Exam Two Study Questions Flashcards
Why do basal cell carcinomas have a limited capacity to metastasize?
If tumor cells lodge at distant sites, they rarely multiply and grow due to absence of necessary growth factors derived from the stroma of the original tumor site.
What are the problem locations/danger zones for BCCs?
Around the eyes, in the nasolabial folds, around the ear canal, in the posterior auricular sulcus
Persons age ____ have a ___x fold incidence of BCC than those _____
Persons 55-75 have a 100x risk than patients under 20
About ____% of pts who have had BCC will develop another lesion within 5 years.
40
What is the most important environmental RF for developing BCC?
Chronic UV exposure
Which proposes a greater risk for BCC - intermittent, intense increments of UV exposure or continuous similar dosage over longer period?
Intermittent, intense increments
Describe a “rodent ulcer”
Some nodular BCCs are called “rodent ulcers”:
Center ulcerates/bleeds, accumulates crust/scale
Ulcerated areas heal with scarring
What is unique about morpheaform BCC that makes identification and treatment difficult?
Borders are in distinct and blend with normal skin making border localization by inspection or biopsy impossible
What are treatments of morpheaform BCCs?
Preferably mohs micro graphic surgery
Wide excision
Why must BCCs be treated early on?
They are locally invasive, aggressive, and destructive to surrounding tissues
Diagnosis of BCC must be confirmed by _____
Biopsy
What is more effective for BCCS - surgical excision or ED&C? Why?
Surgical excision is more effective because there is better margin control (still less effective margin control than Mohs)
Why would one choose radiation therapy to treat a BCC?
Non-invasive - relatively sparing of critical structures
Relatively painless
Good for patients who are not otherwise candidates for surgery
High cure rate for selected lesions
List three features of BCCs that account for a high likelihood for recurrence after initial treatment
Most SSCs that occur in sun-exposed areas of the skin have a very ___ rate of metastasis.
Low
In dark-skinned individuals, SCCs tend to arise where and are associated with what?
Non sun-exposed area (legs, anus) and frequently are associated with chronic inflammation, chronic wounds, or scarring
Genetic RFs for SCCs
Fair skin
Light eyes
Red hair
Northern European origin
What areas are more susceptible to the development of SCC?
Sites of chronic inflammation, chronic wounds, or scars
A lesion on the vermillion border is ____ until proven otherwise.
SCC
Metastasize rate of BCC and SCC
BCC - rare, 0.003%
SCC - 5-10%
Cumulative UVB sun exposure in the past ____ years of a person’s life increases the likelihood of SCC in the presence of other RFs.
5-10
Features of SCC lesions that correlate with high risk for recurrence and regional or distant metastasis
Non-sun exposed areas
SCCs not derived from AKs
Most common non-melanoma skin cancer
BCC
Death may result from untreated BCC due to
Hemorrhage of eroded large vessels of meningitis
Types of BCC
Nodular
Pigmented
Micronodular
Morpheaform (sclerosing)
Superficial
BCC clinical features
Malignant skin tumors arising from epidermis, developing hair follicles; rarely occur on lips/genital mucosa
Locally invasive, aggressive, destructive
Nodular BCC clinical features
Most common
Round, oval, flat
Pearly with Telangiectasia
Translucent when stretched
Can ulcerate and bleed > heal > cycle
Irregular growth pattern > mass with multilobular surface
Nodular BCC may appear similar to what benign growths
Dermal nevi, small epidermal inclusion cysts, sebaceous hyperplasia
What are some alterative herbs using in dermatology?
Trifolium pratense (red clover)*
Arctium lappa (burdock)*
Mahonia spp (Oregon grape)
rumex (yellow dock)
Taraxacum
Smilax (sarsaparilla)
Curcuma longa
Urtica dioica
*specificity of seat in the skin
What are some antioxidants/ inflammation modulating herbs using in dermatology?
Berberis vulgaris
Camellia sinensis
Silybum marianum
+ all alteratives
What are some immune modulating herbs using in dermatology?
Eleuthercoccus senticosus
Ganoderma lucidum
What do alteratives do?
Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination
“blood purifier”
Non-specific, broad
Trifolium pratense - common name, part used, energetics
Red clover
Flower
Cooling
Trifolium pratense main constituents
Phenolic glycosides
Isoflavones
Red clover actions
Alterative
Phytoestroenic
Anti-inflammatory
Lymphagogue
Vulnerary
Red clover derm indications
Acne
Ulcers of skin, mucous membranes
Burns with poor healing
Articum lappa - common name, part used, energetics
Burdock
Root (sometimes seed and leaf)
Cooling
Burdock actions
Root: alterative
Leaves: topical, antimicrobial, anti-inflammatory poultice
Seeds: alterative, vulnerary
Burdock derm indications
Root: dry, scaly skin conditions - psoriasis, eczema, dandruff, wounds and ulcers (poultice)
Seeds: skin conditions including exanthems
Mahonia/berberis common name, part used, energetics
Oregon grape
Root bark and stem bark
Cooling, drying
Oregon grape actions
Alterative, antimicrobial
Mahonia/berberis - common name, part used, energetics
Oregon grape
Root bark and stem bark
Cooling, drying
Oregon grape actions
Alterative, antimicrobial
Oregon grape derm indications
Psoriasis, eczema, herpes, pityriasis, acne, syphillis, skin infections
Camellia sinensis - common name, part used
Green tea
Leaf
Green tea actions
Modulates inflammation, dec sebum production, antimicrobial
Green tea derm indications
Topically used for acne vulgaris and rosacea, condyloma accuminata, atopic dermatitis, hypertrophic scar formation, wound healing
UV protection
Dec age related changes
Green tea CI/Caution
Take away from iron supplementation
Berberis vulgaris common name, part used
Barberry
Berries, rhizome, root
Actions of barberry
Berries: antioxidant, inflammation modulator
Rhizome and root: inflammation modulator, antimicrobial, affects glucose metabolism
Indications of barberry
Berries: acne, other inflammatory conditions
Rhizome and root: berberine source
Silybum marianum common name, part used
Milk thistle
Seed
Milk thistle actions
Hepatoprotective, bitter, antioxidant, galactogogue
Derm indications milk thistle
Acne
What are some herbs good for internal immune modulation?
Eleutherococcus and herpes simplex, ganoderma lucidum
Eleutherococcus senticosis common name, part used, energetics
Siberian ginseng
Root (most researched), stem bark and leaf
Warm, stimulating (higher doses), dispels wind dampness
Actions Siberian ginseng
Adaptogen, immunomodulating, mild CNS stimulant
Indications Siberian ginseng
Build vitality, inc resistance to infection, stress + toxicity, improve physical performance, improve mood
CI/caution Siberian ginseng
Adulteration common; monitor blood glucose in diabetics and hypoglycemias
Ganoderma lucidum common name, part used
Reishi, ling zhi
Fruiting body
Actions reishi
Anti-allergic
Anti-hypertensive
Dec platelet aggregation
Dec LDL
Dec arrhythmia
Dec angina
Indications reishi
Cancer tx to manage fatigue and increase immune function
HTN
Immune def
Insomnia
Hepatitis
What actions of vulnerary herbs are beneficial in dermatology?
Inc cell proliferation
Promotes angiogenesis
Inc collagen formation
Inc rate of epithelialization
Speeds contraction of wounds
Controls inflammation
Inc tensile strength
Calendula part used, energetics
Flower, drying
Calendula actions
Vulnerary, antiinflammatory, antimicrobial
Calendula indications
Lacerations, abrasions, excoriations, ulcers, eczema, rashes
Echinacea part used and energetics
Root and rhizome, whole plant
Cooling, drying, stimulating
Echinacea actions
Vulnerary
Immunomodulator
Anti-inflammatory
Anti-microbial
Echinacea indications
Infection, sepsis, pharyngitis, snake bites, ulcers
What is the best agreed upon screening protocol for malignant melanoma?
Skin survey
During the ______ growth phase, a malignant melanoma is almost always unable by excision alone.
Horizontal
Nodular melanomas have no identifiable ___ growth phase and enter the ____ growth phase almost from their inception.
Radial/horizontal
Vertical
Over __% of superficial spreading malignant melanomas are diagnosed as thin, highly curable tumors of less than __ thickness.
60%
1mm
Nodular malignant melanomas are the most difficult to diagnose at an early stage, at least half are greater than ___ in thickness when dx
2mm
The majority of Lentigo melanomas are diagnosed at ___(size)
Under 1 mm of thickness
The most common type of malignant melanoma among Asians and African Americans is the _____ melanoma, which most commonly arise on _______ surfaces
Acral lentiginous melanoma
Palmar, plantar, subungual surfaces
_____ is the single most important determinant of prognosis for a malignant melanoma
Tumor thickness
Stage T1 <1mm malignant melanomas have a 10 yr survival rate of ____
92%
The definitive “initial” surgical treatment for primary cutaneous melanoma is a _____
Wide local excision, down to the deep fascia
any malignant melanoma positive biopsy needs to be referred for ____.
Mohs procedure
Anesthetic are generally (vasodilators/vasoconstrictors)
Vasodilators (other than cocaine)
Benefits of adding epinephrine to local anesthetic
Dec bleeding
Prolongs anesthesia by slowing absorption
Min amount of anesthesia needed (less sys toxicity)
Risks of epinephrine
Hypoxic damage if used in area with limited circulation
What are some of the major drug interactions/bad effects with local anesthetics?
