Neonatal Dermatologic Findings. Common and Usually Benign Dermatologic Findings.
Dermatologic Procedures: Pearls and Pitfalls.ppt
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Transcript of Dermatologic Procedures: Pearls and Pitfalls.ppt
Dermatologic Procedures: Pearls and Pitfalls
By
Daniel J. Ladd, Jr., D.O.
Dermatology Resident, KCOM
Financial Disclosure
• Lecture sponsored by DERMIK
• Very generous considering content of lecture has little or nothing to do with their products.
• BENZACLIN for ACNE
• PENLAC for ONYCHOMYCOSIS
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• SAFE• EFFECTIVE• EASY TO USE• ACNE takes 8W• Treating ACNE is like
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PENLAC QD FOR ONYCHOMYCOSIS
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INTERACTION WORRIES
• NO LFT’S• NO CHF WORRIES
Common Procedures
• Shave Biopsy
• Punch Biopsy
• Excisional Biopsy
• Cryosurgery
Pearl #1
• Pearl: General rule of thumb is to shave a tumor and punch a rash.
• Pitfall: A shave biopsy of a deep melanoma destroys the prognosis/Breslow’s thickness. Result: Now you must assume the worst and put the patient through extensive surgeries and chemotherapy. Moral: Fully excise or refer all suspected melanomas.
Pearl #2
• Pearl: Know where your biopsy is going. Always specify “must be diagnosed by a dermatopathologist”.
• Pitfall: If you do not specify as above it will go to a general pathologist. They may give you less than ideal diagnostic information or even miss the diagnosis. Your patient will not be impressed.
Pearl #3
• Pearl: Communicate with your dermatopathologist; “asymptomatic scaling erythematous annular plaques with central clearing localized to the bilateral shins for 2 weeks, consider tinea vs. granuloma annulare vs. necrobiosis lipoidica” = high yield
• Pitfall: “itchy rash, leg” = low yield
Pearl #4
• Pearl: When the patient asks “what do you think it (the lesion) is?”, the correct answer is “If I knew that I wouldn’t have to do the biopsy”.
• Pitfall: Never attempt to reassure the patient by saying the lesion is “probably going to be nothing at all”, they’ll wonder why you’re putting them through all of this.
Local Anesthesia
• “Doc, will this hurt?”• “I’m not sure, they’ve
only let me try this on animals so far”
• “No, it shouldn’t hurt me a bit”
• “More than a tickle but less than paying taxes”
Local Anesthesia
• Pearl: fears of epinephrine induced necrosis at distal sites (nose, ears, penis, toes, fingertips) are largely unfounded.
• Pitfalls: patients with severe peripheral vascular disease, diabetic angiopathy and Raynaud’s phenomenon may be exceptions to the rule.
Pearl #5
• Local Anesthesia:
• Pearl: INJECT SLOWLY and your patients will love you forever. Decreases pain more than warming or adding bicarbonate.
• Pitfall: ALWAYS make sure they are lying down, especially the patient who “talks tough”.
Pearl #6
• Local Anesthesia
• Pearl: It is OK to give Xylocaine to patients who had allergic reactions to Novocaine at the dentist’s office, Lidocaine is an Amide and Novocaine is an Ester.
• Pitfall: They may not know which medication they reacted to: use Bacteriostatic NS when in doubt.
Pearl #7
• Local Anesthesia
• Pearl: For pediatric patients, let them sit in the lobby with ELA-Max or EMLA covered with Saran Wrap for 30 minutes.
• Pitfall: The above may fail. At this point either refer or insert earplugs and proceed. Remember: very few pediatric rashes will require biopsy for diagnosis.
Pearl #8
• Pearl: Insert needle at a 30 degree angle and slowly retract the needle as you inject the anesthetic. When the tissue blanches you are at the right level.
• Pitfall: If you see a linear trail of blanched skin radiating from the injection site you are probably in a vessel.
Pearl #9
• Regarding Coumadin.
• Pearl: Do not take patients off Coumadin to perform a small dermatologic procedure such as biopsy, excision or Moh’s surgery.
