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Dermatologic Procedures: Pearls and Pitfalls.ppt

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  • 1. Dermatologic Procedures: Pearls and Pitfalls By Daniel J. Ladd, Jr., D.O. Dermatology Resident, KCOM
  • 2. 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
  • 3. BENZACLIN BID for ACNE
    • SAFE
    • EFFECTIVE
    • EASY TO USE
    • ACNE takes 8W
    • Treating ACNE is like brushing TEETH
  • 4. PENLAC QD FOR ONYCHOMYCOSIS
    • SAFE
    • EFFECTIVE
    • EASY TO USE
    • NO DRUG INTERACTION WORRIES
    • NO LFT’S
    • NO CHF WORRIES
  • 5. Common Procedures
    • Shave Biopsy
    • Punch Biopsy
    • Excisional Biopsy
    • Cryosurgery
  • 6. 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.
  • 7. 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.
  • 8. 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
  • 9. 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.
  • 10. 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”
  • 11. 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.
  • 12. 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”.
  • 13. 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.
  • 14. 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.
  • 15. 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.
  • 16. 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.
  • 17. Hemostasis
    • Chemical
    • Electrical
    • Physical
  • 18. Chemical Hemostasis
    • Drysol
    • Aluminum Chloride
    • Quick, easy, cheap.
    • Q-tip application.
    • No odor or discoloration.
    • Good for superficial biopsy - shave.
  • 19. 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.
  • 20. High Frequency Electrosurgery
    • Monoterminal elecrodessication- low levels of current.
    • Risk of Bradycardia or Asystole in patients with Pacemakers or Defibrillators.
    • Requires dry field.
  • 21. Electrocautery
    • Heated metal results in tissue dessication, coagulation and necrosis.
    • Safe to use in patients with pacemakers.
    • Does not require a dry field.
  • 22. Shave Biopsy
    • Sterile #15 blade
    • 4x4’s
    • Drysol solution
    • Sterile Q-tips
    • Path specimen container
  • 23. Shave Biopsy - skin tension
  • 24. Shave Biopsy - flush with surface
  • 25. 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.
  • 26. 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.
  • 27. Punch Biopsy
    • Sterile procedure!
    • Sterile gloves
    • 3 or 4 mm Punch
    • 4x4s, Drysol, Q-tips
    • Needle driver, forceps
    • Suture
    • Path specimen bottle
  • 28. 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.
  • 29. 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.
  • 30. 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
  • 31. 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.
  • 32. 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.
  • 33. 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.
  • 34. 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!
  • 35. Pearl # 10 : Danger Zones
  • 36. 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.
  • 37.  
  • 38.  
  • 39.  
  • 40.  
  • 41.  
  • 42.  
  • 43.  
  • 44.  
  • 45. BENZACLIN BID for ACNE
    • SAFE
    • EFFECTIVE
    • EASY TO USE
    • ACNE takes 8W
    • Treating ACNE is like brushing TEETH
  • 46. PENLAC QD FOR ONYCHOMYCOSIS
    • SAFE
    • EFFECTIVE
    • EASY TO USE
    • NO DRUG INTERACTION WORRIES
    • NO LFT’S
    • NO CHF WORRIES
  • 47. THANKS DERMIK!