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

4/3/18 Examination Skills and Basic Outline Dermatology Procedures for the Non- Dermatologist • Dermatology examination pearls • Morphology primer Lindy P. Fox, MD • Basic dermatology procedures Professor of Clinical Dermatology Director, Hospital Consultation Service – Liquid Nitrogen Department of Dermatology University of California, San Francisco – Skin Biopsies lindy.fox@ucsf.edu – Electrocautery I have no conflicts of interest to disclose • Practice cases I may be discussing off-label use of medications 1 General Approach Details that Matter • Big picture (what you see from the door) – Age of patient • Skin should be accessible – Well vs ill – General view of the lesions /degree of involvement, location/distribution, symmetry – Patient should be undressed • Widespread/generalized (“diffuse”) • Scattered • Lighting • Localized • Primary lesion(s) – Natural is ideal • Secondary change • Other descriptors • Table placement – Color – Size (measure!) – Be able to walk around table – Shape – Demarcation – Arrangement/Pattern – Distribution (closer-up) – Consistency/tactile quality • Pertinent negatives 1

4/3/18 Review of Relevant Anatomy 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 Morphologic Terms for Primary Lesions • Macule ---- Patch • Papule ---- Plaque THE MOST IMPORTANT STEP • Vesicle ---- Bulla • Pustule Identify the PRIMARY lesion • Nodule • Mass (Tumor) 2

4/3/18 Morphologic Terms for Secondary Changes Morphologic Terms for Primary Lesions • Erosion • Macule ---- Patch • Ulceration • Papule ---- Plaque • Lichenification • Vesicle ---- Bulla • Scale • Pustule • Crust • Nodule • Purpura • Mass (Tumor) • Atrophy Macule Patch • Greater than or equal to 1cm • Smaller than 1cm • Completely flat (non-palpable) • Completely flat • No surface change at all – non-palpable • No surface change at all 3

4/3/18 Papule-acuminate Papule Oral condyloma • Smaller than 1cm • Raised (palpable) – Additional descriptors- demarcation, color, shape • Flat topped • Rounded/dome-shaped • Umbilicated • Acuminate (comes to a point) Plaque Vesicle, Bulla, Pustule • Fluid-filled • Greater than or equal to 1cm • Vesicle • Raised (palpable) – smaller than 1 cm, serous or bloody fluid • Bulla • Depressed or atrophic plaque OK – greater than or equal to 1cm – serous, bloody or purulent fluid • Pustule – always under 1cm – purulent fluid 4

4/3/18 Vesicles Bulla Zoster Bullous Pemphigoid Pustules Nodule Pustular psoriasis • Dome-shaped growth > 1cm • Additional descriptors: – depth (dermal, SQ) – consistency – mobility 5

4/3/18 Secondary changes Erosion, Ulcer • Erosion • Erosion – Epidermis is partially removed • Ulceration – Dermis not exposed • Lichenification • Ulcer • Crust – Epidermis fully removed • Scale – Dermis is exposed • Purpura • Atrophy Linear Erosions Erosion - Pemphigus Vulgaris Excoriations due to Sezary Syndrome 6

4/3/18 Scale=changes in stratum corneum: Crust= Dried fluid (blood, pus, serum) Erythroderma + Scale (Exfoliative erythroderma) 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 7

4/3/18 Atrophy= Thinning Basic Dermatology Procedures Epidermal Dermal • Liquid Nitrogen • Skin Biopsies • Electrocautery Liquid Nitrogen Cryosurgery • Indications – Benign, premalignant, in situ malignant lesions Liquid Nitrogen Cryosurgery • Objective – Selective tissue necrosis • Reactions predictable – Crust, bulla, exudate, edema, sloughing • Post procedure hypopigmentation – Melanocytes are more sensitive to freezing than keratinocytes 8

4/3/18 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 From: Bolognia, Jorizzo, and Schaffer. Dermatology 3 rd ed. Elsevier 2012 Am Fam Physician. 2004 May 15;69(10):2365-2372 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) 9

4/3/18 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 Cryosurgery for Planar Warts • Freeze time 20-60 seconds • Margin- 2-3mm • May consider • Thaw 30-45 seconds cotton tipped • TWO cycles better than one applicator • Repeat every 3-4 weeks technique • Average # of warts cleared= 40% • Average # of treatments to clear warts = 12 – ONE YEAR! 10

4/3/18 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 11

4/3/18 Cryosurgery for Seborrheic Keratoses Cryosurgery for Lentigines • Freeze- thaw cycle • Quick 3-4s freeze depends on thickness • Avoid overfreezing • Thin/flat- freeze 5-10s – Risk of hypopigmentation • Large/thick-freeze >10s, may need second cycle Cryosurgery for SCC in situ * • One 30 second freeze Or • Two 20 second freezes Skin Biopsies • Close follow up *ED+C still preferred treatment option 12

4/3/18 Skin Biopsy Skin Biopsy Types • Procedure itself is easy • Curettage • Knowing when and where to biopsy much • Snip/scissors more difficult • Shave biopsy • Pathologist can only comment on the tissue • Saucerization provided (not what’s left on patient) • Punch • Potential pitfalls in technique • 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 • Hold like pencil – Limited to the epidermis • Draw pressure under the lesion (epidermis) – Fragmented tissue From: Bolognia, Jorizzo, and Schaffer. Dermatology 3 rd ed. Elsevier 2012 13

4/3/18 Snip/Scissors Biopsy • Pedunculated lesions • Benign growths – Acrochordons (skin tags) – Filiform warts – Pedunculated nevi • If very thin attachment to skin (stalk) don’t need anesthesia • Use iris or Gradle scissors • May require hemostasis with aluminum chloride, electrodesiccation From: Bolognia, Jorizzo, and Schaffer. Dermatology 3 rd ed. Elsevier 2012 www.hovesskinclinic.co.uk 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) Onsurg.com Am Fam Physician. 2011 Nov 1;84(9):995-1002 14

4/3/18 Good Shave Biopsy • Be sure to get below simple hyperkeratosis and upper dermis • Palms, soles, hyperkeratotic lesions • Require hemostasis with aluminum chloride, electrodesiccation From: Bolognia, Jorizzo, and Schaffer. Dermatology 3 rd ed. Elsevier 2012 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 • Intention is to get to deep dermis – Atypical pigmented lesions (to r/o melanoma) • Requires hemostasis with aluminum chloride, electrodesiccation – Keratoacanthoma/SCC From: Bolognia, Jorizzo, and Schaffer. Dermatology 3 rd ed. Elsevier 2012 15