Dermatological Assessment and Procedures

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Dermatological Assessment and Procedures

• Bucky Boaz, ARNP-C

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What is Skin Cancer?

• Skin cancer happens when some of the cells of the
  epidermis begin to grow out of control

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Types of Skin Cancer

• Basal Cell Carcinoma
• Melanoma
• Squamous Cell Carcinoma

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Basal Cell Carcinoma

• The cancer that affects the cells at the lowest
  level of the epidermis, called the basal cells.
• Basal means at the bottom.

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Melanoma

• The cells affected are in the melanocytes, the
  cells between the basal cells.
• Melanocytes produce melanin, skin color
• Most serious, least common

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Squamous Cell Carcinoma

• The cancer is found within the layer of flat
  cells just above the basal cells.
• Squamous means like scales

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What Causes Skin Cancer?

• 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.

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Who is at Risk?

• Increased sun exposure.
• Sun burns
• Age
• Lots of moles or freckles
• Location

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How is Skin Cancer Diagnosed?

• Skin exam
• Biopsy
• If concerned about possible cancer spread
• Blood tests
• X-rays
• CT scans

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Assessing the Skin

• Normal Mole
• Round or oval, and even colored.
• Many moles indicate an increased risk of melanoma
  skin cancer

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Assessing the Skin

• Atypical Mole
• Mix of brown, smudged border, and is often bigger
  than 5mm.
• Increased risk of melanoma skin cancer

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Assessing the Skin

• Melanoma
• Most serious
• Fastest growing
• US cases have almost doubled in past two decades

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Assessing the Skin
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Assessing the Skin
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Assessing the Skin

• Melanoma
• Cure Rate
• 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.

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Assessing the Skin

• Melanoma
• Begins as an uncontrollable growth of
  pigment-producing cells in the skin.
• This growth leads to the formation of
  dark-pigmented malignant moles or tumors

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Assessing the Skin

• Melanoma
• May appear without warning, but may also develop
  from or near a mole.

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Assessing the Skin

• Melanoma what to watch for
• 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

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Assessing the Skin

• Basal Cell Carcinoma
• Small, fleshy bumps or nodules on the head and
  neck.
• Found among fair skin people.
• Does not grow quickly, rarely spreads.

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Assessing the Skin

• Squamous Cell Carcinoma
• Nodules or red-scaly patches.
• Second most common skin cancer in fair-skinned
  people.
• Rarely found in dark-skinned people.
• Can develop into large masses, can spread

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Assessing the Skin

• Actinic Keratosis
• 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.

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Mind Your ABCDs
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Procedures for Skin Lesions
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Options for Lesion Removal

• Cryosurgery
• Skin Biopsy

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Cryosurgery

• 1st performed in late 19th century
• Advantages
• Easy to perform
• Heals quickly
• Post-op care simple
• No surgery
• High risk patients

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Cryosurgery

• Liquid nitrogen most commonly used cryogen
• Inexpensive
• Readily available
• Boiling point 196C
• Stored in insulated container
• Refilled regularly

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Cryosurgery Techniques

• Direct cryogen application
• Cotton-tipped applicator
• 10 second freeze
• Include small rim of normal tissue
• Thaw 20-45 seconds

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Cryosurgery Techniques

• Spray technique
• Constant flow of liquid nitrogen onto lesion,
  rapid freeze.
• 3 patterns
• Ever-enlarging circle
• Side to side
• Central point
• Two freeze-thaw cycles required

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Cryosurgery

• Most common side effects
• Immediate erythema and edema at treatment site.
• Throbbing sensation for several minutes to half
  an hour.

• Healing Pattern
• Within 24 hrs blister.
• Followed by scab for 2-3 weeks.
• Postinflammatory hypopigmentation

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Skin Biopsy

• Snip excision
• Shave biopsy
• Punch biopsy
• Incisional Biopsy
• Elliptic excision biopsy

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Choosing a Technique

• 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

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Snip Excision

• 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.

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Snip Excision

• Lesions such as acrochordons, filiform verruca,
  or seborrheic keratosis.
• Reasons cosmesis, itching, irritation, catching
  on clothing

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Shave Biopsy

• Simple, practical method of removing a lesion or
  obtaining a skin biopsy
• A blade is used to slice very thin sections of
  skin

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Shave Biopsy

• Indications
• Exophytic lesions
• Seborrhea keratosis
• Verruca
• Skin tags
• Small nevi
• Useless
• Deep dermis
• Subcutaneous fat

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Shave Biopsy

• The Procedure
• Consent
• Prep skin
• Intradermal injection of local anesthetic
• Pinch skin to elevate
• 15 blade cut longitudinally
• Swinging motion
• Aluminum Chloride
• Antibiotic ointment

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Punch Biopsy

• Uses a punch or trephine
• Ideal for histologic diagnosis
• Size is important

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The Punch Biopsy

• The Procedure
• 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

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The Incisional Biopsy

• Indications
• Inflammatory disorders
• Suspected fungal
• Suspected bacterial

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The Incisional Biopsy

• Procedure
• Anesthesia and prep
• Incision perpendicular
• Counter traction on skin, full thickness incision
• Second cut parallel
• Elliptical result
• Suture

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The Excisional Biopsy

• Fusiform or elliptic
• Procedure of choice for melanoma
• Lengthwidth 31
• Long axis parallel to skin tension or wrinkle
  lines

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The Excisional Biopsy

• Procedure
• 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

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Surgical Margins

• Margins fit lesions
• Benign lesions narrow 1-2mm
• Malignant
• Basal cells 3-4mm
• Squamous cell 5mm
• Melanoma narrow margin with axis toward
  draining lymph node. If positive, refer to
  surgeon.

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Undermining

• If edges invert when pushed together, undermining
  is necessary
• Used to avoid wound tension and dehiscence
• Done with blunt scissors
• Scalp midfat or fatgalea junction
• Face subq fat
• Small torso or extremity upper subq
• Large deep fascia

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Danger Zones in Undermining

• Motor nerves lie superficially
• Later zygoma temporal branch of facial nerve
• Posterior triangle of neck
• Lateral popliteal space

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Processing the Biopsy Sample

• 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.

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Questions?