Dermatologic Procedures: Pearls and Pitfalls

1. Dermatologic Procedures: Pearls and Pitfalls By Daniel J. Ladd, Jr., D.O. Dermatology Resident, KCOM

2. Financial Disclosure • Lecture sponsored by DERMIK • Very generous considering content of lecture has little or nothing to do with their products. • BENZACLIN for ACNE • PENLAC for ONYCHOMYCOSIS

3. BENZACLIN BID for ACNE • SAFE • EFFECTIVE • EASY TO USE • ACNE takes 8W • Treating ACNE is like brushing TEETH

4. PENLAC QD FOR ONYCHOMYCOSIS • SAFE • EFFECTIVE • EASY TO USE • NO DRUG INTERACTION WORRIES • NO LFT’S • NO CHF WORRIES

5. Common Procedures • Shave Biopsy • Punch Biopsy • Excisional Biopsy • Cryosurgery

6. Pearl #1 • Pearl: General rule of thumb is to shave a tumor and punch a rash. • Pitfall: A shave biopsy of a deep melanoma destroys the prognosis/Breslow’s thickness. Result: Now you must assume the worst and put the patient through extensive surgeries and chemotherapy. Moral: Fully excise or refer all suspected melanomas.

7. Pearl #2 • Pearl: Know where your biopsy is going. Always specify “must be diagnosed by a dermatopathologist”. • Pitfall: If you do not specify as above it will go to a general pathologist. They may give you less than ideal diagnostic information or even miss the diagnosis. Your patient will not be impressed.

8. Pearl #3 • Pearl: Communicate with your dermatopathologist; “asymptomatic scaling erythematous annular plaques with central clearing localized to the bilateral shins for 2 weeks, consider tinea vs. granuloma annulare vs. necrobiosis lipoidica” = high yield • Pitfall: “itchy rash, leg” = low yield

9. Pearl #4 • Pearl: When the patient asks “what do you think it (the lesion) is?”, the correct answer is “If I knew that I wouldn’t have to do the biopsy”. • Pitfall: Never attempt to reassure the patient by saying the lesion is “probably going to be nothing at all”, they’ll wonder why you’re putting them through all of this.

10. Local Anesthesia • “Doc, will this hurt?” • “I’m not sure, they’ve only let me try this on animals so far” • “No, it shouldn’t hurt me a bit” • “More than a tickle but less than paying taxes”

11. Local Anesthesia • Pearl: fears of epinephrine induced necrosis at distal sites (nose, ears, penis, toes, fingertips) are largely unfounded. • Pitfalls: patients with severe peripheral vascular disease, diabetic angiopathy and Raynaud’s phenomenon may be exceptions to the rule.

12. Pearl #5 • Local Anesthesia: • Pearl: INJECT SLOWLY and your patients will love you forever. Decreases pain more than warming or adding bicarbonate. • Pitfall: ALWAYS make sure they are lying down, especially the patient who “talks tough”.

13. Pearl #6 • Local Anesthesia • Pearl: It is OK to give Xylocaine to patients who had allergic reactions to Novocaine at the dentist’s office, Lidocaine is an Amide and Novocaine is an Ester. • Pitfall: They may not know which medication they reacted to: use Bacteriostatic NS when in doubt.

14. Pearl #7 • Local Anesthesia • Pearl: For pediatric patients, let them sit in the lobby with ELA-Max or EMLA covered with Saran Wrap for 30 minutes. • Pitfall: The above may fail. At this point either refer or insert earplugs and proceed. Remember: very few pediatric rashes will require biopsy for diagnosis.

15. Pearl #8 • Pearl: Insert needle at a 30 degree angle and slowly retract the needle as you inject the anesthetic. When the tissue blanches you are at the right level. • Pitfall: If you see a linear trail of blanched skin radiating from the injection site you are probably in a vessel.

16. Pearl #9 • Regarding Coumadin. • Pearl: Do not take patients off Coumadin to perform a small dermatologic procedure such as biopsy, excision or Moh’s surgery. • Pitfalls: Depend on the reason why they are on Coumadin in the first place. Also problematic if you do not have tools for hemostasis.

