Examination Skills and Basic Outline Dermatology Procedures for the - - PDF document

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Examination Skills and Basic Dermatology Procedures for the Non- Dermatologist

1

Lindy P. Fox, MD

Professor of Clinical Dermatology Director, Hospital Consultation Service Department of Dermatology University of California, San Francisco

lindy.fox@ucsf.edu

I have no conflicts of interest to disclose I may be discussing off-label use of medications

Outline

• Dermatology examination pearls
• Morphology primer
• Basic dermatology procedures

– Liquid Nitrogen – Skin Biopsies – Electrocautery

• Practice cases

General Approach

• Big picture (what you see from the door)

– Age of patient – Well vs ill – General view of the lesions /degree of involvement, location/distribution, symmetry

• Widespread/generalized (“diffuse”)
• Scattered
• Localized
• Primary lesion(s)
• Secondary change
• Other descriptors

– Color – Size (measure!) – Shape – Demarcation – Arrangement/Pattern – Distribution (closer-up) – Consistency/tactile quality

• Pertinent negatives

Details that Matter

• Skin should be accessible

– Patient should be undressed

• Lighting

– Natural is ideal

• Table placement

– Be able to walk around table

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Some Pearls

• Mucosal complaint

– Examine all mucosal surfaces

• Acral complaint

– Examine hands and feet

• Hair and nails

– Tell a story- are like rings of a tree

Review of Relevant Anatomy

THE MOST IMPORTANT STEP

Identify the PRIMARY lesion

Morphologic Terms for Primary Lesions

• Macule ---- Patch
• Papule ---- Plaque
• Vesicle ---- Bulla
• Pustule
• Nodule
• Mass (Tumor)

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Morphologic Terms for Secondary Changes

• Erosion
• Ulceration
• Lichenification
• Scale
• Crust
• Purpura
• Atrophy

Morphologic Terms for Primary Lesions

• Macule ---- Patch
• Papule ---- Plaque
• Vesicle ---- Bulla
• Pustule
• Nodule
• Mass (Tumor)

Macule

• Smaller than 1cm
• Completely flat

– non-palpable

• No surface change at all

Patch

• Greater than or equal to 1cm
• Completely flat (non-palpable)
• No surface change at all

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Papule

• Smaller than 1cm
• Raised (palpable)

– Additional descriptors- demarcation, color, shape

• Flat topped
• Rounded/dome-shaped
• Umbilicated
• Acuminate (comes to a

point)

Papule-acuminate

Oral condyloma

Plaque

• Greater than or equal to

1cm

• Raised (palpable)
• Depressed or atrophic

plaque OK

Vesicle, Bulla, Pustule

• Fluid-filled
• Vesicle

– smaller than 1 cm, serous or bloody fluid

• Bulla

– greater than or equal to 1cm – serous, bloody or purulent fluid

• Pustule

– always under 1cm – purulent fluid

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Vesicles Zoster Bulla Bullous Pemphigoid Pustules Pustular psoriasis Nodule

• Dome-shaped growth >

1cm

• Additional descriptors:

– depth (dermal, SQ) – consistency – mobility

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Secondary changes

• Erosion
• Ulceration
• Lichenification
• Crust
• Scale
• Purpura
• Atrophy

Erosion, Ulcer

• Erosion

– Epidermis is partially removed – Dermis not exposed

• Ulcer

– Epidermis fully removed – Dermis is exposed

Linear Erosions

Excoriations due to Sezary Syndrome

Erosion - Pemphigus Vulgaris

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Scale=changes in stratum corneum:

Erythroderma + Scale (Exfoliative erythroderma)

Crust= Dried fluid (blood, pus, serum)

Lichenification=exaggeration of skin markings

Purpura= bleeding into the skin

• By definition, non-blanching
• Macular or papular (palpable v non-

palpable)

Macular purpura- amyloid Purpuric papules- Scurvy

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Atrophy= Thinning

Epidermal Dermal

Basic Dermatology Procedures

• Liquid Nitrogen
• Skin Biopsies
• Electrocautery

Liquid Nitrogen Cryosurgery Liquid Nitrogen Cryosurgery

• Indications

– Benign, premalignant, in situ malignant lesions

• Objective

– Selective tissue necrosis

• Reactions predictable

– Crust, bulla, exudate, edema, sloughing

• Post procedure hypopigmentation

– Melanocytes are more sensitive to freezing than keratinocytes

4/3/18 9 Liquid Nitrogen Cryosurgery Principles

• - 196°C (−320.8°F)
• Temperatures of −25°C to −50°C (−13°F to −58°F)

within 30 seconds with spray or probe

• Benign lesions: −20°C to −30°C (−4°F to −22°F)
• Malignant lesions: −40°C to −50°C.
• Rapid cooling à intracellular ice crystals
• Slow thawing à tissue damage
• Duration of THAW (not freeze) time is most

important factor in determining success

Am Fam Physician. 2004 May 15;69(10):2365-2372 From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

