Derm Procedures Flashcards
Cryotherapy
Destruction of tissue by freezing.
Advantages of Cryotherapy
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.
Disadvantages of Cryotherapy
- 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,
Cryotherapy Counterindications
Previous bad reactions, not accepting possibility of pigment changes, areas of poor circulation, sclerosing or recurrent BCC or SCC, malignant melanoma
Areas to avoid Cryotherapy
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
Common error with Cryotherapy
Undertreatment (not freezing for long enough)
Skin Biopsy
Removal of lesion for diagnostic and or treatment purposes
Indications for skin biopsy
Dx: Rashes or blisters invloving dermis, processes involving subcutis
Dx and Tx: atypical moles and pigmented lesions
Skin Biopsy Advantages
- Quick, simple, cost effective
- confirm Dx
- determine appropriate Tx
- avoidance of uneccessary referrals
Skin Biopsy Disadvantages
- increased risk of scarring, especially with full-thickness lesions
- bleeding
- need for repeat procedure if + margins (didn’t get it all)
Contraindications for skin biopsy
Allergy, bleeding disorder, performing a partial thickness biopsy for Dx of melanoma
Types of skin biopsies
Shave, punch, excisional
Shave biopsy
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
Punch biopsy
lesions extending into dermis/subcute. punch instrument removes a cylindrical specimen
Excisional biopsy
Lesions that are larger and require removal with adequate borders
Biopsy recommendations
- Lesions should be excised for Dx purposes with narrow margins.
- consider aesthetic result desired by the patient
special biopsy considerations for melanoma
if suspected, use 1-3 mm margins. Type of biopsy used does not influence survival rates
Local Anesthesia indications
minimize pt discomfort, isolate pathology (ex: nerve block)
Local anesthesia contraindications
allergy (unlikely), Hx of CNS symptoms with anesthetic toxicity, hx of cardiovascular sx with previous use
Historical perspective on epinephrine use
historically, the mantra was never use epi on fingers, toes, penis, nose, ears. Current literature indicates this is no longer a major concern.
Cautions for epinephrine use
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
Lidocaine
Onset: Fast
Duration: 30-60 mins
Uses: pts with vascular disease, nerve blocks, bleeding expected to be minimal
Lidocaine with Epi
Onset: Fast
Duration: >60 mins
Uses: clean wounds, highly vascular areas to improve view (bleeding)
Bupivicaine
Onset: Slow
Duration: >120 mins
Uses: longer duration is needed, nerve blocks (typically in the OR setting)
Prepping the patient for local anesthetic
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
General process for local anesthetic
- clean top of vial with EtOH
- Draw desired volume with safety needle
- switch to 25-30 gauge needle (depending on the area)
- clean skin with EtOH and allow to dry
- advance needle through skin
- draw back on plunger slightly to avoid injecting into a vessel
Nerve blocking
form a wall of anesthetic with needle to surround the area being anesthetized
Injection errorrs
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
Tips for minimizing pain
- 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
Topical anesthetic adv/disadv
+ : 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
Topical Anesthesia for intact skin
Ethyl Chloride spray, EMLA
Topical Anesthesia for non-intact skin
Topicaine, LET/LAT
Saucerization biopsy
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
Glasgow 7-point checklist
Major: Change in lesion size, irregular border, irregular pigmentation
Minor: inflammation, itch/altered sensation, lesion larger than others, oozing and crusting
Abscess
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)
furuncle
abscess is formed by a sweat gland or hair follicle
carbuncle
collection of furuncles
paronychia
abscess that involves the nail
felon
abscess in the soft tissue of distal phalynx (finger)
Hordeolum
abscess on the eyelid
chalazion
chronic abscess of eyelid in meibomian glands
I&D procedure
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.
I&D f/u needs
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