17. Hemostasis • Chemical • Electrical • Physical

18. Chemical Hemostasis • Drysol • Aluminum Chloride • Quick, easy, cheap. • Q-tip application. • No odor or discoloration. • Good for superficial biopsy - shave.

19. Chemical Hemostasis • Monsel’s solution. • 20% ferric subsulfate. • Cheap, easy to use. • Risk of tattooing. • Superficial only! • Caustic, may destroy connective tissue if sutured into wound.

20. High Frequency Electrosurgery • Monoterminal elecrodessication- low levels of current. • Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators. • Requires dry field.

21. Electrocautery • Heated metal results in tissue dessication, coagulation and necrosis. • Safe to use in patients with pacemakers. • Does not require a dry field.

22. Shave Biopsy • Sterile #15 blade • 4x4’s • Drysol solution • Sterile Q-tips • Path specimen container

23. Shave Biopsy - skin tension

24. Shave Biopsy - flush with surface

25. Shave Biopsy • Endpoint is “pinpoint bleeding” • Indicates you are at the level of the papillary dermis • This is where scarring begins and patient satisfaction decreases.

26. Shave biopsy • Pearl: Stay superficial and you can achieve minimal scarring. • Pink atrophic area has a full year to heal. • Pitfalls: Skin of upper chest and back scars no matter what. Same with Keloid prone pts.

27. Punch Biopsy • Sterile procedure! • Sterile gloves • 3 or 4 mm Punch • 4x4s, Drysol, Q-tips • Needle driver, forceps • Suture • Path specimen bottle

28. Punch Biopsy • Twist punch tool until buried to the hub* • *Caveat: Have a firm grasp of anatomy and skin thickness in the area you are punching before you punch it. • Finger tendons, facial and neck structures.

29. Punch Biopsy • Hemostasis works best in 2 steps. • First use the Q-tip to buy time to grab needle driver and suture. • Suture so that closure is low tension - simple palpation reveals.

30. Punch Biopsy • Use 6-0 Prolene on the face. • 4-0 Prolene most other areas. • Silk for mucosal areas. • 2 simple interrupted sutures. • Out 7d face, 10d otw

31. Excisional Biopsy • Pearl: If you suspect melanoma excisional biopsy DOWN TO FAT. • Pitfalls: Punch biopsy, while deep enough is NOT representative of the entire lesion. Shave too shallow, prognosis destroyed. • Pitfalls: Excision takes more time, reimbursement same, but medicolegally still a bargain because it is the standard of care.

32. Excisional Biopsy • Using a Sharpie felt tip pen mark a circle around lesion with about 1-2 mm margins around clinically apparent lesion. • Ellipse should be 3 times longer than circle around lesion.

33. Excisional Biopsy • Pearl: Try to postion the final suture line within existing wrinkle lines / least tension. • Whether lesion is malignant or not, your patient will never forget their scar.

34. Excisional Biopsy • Sterile procedure! • H2O2 and Betadine • Pearl: Try not to apply the above too aggressively or to get excess Xylocaine on your ellipse drawing • Pitfall: ink will rinse away, now you’re lost!

35. Pearl # 10 : Danger Zones

36. Pitfall #10: Facial Nerve Damage • Temporal branch - forehead and eyebrow ptosis, may obstruct vision. • Zygomatic branch - impaired blinking, eye dries out, clarity of vision is affected. • Buccal branch - drooping corner of mouth, • Marginal Mandibular - lower lip function.

45. BENZACLIN BID for ACNE • SAFE • EFFECTIVE • EASY TO USE • ACNE takes 8W • Treating ACNE is like brushing TEETH

46. PENLAC QD FOR ONYCHOMYCOSIS • SAFE • EFFECTIVE • EASY TO USE • NO DRUG INTERACTION WORRIES • NO LFT’S • NO CHF WORRIES

47. THANKS DERMIK!