Liquid Nitrogen Cryosurgery

• Fast freeze, slow thaw cycles

– Times vary per condition (longer for deeper lesion) – One cycle for benign, premalignant – Two cycles for warts, malignant (not commonly done)

• Lateral spread of freeze (indicates depth of freeze)

– Benign lesions 1-2mm beyond margins – Actinic keratoses- 2-3mm beyond margins – Malignant- 3-5+mm beyond margins (not commonly done)

4/3/18 10 Liquid Nitrogen Cryosurgery Technique

• Hold spray gun 1-1.5cm away from target
• Freeze until ice field fills the margin
• Maintain the spray for the appropriate time

BEYOND initial time of ice field formation

• If more than one cycle required, allow for

complete thawing before beginning next cycle

Cryosurgery for Common Warts

• Freeze time 20-60 seconds
• Margin- 2-3mm
• Thaw 30-45 seconds
• TWO cycles better than one
• Repeat every 3-4 weeks
• Average # of warts cleared= 40%
• Average # of treatments to clear

warts = 12

– ONE YEAR!

Cryosurgery for Planar Warts

• May consider

cotton tipped applicator technique

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Ring Wart Bullae

http://www.dermnet.com

Cryosurgery for Actinic Keratoses

• One freeze-thaw cycle
• margin- 2-3mm
• Freeze time

– AK 5-7s – Actinic cheilitis 10-20s

www.dermquest.com

4/3/18 12 Cryosurgery for Seborrheic Keratoses

• Freeze- thaw cycle

depends on thickness

• Thin/flat- freeze 5-10s
• Large/thick-freeze >10s,

may need second cycle

Cryosurgery for Lentigines

• Quick 3-4s freeze
• Avoid overfreezing

– Risk of hypopigmentation

Cryosurgery for SCC in situ*

• One 30 second freeze

Or

• Two 20 second freezes
• Close follow up

*ED+C still preferred treatment option

Skin Biopsies

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Skin Biopsy

• Procedure itself is easy
• Knowing when and where to biopsy much

more difficult

• Pathologist can only comment on the tissue

provided (not what’s left on patient)

• Potential pitfalls in technique

Skin Biopsy Types

• Curettage
• Snip/scissors
• Shave biopsy
• Saucerization
• Punch
• Incisional
• Excisional (in toto)

Curettage with Biopsy

• Samples epidermis only
• Clinically benign lesions involving the epidermis

– Verrucae (warts), seborrheic keratoses, actinic keratoses

• Send pathology at same time as treating the

lesion

• Limitations

– Limited to the epidermis – Fragmented tissue

From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

• Hold like pencil
• Draw pressure under the lesion (epidermis)

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Snip/Scissors Biopsy

• Pedunculated lesions
• Benign growths

– Acrochordons (skin tags) – Filiform warts – Pedunculated nevi

From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

• If very thin attachment to skin (stalk) don’t need anesthesia
• Use iris or Gradle scissors
• May require hemostasis with aluminum chloride, electrodesiccation

Shave Biopsy

• Samples epidermis and papillary (superficial)

dermis

• Ideal for elevated lesions involving the epidermis

and superficial dermis

– Inflammatory dermatoses of epidermis, superficial dermis (psoriasis, eczema, CTCL, lichen planus) – Nevi, benign adnexal tumors – Diagnosis of basal cell or squamous cell carcinoma – Diagnosis of lentigo maligna (MIS)

Am Fam Physician. 2011 Nov 1;84(9):995-1002 Onsurg.com www.hovesskinclinic.co.uk

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From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

• Be sure to get below simple hyperkeratosis and upper dermis
• Palms, soles, hyperkeratotic lesions
• Require hemostasis with aluminum chloride, electrodesiccation

Good Shave Biopsy

Slide courtesy of Jeff North, MD

Saucerization Biopsy

• Deeper biopsy with intentional deeper placement of

the blade

• Samples epidermis and superficial and deep dermis
• Advantage

– Histologic examination of the entire circumference of the lesion with adequate depth to assess invasion

• Ideal for

– Inflammatory dermatoses with dermal infiltrate – Atypical pigmented lesions (to r/o melanoma) – Keratoacanthoma/SCC

From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

• Intention is to get to deep dermis
• Requires hemostasis with aluminum chloride, electrodesiccation

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Punch Biopsy

• Samples epidermis, dermis and superficial subcutaneous fat
• Varying barrel sizes- 2mm- 8mm
• Ideal for

– Inflammatory dermatoses with deep dermal infiltrate (lupus) – Infiltrative diseases (amyloid, sarcoid, lymphoma cutis) – Blistering diseases (pemphigus, pemphigoid) – Depressed lesions (scleroderma)