MAO inhibitors > hypertensive crisis
Carbamazepine and cyclobenzaprine > potentiate effects
Tricyclics > hypertensive crisis, dysrhythmia
Phenothiazines > hypotension
Define infiltration anesthesia
Injection of local anesthetic directly into tissue without considering course of cutaneous nerves
benefits of field block
In both, not injecting anesthesia directly into lesion avoids distortion of anatomy of lesion and allows pathologist to correctly interpret biopsy
Less drug can be used to provide more anesthesia
Routes of administration of local anesthesia
Topical
Local infiltration
Field block
Digit block/nerve block
IV regional
Spinal
Epidural
Max dosage 1% lidocaine with and without epi
1% - 4.5 mg/kg
1% with epi - 7 mg/kg
Max dosage 0.25% bupivacaine with and without epi
0.25% - 3 mg/kg
0.25% with epi - 3.5 mg/kg
What are langers lines? How are they used in minor surgery?
Topological lines on the human body corresponding to the natural orientation of collagen fibers in dermis and parallel to underlying muscle fibers
Incisions made parallel to langers lines minimize wound tension, heal faster, and produce less scarring
What are the “problem areas” of the body for increased risk of scarring/keloids?
Upper chest and back
Shoulders
How do kraissls lines compare to langers lines?
Langers lines = cadavers
Kraissls lines = living people
When does the inflammatory stage of healing occur and what happens during this stage?
Immediate > 2-5 days
-bleeding stops (vasoconstriction>clot>scab)
-inflammation (opening of blood supply > cleansing of wound)
When does the proliferative stage of healing occur and what happens during this stage?
5 days - 3 weeks
-granulation (new collagen, new capillaries)
-contraction (wound edges pull together)
-epithelialization (cells cross over moist surface)
When does the maturation stage of healing occur and what happens during this stage?
3 weeks - 2 years
-collagen forms > inc tensile strength
-scar tissue only 80% strong as original tissue
What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?
5-6%
Clean v clean contaminated v contaminated v infected
Clean - free from microorganisms
Clean contaminated - non-significant contamination, <6 hr til med care
Contaminated - without local infection, >6 hr til med care
Infected - intense inflammatory reaction and infectious process
Is there a golden period for closing lacerations?
> 8 hrs body, >12-24 face
Not really used any longer
What are the two possibilities that lead to a wound healing by secondary intention?
Wound left open on purpose > allowed to heal without closure from inner layer towards surface
wound fails to heal via primary intention
Advantages of healing by secondary intention
Simplicity
Low risk of infection
Disadvantages healing by secondary intention
Long healing times
Larger scars
Steps of delayed primary closure
Debride wound
Pack wound with sterile dressing
Cover with supporting bandage
Repeat daily
When should DPC be used?
Heavily contaminated wounds (combat wounds/major trauma)
Electrofulguration v electrodessication
Electrofulguration - electrode held away from the skin, produces spark and shallow effect
Electrodessication - touch skin with electrode to destroy tissue
Advantages of cryotherapy over electrosurgery
Faster and easier
No anesthesia
Less scarring
No smoke plume; no need for smoke evaluator
No risk of HPV/HIV
Tx of choice for actinic keratosis and simple warts
Disadvantages of cryotherapy v electrosurgery
Hypopigmentation
Less effective for large pedunculated lesions eg condylomata
Final results not immediately visible
More postop swelling
Transient discomfort
What tx is good for port wine stain?
Laser tx
CI electrosurgery
Pacemakers, metal plates, prosthetics
Lesions in folds of skin, face
Don’t let pt touch metal table
What areas are steri-strips good for?
Face, contoured areas, joints, areas of swelling, edema, hematomas
Best uses for surgical glue
Small, superficial lacerations
May be used on larger wounds after first applying subcutaneous sutures
Cautions surgical glue
Wounds must be dry
Only use with low infection risk
Don’t use over joints/high friction areas
Deeper lacerations to torso and extremities need subdermal sutures first
What types of wounds are not suitable for steri-strips and glue?
Lacerations into the deep dermal layers and sub-q
Wounds missing tissue
Wounds w inc wound tension
Advantages of staples over sutures
Quick placement
Fewer infections
Lower tissue reaction
Suture removal times
Face: 3-5
Scalp: 5-7
Extrem low tension: 6-10
Extrem high ten: 10-14
Abdomen, chest, back: 6-12
Clinical benefits of radio surgery
Hemorrhage control
Reduced postop discomfort
Min scar tissue
Readability of biopsy
Enhanced healing
Good cosmetic results
Skin lesions treatable with radiosurgery
Hemangiomas
Dermatofibromas
Compound nevi
Sebaceous hyperplasia
Thick Seborrheic keratosis
Spider angioma
Cherryangioma
When trimming a wound edge the goal is to produce an opening _________ which helps produce eversion of the edges
Wider at the base than the surface
Small v large bleeders
Small “oozing” venous/capillary bleeders
Large “spurting” arterial bleeders
