Derm Procedures

Question 1

Cryotherapy

Answer 1

Destruction of tissue by freezing.

Question 2

Advantages of Cryotherapy

Answer 2

Convenient and fast while avoiding needles. There is also minimal pain and scarring. Low infection rate. Tends to be cost effective and patients can return to activity.

Question 3

Disadvantages of Cryotherapy

Answer 3

• Painful (but brief)
• possible pigment change while healing and increased scarring in darker skinned patients
• can destroy hair follicles
• no pathology report to confirm Dx
• increased risk of sunburn in the area treated,

Question 4

Cryotherapy Counterindications

Answer 4

Previous bad reactions, not accepting possibility of pigment changes, areas of poor circulation, sclerosing or recurrent BCC or SCC, malignant melanoma

Question 5

Areas to avoid Cryotherapy

Answer 5

Where would hair loss or pigment changes be bothersome?
Where are poor circulation areas?
- Periorbital area, nasolabial fold, preauricular area, lips (BCC)
- Port wine stains
- Unconfirmed skin cancer

Question 6

Common error with Cryotherapy

Answer 6

Undertreatment (not freezing for long enough)

Question 7

Skin Biopsy

Answer 7

Removal of lesion for diagnostic and or treatment purposes

Question 8

Indications for skin biopsy

Answer 8

Dx: Rashes or blisters invloving dermis, processes involving subcutis
Dx and Tx: atypical moles and pigmented lesions

Question 9

Skin Biopsy Advantages

Answer 9

• Quick, simple, cost effective
• confirm Dx
• determine appropriate Tx
• avoidance of uneccessary referrals

Question 10

Skin Biopsy Disadvantages

Answer 10

• increased risk of scarring, especially with full-thickness lesions
• bleeding
• need for repeat procedure if + margins (didn’t get it all)

Question 11

Contraindications for skin biopsy

Answer 11

Allergy, bleeding disorder, performing a partial thickness biopsy for Dx of melanoma

Question 12

Types of skin biopsies

Answer 12

Shave, punch, excisional

Question 13

Shave biopsy

Answer 13

Lesions that are predominantly epidermal w/o extension into the dermis. Includes warts, papillomas, skin tags, SCC or superficial BCC. Don’t use on suspicious pigmented lesions. Scrape off

Question 14

Punch biopsy

Answer 14

lesions extending into dermis/subcute. punch instrument removes a cylindrical specimen

Question 15

Excisional biopsy

Answer 15

Lesions that are larger and require removal with adequate borders

Question 16

Biopsy recommendations

Answer 16

• Lesions should be excised for Dx purposes with narrow margins.
• consider aesthetic result desired by the patient

Question 17

special biopsy considerations for melanoma

Answer 17

if suspected, use 1-3 mm margins. Type of biopsy used does not influence survival rates

Question 18

Local Anesthesia indications

Answer 18

minimize pt discomfort, isolate pathology (ex: nerve block)

Question 19

Local anesthesia contraindications

Answer 19

allergy (unlikely), Hx of CNS symptoms with anesthetic toxicity, hx of cardiovascular sx with previous use

Question 20

Historical perspective on epinephrine use

Answer 20

historically, the mantra was never use epi on fingers, toes, penis, nose, ears. Current literature indicates this is no longer a major concern.

Question 21

Cautions for epinephrine use

Answer 21

skin flap does not appear viable (no point in fixing), contamination (same), patients with contraindications (PVD, DM, HTN, arterosclerosis, heart block, cerebrovascular disease) or are taking MAOIs

Question 22

Lidocaine

Answer 22

Onset: Fast
Duration: 30-60 mins
Uses: pts with vascular disease, nerve blocks, bleeding expected to be minimal

Question 23

Lidocaine with Epi

Answer 23

Onset: Fast
Duration: >60 mins
Uses: clean wounds, highly vascular areas to improve view (bleeding)

Question 24

Bupivicaine

Answer 24

Onset: Slow
Duration: >120 mins
Uses: longer duration is needed, nerve blocks (typically in the OR setting)

Question 25

Prepping the patient for local anesthetic

Answer 25

Plan, discomfort, risks. Consent form! Position patient correctly to expose the area and maximize comfort. They probably shouldn’t watch and should indicate personnel if feeling nauseated, lightheaded, pain

Question 26

General process for local anesthetic

Answer 26

1. clean top of vial with EtOH
2. Draw desired volume with safety needle
3. switch to 25-30 gauge needle (depending on the area)
4. clean skin with EtOH and allow to dry
5. advance needle through skin
6. draw back on plunger slightly to avoid injecting into a vessel

Question 27

Nerve blocking

Answer 27

form a wall of anesthetic with needle to surround the area being anesthetized

Question 28

Injection errorrs

Answer 28

Injecting while advancing
not using enough/too much anesthetic, not waiting long enough for it to work
injecting into an infection/not cleaning the skin first
needle recapping errors

Question 29

Tips for minimizing pain

Answer 29

• keep soln at room temp
• small gauge needle
• inject slowly and methodically
• minimize number of needle insertions/removals
• pinch skin while administering (distraction)
• use topical anesthetic on children

Question 30

Topical anesthetic adv/disadv

Answer 30

+ : painless, not distortion of wound margins, less anxiety (no needles)
- : longer time to achieve numbing effect, does not penetrate to deeper layers

Contras: allergy to preservative in cream or ointment

Question 31

Topical Anesthesia for intact skin

Answer 31

Ethyl Chloride spray, EMLA

Question 32

Topical Anesthesia for non-intact skin

Answer 32

Topicaine, LET/LAT

Question 33

Saucerization biopsy

Answer 33

thick disk of tissue is removed with a blade. Specimen extends to at least the mid-dermis or subcute (1-4cm deep). Indicated with patients with wider pigmented lesions

Question 34

Glasgow 7-point checklist

Answer 34

Major: Change in lesion size, irregular border, irregular pigmentation
Minor: inflammation, itch/altered sensation, lesion larger than others, oozing and crusting

Question 35

Abscess

Answer 35

localized collection of pus/infection surrounded by inflammation.

Cause: Staph aureus
Locations: buttocks, extremities, breast, hair follicles
Treatment: I&D, smaller abscesses may respond to ABx (good idea if immunocompromised or if cellulitis is present) and warm compresses. MRSA may play a role if it recurs (get culture)

Question 36

furuncle

Answer 36

abscess is formed by a sweat gland or hair follicle

Question 37

carbuncle

Answer 37

collection of furuncles

Question 38

paronychia

Answer 38

abscess that involves the nail

Question 39

felon

Answer 39

abscess in the soft tissue of distal phalynx (finger)

Question 40

Hordeolum

Answer 40

abscess on the eyelid

Question 41

chalazion

Answer 41

chronic abscess of eyelid in meibomian glands

Question 42

I&D procedure

Answer 42

inform of recommendations and discuss possible risks/complications (sign consent form). Clean area, use a field block, make wide incision with #11 blade. Always wear a protective shield. Apply external pressure to express contents. Explore the cavity; remove cyst wall if present and obtain culture if necessary. Pack eith iodoform gauze if deep cavity.

Question 43

I&D f/u needs

Answer 43

Change packing and re-check wound every 3-5 days in the clinic. Apply sterile dressing and have patient change outer dressing multiple times per day as needed for drainage. Remind patient to be seen immediately if they develop a recollection of pus, fever, and/or chills, increased pain/swelling/redness or streaking