• Limitations

– Only samples portion of larger lesion – Requires suture (>3mm) – Not ideal for subcutaneous lesions

• NO contraindications to punch biopsy other than avoiding

bowel and brain

Punch Biopsy

• Stabilize skin around punch with free hand
• Twist with firm downward pressure in one direction
• Gently lift tissue with forceps at edge of epidermis (do not crush)
• If plug not elevating, angle scissors downward to base
• Try to make sure there is some fat at the base of the sample

Slide courtesy of Wilson Liao, MD

Good Punch Biopsy

Slide courtesy of Jeff North, MD

Incisional Biopsy

• Samples epidermis, dermis, subcutaneous fat
• Removes wedge from center or edge of lesion
• Ideal for

– Large tumors – Subtle diseases of connective tissue – Diseases of the fat (panniculitis) – Diseases of the fascia

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From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

Excisional Biopsy

• Samples epidermis, dermis, subcutaneous fat
• Intended to be definitive treatment
• Ideal for

– Suspected invasive melanoma

Skin Biopsies- Potential Pitfalls

• Crush artifact
• Leaving part of tissue in punch tool
• Multiple specimens, mislabeling

Crush Artifact

Slide courtesy of Jeff North, MD

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Failure to Deliver

• Leaving part of the biopsy in the punch tool

Biopsy

Slide courtesy of Jeff North, MD

Multiple Biopsy Specimens

• Critically important to have an established

protocol/routine to ensure the correct biopsy goes in the correct bottle A B C

Slide courtesy of Jeff North, MD

Shave Biopsy Tray Punch Biopsy Tray

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How to biopsy a specific lesion

Lesion Type of biopsy

Papulosquamous (eczema, psoriasis) Shave or saucerization biopsy r/o melanoma Saucerization or excisional biopsy Blister Punch biopsy at the edge for H+E and DIF Wart, seborrheic keratosis, actinic keratosis Shave biopsy or curettage Scalp (alopecia) Punch biopsy from hair containing region adjacent to alopecia, request transverse sections

Where to Biopsy

Lesion Location of biopsy Tumor Thickest portion, avoid necrotic tissue Blister Edge of the lesion, include about 2mm

• f blister edge; send for H+E and DIF

Ulceration/necrotic lesion Edge of ulcer or necrosis plus adjacent skin Generalized polymorphic eruption Characteristic lesion of recent onset (+/- more developed lesion) Small vessel vasculitis (palpable purpura) Characteristic lesion of recent onset (ideally <24 hours old)

Adapted from: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

Electrosurgery Electrosurgery

• Electrodesiccation

– Superficial tissue destruction

• Electrocoagulation

– Deep tissue destruction

• Electrosection

– Cutting

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Electrosurgery

• Electrodesiccation

– Superficial tissue destruction

• Electrocoagulation

– Deep tissue destruction

• Electrosection

– Cutting

Electrodesiccation

• Damped, high-

voltage current

• Causes superficial

tissue damage via dehydration

Electrodesiccation Indications- Epidermal Lesions

• Acrochordons
• Actinic keratosis
• Angioma (small)
• Hemostasis
• Lentigo
• Seborrheic keratoses/dermatosis papulosa

nigra

• Verrucae

Electrodesiccation for Epidermal Lesions- Technique

• Typically doesn’t require anesthesia
• Use lowest setting that produces a very subtle

gray char

• May see pinpoint bleeding (indicates you have

reached dermis and time to stop)

• Doesn’t require post procedure wound care other

than vaseline

• Target lesions “fall off” within 1-2 weeks
• Typically doesn’t scar or lead to pigmentary

damage if done correctly

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From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012 From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012 From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012 From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

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From: Bolognia, Jorizzo, and Schaffer. Dermatology 3rd ed. Elsevier 2012

Basic Dermatology Procedures Summary Points- Liquid Nitrogen

• Duration of thaw determines amount of tissue

damage

• Warts require monthly treatments for 12 months
• Avoid over freezing (to avoid hypopigmentation)

Basic Dermatology Procedures Summary Points- Skin Biopsies

• Pathologists can only comment on the tissue

provided

• Curettage is a good way to treat warts, SKs
• Shave/saucerizaton biopsies are best for

inflammatory lesions, BCC, SCC

• Punch biopsies are best to evaluate deep dermis
• Incisional biopsies are the best way to assess the

subcutis

• Try to perform excisional biopsies for melanoma,

but large saucerization acceptable

• Electrodesiccation is a good option to

cosmetically treat seborrheic keratoses, dermatosis papulosa nigra

• If curette or shave remove a wart,

electrodesiccate the base to decrease risk of recurrence

Basic Dermatology Procedures Summary Points- Electrocautery

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Practice Cases

Where would you biopsy? What technique would you use?

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