Dermatological Assessment and Procedures Bucky Boaz, ARNP-C

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

Types of Skin Cancer Basal Cell Carcinoma Melanoma Squamous Cell Carcinoma

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’.

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

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

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.

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

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

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

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

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

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.

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

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

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

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.

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

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.

Mind Your ABCD’s AsymmetryColorBorderDiameter

Options for Lesion Removal Cryosurgery Skin Biopsy

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

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

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

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

Cryosurgery 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

Skin Biopsy Snip excision Shave biopsy Punch biopsy Incisional Biopsy Elliptic excision biopsy

Choosing a Technique 1 st factor = purpose of procedure 2 nd factor = differential diagnosis of the skin lesion 3 rd factor = physical determinants 4 th factor = spatial characteristics of the lesion 5 th factor = cosmesis

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.

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

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

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

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

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

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

The Incisional Biopsy Indications Inflammatory disorders Suspected fungal Suspected bacterial

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

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

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

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.

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

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

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.

Questions?