Dermatologic Procedures: Pearls and Pitfalls

By

Daniel J. Ladd, Jr., D.O.

Dermatology Resident, KCOM

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

BENZACLIN BID for ACNE

• SAFE• EFFECTIVE• EASY TO USE• ACNE takes 8W• Treating ACNE is like

brushing TEETH

PENLAC QD FOR ONYCHOMYCOSIS

• SAFE • EFFECTIVE• EASY TO USE• NO DRUG

INTERACTION WORRIES

• NO LFT’S• NO CHF WORRIES

Common Procedures

• Shave Biopsy

• Punch Biopsy

• Excisional Biopsy

• Cryosurgery

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.

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.

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

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.

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”

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.

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”.

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.

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.

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.

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.

Hemostasis

• Chemical

• Electrical

• Physical

Chemical Hemostasis

• Drysol• Aluminum Chloride• Quick, easy, cheap.• Q-tip application.• No odor or

discoloration.• Good for superficial

biopsy - shave.

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.

High Frequency Electrosurgery

• Monoterminal elecrodessication- low levels of current.

• Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators.

• Requires dry field.

Electrocautery

• Heated metal results in tissue dessication, coagulation and necrosis.

• Safe to use in patients with pacemakers.

• Does not require a dry field.

Shave Biopsy

• Sterile #15 blade• 4x4’s• Drysol solution• Sterile Q-tips• Path specimen

container

Shave Biopsy - skin tension

Shave Biopsy - flush with surface

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.

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.

Punch Biopsy

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

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.

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.

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

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.

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.

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.

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!

Pearl # 10 : Danger Zones

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.

BENZACLIN BID for ACNE

• SAFE• EFFECTIVE• EASY TO USE• ACNE takes 8W• Treating ACNE is like

brushing TEETH

PENLAC QD FOR ONYCHOMYCOSIS

• SAFE • EFFECTIVE• EASY TO USE• NO DRUG

INTERACTION WORRIES

• NO LFT’S• NO CHF WORRIES

THANKS DERMIK!