Skin

1. Skin Tag Removal &
Skin Biopsies

2. Skin Tags
• Usually found on the
neck, chest, back,
armpits, under the
breasts, or in the groin
area
• Usually don't cause any
pain, but they can
become irritated if
anything, such as
clothing or jewelry, rubs
on them
Small flap of tissue that
hangs off the skin by a
connecting stalk

3. Skin Tag Removal
• Cryotherapy often used and effective for treatment of
benign skin lesions use in patients with light skin and
for treatment of lesions in most non–hairbearing areas
of the body
• Electrocautery is an attractive alternative to
cryotherapy when pigmentation issues are of concern
and is more useful in the treatment of vascular lesions.
• Removal with scissors and/or scalpel also an option
(which we will do today)
– Good for pedunculated lesions like skin tags

4. Cryotherapy
• Benign skin lesions that are suitable for freezing include:
actinic keratosis, solar lentigo, seborrheic keratosis, viral wart,
molluscum contagiosum, and dermatofibroma.
• Advantages:
– Requires little time and fits easily into the provider’s office
schedule.
– A short preparation time, low risk of infection, and minimal
wound care.
– Requires no expensive supplies or injectable anesthesia,
and the patient does not have to return for suture removal.
• Skin lesions often can be treated in a single session, although
some require several treatments.

5. • Skin Tag Removal
https://www.youtube.com/watch?feature=player
_embedded&v=lVglXVe-cJI#t=137
• Equipment Needed
– Alcohol prep
– Forceps
– Sterile Scissors and or scalpel
– Hemostatic solutions (eg. aluminum chloride, silver
nitrate sticks)
– Bandaid

6. Benign and Premalignant
Skin Lesions
• Seborrheic keratosis
– Benign warty-appearing growths
• Treat with liquid nitrogen or mechanically remove
• Premalignant actinic keratosis
– Rough or scaly rash may progress in years to
squamous cell carcinoma
– Topical therapy and/or cryosurgery

7. Benign Seborrheic Keratosis
• Benign warty-appearing growths
• Treat with liquid nitrogen or mechanically remove

8. Premalignant Actinic Keratosis
• Rough, scaly patches appearing on
sun-exposed skin.
• Appearing skin-color to red to brown,
AKs represent focal areas of abnormal
keratinocyte proliferation.
• Considered a premalignant condition
with low risk of progression to
squamous cell carcinoma
• Topical therapy and/or cryosurgery

9. Introduction to Biopsies
• Biopsy is appropriate when there is suspicion of neoplasia or for
diagnosing certain skin conditions
• Primary Care practices see increasing numbers of derm patients who
come to them first and may not ever see a dermatologist, even if referred
• If you perform a biopsy, you must be able to:
– establish a differential diagnosis
– be prepared to interpret the pathology report
– be able to recognize whether the pathologic process is consistent with the
clinical presentation,
– be able to arrange for appropriate treatment.
• Otherwise send to specialist and if you suspect a skin cancer you should
always send to Derm
– Teledermatology is coming (federal push) so it is possible PCPs may start
doing more bx with teledermatology consultation

10. Malignant Melanoma

11. Basal Cell Carcinoma
• Nodular BCCs: raised pearly
white, smooth translucent
surface with telangiectasias and
loss of the normal pore pattern;
may be pigmented
or ulcerate.
• Superficial BCCs: red or pink
scaling plaques with a thready
border (slightly raised and
pearly).
• Sclerosing BCC: ivory or colorless,
flat or atrophic, indurated, may
resemble scars.

12. Squamous Cell Carcinoma
• Growing or ulcerated lesion
that does not heal and/or
bleeds easily
• Sun-exposed area or a
mucus membrane
– Common areas:
• lower lip, the nose, the rim of
the ears, and the arms

13. Punch Biopsy
• Performed when knowledge of the depth of
the lesion is required, such as with pigmented
lesions, for which the depth of the lesion is
one of the most important prognostic
indicators of malignant melanoma.
• Punches are also useful when the lesion is
small and can be entirely removed

14. Punch Procedure
• Measure diameter of lesion
– Punch should remove the lesion with at least a 1-cm
margin, as any portion of a lesion that remains as well as
the adjacent skin may contain pathologic changes
• Don gloves and prep area with alcohol wipes
• Anesthetize area
– 1% to 2% lidocaine with or without epinephrine is used
• Set-up sterile field , draping the area intended to be
sampled
• The punch is pushed into the skin as the provider
rotates it between thumb and forefingers.
– The punch is inserted until resistance eases, indicating that
the punch has reached the subcutaneous fat.

15. Punch Procedure
• The punch is pushed into the skin as the provider rotates it
between thumb and forefingers.
• The punch is inserted until resistance eases, indicating that the punch
has reached the subcutaneous fat.
• Place in specimen cup without damaging any tissue
• https://www.youtube.com/watch?v=mPCn_j4PeAU&feature=player_embedded

16. Shave Biopsies
• Used when a full-thickness specimen is not required for
diagnosis.
– includes nonmelanocytic lesions like actinic keratoses,
basal and squamous cell carcinomas, warts, and seborrheic
keratosis.
• Procedure same as punch except shave portion:
– A No. 15 scalpel is selected (razor blades are also used)
– The blade is obliquely pressed through the skin to remove
all or part of the lesion
• If the lesion is small, the lesion can sometimes be removed
entirely.
• Removal of larger lesions through a shave, is likely to leave a
visible scar.
• The goal of a shave biopsy is to produce a saucer-shaped skin
defect that has smooth edges.
• The specimen is removed with forceps and placed into a container
with fixative. Bleeding

17. Shave Biopsy
https://www.youtube.com/watch?v=nbdmmukko4s&feature=player_detailpage