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Dermatologic procedures
RecognitionAnatomy/physiology
Treatment method/workshops
Warts
Common warts/Verruca VulgarisFlat warts/Verruca PlanaPlantar warts/Verruca Plantaris
Common warts
HPV type 2Age: 5-20Natural hx:
–½ resolve in 1 yr, 2/3 in 2 yrs.Location
–Hands (fingers/palms) periungualDistinguishing characteristics:
–Tiny black dots (dilated caps)
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Common wart
Periungual wart
Flat warts
Primarily HPV type 32-4mm flat topped papulesGenerally multiple and grouped on
face, neck, dorsum of hand, wrist, knees
Highest spontaneous remission
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Flat warts
Plantar warts
Primarily HPV 1Generally at pressure pts of footCan be confused with a callousSoft bulky core and black bleeding
pts when pared
Plantar wart
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Treatment of Warts
Discuss with pt:– Indications–Contraindications–Prognosis
2-3 months is a reasonable trial
Treatment of Flat warts
Frequently resolve, so tx should be mild
CryocauterySalicylic acidTopical tretenoin (high conc. bid)
–For extensive lesionsFailures:
–5FU or pulse dye laser
Treatment common and plantar warts
Destruction–Plantar warts: may use same tx
modalities but are tougher to tx–Surgical tx may lead to painful scar,
especially on wt bearing area Immunotherapy
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Cryocautery for warts
Utilize one tx or a freeze thaw => blister
Spray, cotton tip or derm tip–Repeat q 2-3 wks
Complications–Hypopigmention, scaring, nerve damage
Caution in certain pts:–Raynauds, PVD, cryoglobulinemias
Salicylic acid for warts
As effective as cryo
Pt applied
Soak, apply, dry, cover
Debride
Canthorone for warts
.7% canthiridin (Bleomycin used in same way)
Apply, dry, cover 24hrs–q 2-3 wks
Worse blister than cryoHigher incidence of donut wartsEffective for hard to tx
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Surgical treatment of warts
Curettage and electrodessication–Needs anesthesia–Scarring–Reserve for refractory warts
CO2 laser or pulse dye laser
Acrochoran/Skin tags
Small, fleshy, dark brown colorPin sized or largerSessile and pedunculated papillomasCommon to neck, axilla, eyelids
–Less on trunk and groin10-50 y/o60% of people have them by age 69
Skin tag
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Skin tag removal
AsepticClip @ baseSmall ones require no anesthesiaAluminum chloride for hemostasisLarger ones:
–Anesthetize and clip–Electrodessication–Cryo
Dermatofibroma characteristics
Single, round, ovoid papule/nodule ~ 1 cm, reddish brown to yellow hue
Elevated or depressed, primarily on lower extremity
Adherent to epidermisMiddle aged, injuriesMay appear similar to other tumors
Dermatofibroma treatment
When over 2-3 cm:–Excisional Biopsy/Punch–Excise entire lesion
May involute if left alone
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Dermatofibroma
Seborrheic keratosis characteristics
Multiple, oval, slightly raised, lt brown to black
Rarely > 3 cmPrimarily on chest and backAge of onset: 4th – 5th decadeCrumbly with raw moist base
Seborrheic keratosis
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Seborrheic keratosis: Treatment
BIOPSY any atypicalsLiquid nitrogen and curettageLiquid nitrogenCurettage with anesthesia/shaveUtilize aseptic techniques
Seborrheic keratosisDifferential diagnosis
Usually not a problemAtypical (black) may be at timesMore verrocous (not smooth or
infiltratingActinic keratosis usually
erythematous, rough scaly–Treat with cryo–Seen on upper ext. Consider to be
premalignant
Actinic keratosis
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Lipoma Characteristics
Palpable under skinNon tender, freely movable, soft,
irregularExcise if rapidly growing or painfulExcisional biopsy done
Sebaceous cyst/Epidermal cystCharacteristics
Round tense, keratinizing cystFreely movable and superficial
central poreExcise totally or Incisional
Keratocanthoma
Appears on sun or chemically damaged areas or sites of trauma
Skin colored or pink smooth lesion with RAPID growth
Volcano shaped with protruding masses of keratin (lava)
Regresses spontaneously but atypical ones may be Squamous cell
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Keratocanthoma
keratocanthoma
Common locations: hands, face, arms, legs and scalp
Basal cell cancer
Waxy semitranslucent nodules around central depression
Rolled bordersTelangiectasesBleeds easily (as grows, ulcerates)Rarely metsPrimarily on face, head, neck (85%)
–Upper trunk also (dorsum of hand: akand sc)
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Basal Cell
EAR
Basal cell
Basal cell
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Basal cell
Utilizing a dermatoscope
Basal CellTreatment
Depends on the area involvedShave biopsy (to diagnose)Excisional biopsy/Mohs surgery
–3mm margins (to treat)Shave, electrodessication and
curettage (to treat)Radiation
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Squamous Cell CancerCharacteristics
Occurs on skin and mucous membranes
Frequently sun exposed areasSuperficial, hard, arising from
indurated round baseDull red with telangiectasesFew mos. -> larger, nodular,
ulceratedEarly movable, later fixed
Squamous cell cancer
Squamous cell cancer
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Squamous cell
Squamous cellEtiology
UVBThermal injury/ chemical injuryChronic radiationHPVScars
Squamous Cell
Differential diagnosis–Actinic keratosis–Keratoacanthoma
Metastasis–Depending on the cause and treatment
modality may be up to 5.2%
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Squamous CellTreatment
Incisional
Excisional with margin control–5mm margins
Mohs (especially for recurrent)
Radiation (select)
Squamous cellPrevention
*Sunscreen–Especially the first 18 years–Would reduce the incidence of non
melanoma skin cancer by 78%
Malignant melanomaCharacteristics
Prolonged horizontal growth phase– Grow asymmetrically
Develops into tumor nodule– Vertical growth phase
Invasion -> metastatic disease A B C D
– Asymmetry– Border irreg– Color variegation– diameter
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Malignant MelanomaEtiology
Light complexion, eyes, hairBlistering sun burnsHeavy frecklingPoor tanners/sun burn easily20-50% develop in pre-existing
lesions
Dysplastic nevi
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Melanoma Primary Histopathologic Types
Lentigo melanoma
Superficial spreading
Acral lentigenous
Nodular
Lentigo melanoma
Face
Superficial/ tan
Thin vertical spread
Superficial spreading melenoma
70% of melenomas
5th decade
Upper back/shins
Horizontal 1-5 yrs then vertical
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Acral lentigenous melanoma
50 y.o
Blacks
Foot common
Acral lentigenous melanoma
Feet, hands, toenails, fingernails or mucous membranes. May appear originally as a bruise or nail streak.
Nodular melanoma
15% of melanoma Pigmented papule for
a few mos. Arise without clinically
appearing radial growth phase
2:1 male to female Primarily sun exposed
areas Variety of forms
including amelonotic
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Malignant Melanoma
Staging:–Clark and Breslow
Based on:–size– invasion–depth
Malignant melanoma
BIOPSY CORRECTLY!
–Surgical excision1 cm margins depending on depth
– Incisional or PunchThickest and most atypical area
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Things to think about as you progress through your residency regarding
Procedures
Skill set: Learn everything you can while in your residency
Cost of equipmentTrained medical assistantCost of supplies
–Amount needed to order–Expiration dates–Can you do enough procedures to pay
for it?
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Conclusion
Know your lesion before you biopsy or excise
Use the correct procedure
Follow-up on pathology accordingly!
References
See workbook