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Dermatologic Procedures

Dermatologic Procedures. Core Skills for the Family Physician Michael Tuggy, MD. Objectives. Review the diagnosis and management of common skin lesions seen in everyday practice Review the procedure options Walk through selected procedures you must know how to do well.

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Dermatologic Procedures

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  1. Dermatologic Procedures Core Skills for the Family Physician Michael Tuggy, MD

  2. Objectives • Review the diagnosis and management of common skin lesions seen in everyday practice • Review the procedure options • Walk through selected procedures you must know how to do well.

  3. Common Skin Lesions in Clinic • Nevi – junctional, halo, melanocytic, dermal • Seborrheic keratosis • Actinic keratosis • Basal cell carcinoma • Squamous cell carcinoma • Pre-melanotic lesions • Melanoma

  4. Lesion #1

  5. Diagnosis #1 • Junctional nevus • Features – uniform pigmentation, clear margins, minimally raised • DDx: • Melanoma • Dermatofibroma

  6. Treatment Options • Watch • Punch biopsy • Cosmetic shave removal

  7. Lesion #2

  8. Diagnosis #2 • Dysplastic nevus • Features: variable pigmentation within the lesion, sharp margins, often multiple similar nevi. • DDx: • Melanoma (non-melanocytic)

  9. Treatment Options • Punch biopsy • Excisional biopsy • Then Record (image with photos)

  10. Lesion #3

  11. Diagnosis #3 • Compound nevus • Uniform pigmentation, raised center, sharp margin • DDx: • Seborrheic keratosis

  12. Treatment Options • Watch • Punch biopsy • Cosmetic shave removal

  13. Lesion #4

  14. Diagnosis #4 • Actinic Keratosis • Features – red base, yellow-white scale, dry • DDx: • Squamous cell cancer • Seborrhea • Psoriasis • Bowen’s carcinoma 

  15. Treatment Options • Cryotherapy • Electrosurgical ablation • Shave biopsy or punch biopsy

  16. Lesion #5

  17. Diagnosis #5 • Seborrheic Keratosis • Features – waxy, raised verrucous papules • DDx: • Melanoma (again!)

  18. Treatment Options • Cryotherapy • Electrosurgical ablation • Shave biopsy or punch biopsy • Cosmetic shave removal

  19. Lesion #6

  20. Diagnosis #6 • Basal Cell Carcinoma • Features: telangiectasia, raised, pearly borders, fleshy-red color • DDx: • Amelanocytic melanoma • Trichoepithelioma • Papillary adenomatosis

  21. Treatment Options • Curettage and cautery • Shave biopsy then ablation above • Excisional biopsy with 2-4 mm margin • Recurrance – 5-15% depending on size.

  22. Lesion #7

  23. Diagnosis #7 • Squamous cell cancer • Features – central ulcer or scale, raised border • DDx: • Keratoacanthoma • BCC • Superficial spreading melanoma

  24. Treatment Options • Excisional biopsy with 4 mm margin (95% cure rate) for lesions < 2 cm. • Larger margins for lesion > 2 cm. • XRT for recurrent or invasive lesions

  25. Lesion #8

  26. Diagnosis #8 • Atypical nevus • Irregular border, variable pigmentation

  27. Treatment Options • Excisional biopsy with 2-3 mm margin

  28. Lesion #10

  29. Diagnosis #10 • Melanoma • Features – irregular dark black/reddish pigmentation, migrating border

  30. Treatment Options • Punch biopsy • Excisional biopsy with wide margin depending on location (5 mm to 1 cm)

  31. Common Mistakes • Anesthesia: • Errors in size and area blocked • Curettage • Inadequate force used to curette lesion • Dull curette • Excisions • Incision size and direction selection • Wrong method for lesion type (i.e. full excision for benign lesions) • Inadequate margins • Not performing biopsy because its not pigmented

  32. Impacting Outcomes • Long term follow up (start at 6 months, follow through 5 years) is key for cancer excisions • Repeat skin exams every 6-12 months for new lesions • It’s OK to re-excise areas if margins are concerning.

  33. Take Home Points • Do careful skin exams • Biopsy more • There is a lot out there that can look like melanoma • You learn by sampling ‘normal’ tissue • Keep mental notes of what you see and the pathology report correlation.

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