• Pitfalls: Depend on the reason why they are on Coumadin in the first place. Also problematic if you do not have tools for hemostasis.
Hemostasis
• Chemical
• Electrical
• Physical
Chemical Hemostasis
• Drysol• Aluminum Chloride• Quick, easy, cheap.• Q-tip application.• No odor or
discoloration.• Good for superficial
biopsy - shave.
Chemical Hemostasis
• Monsel’s solution.• 20% ferric subsulfate.• Cheap, easy to use.• Risk of tattooing.• Superficial only!• Caustic, may destroy
connective tissue if sutured into wound.
High Frequency Electrosurgery
• Monoterminal elecrodessication- low levels of current.
• Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators.
• Requires dry field.
Electrocautery
• Heated metal results in tissue dessication, coagulation and necrosis.
• Safe to use in patients with pacemakers.
• Does not require a dry field.
Shave Biopsy
• Sterile #15 blade• 4x4’s• Drysol solution• Sterile Q-tips• Path specimen
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Shave Biopsy - skin tension
Shave Biopsy - flush with surface
Shave Biopsy
• Endpoint is “pinpoint bleeding”
• Indicates you are at the level of the papillary dermis
• This is where scarring begins and patient satisfaction decreases.
Shave biopsy
• Pearl: Stay superficial and you can achieve minimal scarring.
• Pink atrophic area has a full year to heal.
• Pitfalls: Skin of upper chest and back scars no matter what. Same with Keloid prone pts.
Punch Biopsy
• Sterile procedure!• Sterile gloves• 3 or 4 mm Punch• 4x4s, Drysol, Q-tips• Needle driver, forceps• Suture• Path specimen bottle
Punch Biopsy
• Twist punch tool until buried to the hub*
• *Caveat: Have a firm grasp of anatomy and skin thickness in the area you are punching before you punch it.
• Finger tendons, facial and neck structures.
Punch Biopsy
• Hemostasis works best in 2 steps.
• First use the Q-tip to buy time to grab needle driver and suture.
• Suture so that closure is low tension - simple palpation reveals.
Punch Biopsy
• Use 6-0 Prolene on the face.
• 4-0 Prolene most other areas.
• Silk for mucosal areas.• 2 simple interrupted
sutures.• Out 7d face, 10d otw
Excisional Biopsy
• Pearl: If you suspect melanoma excisional biopsy DOWN TO FAT.
• Pitfalls: Punch biopsy, while deep enough is NOT representative of the entire lesion. Shave too shallow, prognosis destroyed.
• Pitfalls: Excision takes more time, reimbursement same, but medicolegally still a bargain because it is the standard of care.
Excisional Biopsy
• Using a Sharpie felt tip pen mark a circle around lesion with about 1-2 mm margins around clinically apparent lesion.
• Ellipse should be 3 times longer than circle around lesion.
Excisional Biopsy
• Pearl: Try to postion the final suture line within existing wrinkle lines / least tension.
• Whether lesion is malignant or not, your patient will never forget their scar.
Excisional Biopsy
• Sterile procedure!• H2O2 and Betadine • Pearl: Try not to
apply the above too aggressively or to get excess Xylocaine on your ellipse drawing
• Pitfall: ink will rinse away, now you’re lost!
Pearl # 10 : Danger Zones
Pitfall #10: Facial Nerve Damage
• Temporal branch - forehead and eyebrow ptosis, may obstruct vision.
• Zygomatic branch - impaired blinking, eye dries out, clarity of vision is affected.
• Buccal branch - drooping corner of mouth,
• Marginal Mandibular - lower lip function.
BENZACLIN BID for ACNE
• SAFE• EFFECTIVE• EASY TO USE• ACNE takes 8W• Treating ACNE is like
brushing TEETH
PENLAC QD FOR ONYCHOMYCOSIS
• SAFE • EFFECTIVE• EASY TO USE• NO DRUG
INTERACTION WORRIES
• NO LFT’S• NO CHF WORRIES
THANKS DERMIK!