmentation, clear margins,
  minimally raised
• DDx
• Melanoma
• Dermatofibroma

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Treatment Options

• Watch
• Punch biopsy
• Cosmetic shave removal

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Lesion 2
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Diagnosis 2

• Dysplastic nevus
• Features variable pigmentation within the
  lesion, sharp margins, often multiple similar
  nevi.
• DDx
• Melanoma (non-melanocytic)

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Treatment Options

• Punch biopsy
• Excisional biopsy
• Then Record (image with photos)

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Lesion 3
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Diagnosis 3

• Compound nevus
• Uniform pigmentation, raised center, sharp margin
• DDx
• Seborrheic keratosis

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Treatment Options

• Watch
• Punch biopsy
• Cosmetic shave removal

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Lesion 4
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Diagnosis 4

• Actinic Keratosis
• Features red base, yellow-white scale, dry
• DDx
• Squamous cell cancer
• Seborrhea
• Psoriasis
• Bowens carcinoma ?

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Treatment Options

• Cryotherapy
• Electrosurgical ablation
• Shave biopsy or punch biopsy

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Lesion 5
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Diagnosis 5

• Seborrheic Keratosis
• Features waxy, raised verrucous papules
• DDx
• Melanoma (again!)

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Treatment Options

• Cryotherapy
• Electrosurgical ablation
• Shave biopsy or punch biopsy
• Cosmetic shave removal

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Lesion 6
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Diagnosis 6

• Basal Cell Carcinoma
• Features telangiectasia, raised, pearly borders,
  fleshy-red color
• DDx
• Amelanocytic melanoma
• Trichoepithelioma
• Papillary adenomatosis

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Treatment Options

• Curettage and cautery
• Shave biopsy then ablation above
• Excisional biopsy with 2-4 mm margin
• Recurrance 5-15 depending on size.

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Lesion 7
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Diagnosis 7

• Squamous cell cancer
• Features central ulcer or scale, raised border
• DDx
• Keratoacanthoma
• BCC
• Superficial spreading melanoma

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Treatment Options

• Excisional biopsy with 4 mm margin (95 cure
  rate) for lesions lt 2 cm.
• Larger margins for lesion gt 2 cm.
• XRT for recurrent or invasive lesions

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Lesion 8
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Diagnosis 8

• Atypical nevus
• Irregular border, variable pigmentation

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Treatment Options

• Excisional biopsy with 2-3 mm margin

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Lesion 10
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Diagnosis 10

• Melanoma
• Features irregular dark black/reddish
  pigmentation, migrating border

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Treatment Options

• Punch biopsy
• Excisional biopsy with wide margin depending on
  location (5 mm to 1 cm)

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Common Mistakes

• Anesthesia
• Errors in size and area blocked
• Curettage
• Inadequate force used to curette lesion
• Dull curette
• Excisions
• Incision size and direction selection
• Wrong method for lesion type (i.e. full excision
  for benign lesions)
• Inadequate margins
• Not performing biopsy because its not pigmented

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Impacting Outcomes

• Long term follow up (start at 6 months, follow
  through 5 years) is key for cancer excisions
• Repeat skin exams every 6-12 months for new
  lesions
• Its OK to re-excise areas if margins are
  concerning.

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Take Home Points

• Do careful skin exams
• Biopsy more
• There is a lot out there that can look like
  melanoma
• You learn by sampling normal tissue
• Keep mental notes of what you see and the
  pathology report correlation.