Dermatological Assessment and Procedures

1. Dermatological Assessment and Procedures Bucky Boaz, ARNP-C

2. What is Skin Cancer? • Skin cancer happens when some of the cells of the epidermis begin to grow out of control

3. Types of Skin Cancer • Basal Cell Carcinoma • Melanoma • Squamous Cell Carcinoma

4. 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’.

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

6. Squamous Cell Carcinoma • The cancer is found within the layer of flat cells just above the basal cells. • Squamous means ‘like scales’

7. 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.

8. Who is at Risk? • Increased sun exposure. • Sun burns • Age • Lots of moles or freckles • Location

9. How is Skin Cancer Diagnosed? • Skin exam • Biopsy • If concerned about possible cancer spread: • Blood tests • X-rays • CT scans

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

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

12. Assessing the Skin • Melanoma: • Most serious • Fastest growing • US cases have almost doubled in past two decades

13. Assessing the Skin

14. Assessing the Skin

15. 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.

16. 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

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

18. 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

19. 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.

20. 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

21. 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.

22. Asymmetry Border Color Diameter Mind Your ABCD’s

23. Procedures for Skin Lesions

24. Options for Lesion Removal • Cryosurgery • Skin Biopsy

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

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

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

28. 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

29. 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 Cryosurgery

30. Skin Biopsy • Snip excision • Shave biopsy • Punch biopsy • Incisional Biopsy • Elliptic excision biopsy

31. 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

32. 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.

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

34. 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

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

36. 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

37. Punch Biopsy • Uses a punch or trephine • Ideal for histologic diagnosis • Size is important

38. 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

39. The Incisional Biopsy • Indications • Inflammatory disorders • Suspected fungal • Suspected bacterial

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

41. The Excisional Biopsy • Fusiform or elliptic • Procedure of choice for melanoma • Length:width = 3:1 • Long axis parallel to skin tension or wrinkle lines

42. 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

43. 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.

44. 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

45. Danger Zones in Undermining • Motor nerves lie superficially • Later zygoma – temporal branch of facial nerve • Posterior triangle of neck • Lateral popliteal space

46. 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.

47. Questions?