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Dermatological Assessment and Procedures
Bucky Boaz, ARNP-C
What is Skin Cancer? Skin cancer happens
when some of the cells of the epidermis begin to grow out of control
Types of Skin Cancer Basal Cell Carcinoma Melanoma Squamous Cell Carcinoma
Basal Cell Carcinoma The cancer that
affects the cells at the lowest level of the epidermis, called the basal cells.
Basal means ‘at the bottom’.
Melanoma The cells affected are
in the melanocytes, the cells between the basal cells.
Melanocytes produce melanin, skin color
Most serious, least common
Squamous Cell Carcinoma The cancer is found
within the layer of flat cells just above the basal cells.
Squamous means ‘like scales’
What Causes Skin Cancer? Most skin cancers are
caused by a particular kind of ray from the sun called ultraviolet radiation (UVR).
This is not the light you can see (visible light).
Not the light you can feel (infra-red radiation).
You cannot see or feel UVR.
Who is at Risk? Increased sun
exposure. Sun burns Age Lots of moles or
freckles Location
How is Skin Cancer Diagnosed? Skin exam Biopsy If concerned about
possible cancer spread: Blood tests X-rays CT scans
Assessing the Skin Normal Mole
Round or oval, and even colored.
Many moles indicate an increased risk of melanoma skin cancer
Assessing the Skin Atypical Mole
Mix of brown, smudged border, and is often bigger than 5mm.
Increased risk of melanoma skin cancer
Assessing the Skin Melanoma:
Most serious Fastest growing US cases have
almost doubled in past two decades
Assessing the Skin
Assessing the Skin
Assessing the Skin Melanoma
Cure Rate Melanoma can spread
to other parts of the body quickly, but when detected in its earliest stages, it can be curable.
If not caught early, it is often fatal.
Assessing the Skin Melanoma
Begins as an uncontrollable growth of pigment-producing cells in the skin.
This growth leads to the formation of dark-pigmented malignant moles or tumors
Assessing the Skin Melanoma
May appear without warning, but may also develop from or near a mole.
Assessing the Skin Melanoma: what to
watch for: Changes in size or color
of a mole Dark or irregular
pigmented growth Scaliness or Oozing Bleeding Change in appearance of
bump or nodule Pigment spread Itchiness, tenderness, or
pain
Assessing the Skin Basal Cell Carcinoma
Small, fleshy bumps or nodules on the head and neck.
Found among fair skin people.
Does not grow quickly, rarely spreads.
Assessing the Skin Squamous Cell
Carcinoma Nodules or red-scaly
patches. Second most common
skin cancer in fair-skinned people.
Rarely found in dark-skinned people.
Can develop into large masses, can spread
Assessing the Skin Actinic Keratosis
Sun-induced skin growths occur on body areas exposed to sun.
Face, hands, V of neck susceptible
Pre-malignant Look for raised,
reddish, rough textured growths.
Mind Your ABCD’s
Asymmetry ColorBorder Diameter
Options for Lesion Removal Cryosurgery Skin Biopsy
Cryosurgery 1st performed in late 19th century Advantages:
Easy to perform Heals quickly Post-op care simple No surgery High risk patients
Cryosurgery Liquid nitrogen most
commonly used cryogen Inexpensive Readily available Boiling point 196°C Stored in insulated
container Refilled regularly
Cryosurgery Techniques Direct cryogen
application Cotton-tipped
applicator 10 second freeze Include small rim of
normal tissue Thaw 20-45 seconds
Cryosurgery Techniques Spray technique
Constant flow of liquid nitrogen onto lesion, rapid freeze.
3 patterns Ever-enlarging circle Side to side Central point
Two freeze-thaw cycles required
Cryosurgery Most common side
effects: Immediate erythema
and edema at treatment site.
Throbbing sensation for several minutes to half an hour.
Healing Pattern Within 24 hrs =
blister. Followed by scab for
2-3 weeks. Postinflammatory
hypopigmentation
Skin Biopsy Snip excision Shave biopsy Punch biopsy Incisional Biopsy Elliptic excision biopsy
Choosing a Technique 1st factor = purpose of procedure 2nd factor = differential diagnosis of the
skin lesion 3rd factor = physical determinants 4th factor = spatial characteristics of the
lesion 5th factor = cosmesis
Snip Excision Easiest technique Ideal for lesions with
pedunculated base Lesion is lifted with
forceps to visualize the base, and the base is transected with sharp iris or gradle scissors.
Snip Excision Lesions such as
acrochordons, filiform verruca, or seborrheic keratosis.
Reasons: cosmesis, itching, irritation, catching on clothing
Shave Biopsy Simple, practical
method of removing a lesion or obtaining a skin biopsy
A blade is used to slice very thin sections of skin
Shave Biopsy Indications
Exophytic lesions Seborrhea keratosis Verruca Skin tags Small nevi
Useless Deep dermis Subcutaneous fat
Shave Biopsy The Procedure
Consent Prep skin Intradermal injection of
local anesthetic Pinch skin to elevate #15 blade cut
longitudinally Swinging motion Aluminum Chloride Antibiotic ointment
Punch Biopsy Uses a punch or
trephine Ideal for histologic
diagnosis Size is important
The Punch Biopsy The Procedure
Circular instrument 2mm to 10mm dia. Anesthesia and prep Stretch skin
perpendicular to natural wrinkle lines
Punch perpendicular and vertical pressure
Gently grasp with forceps
Suture
The Incisional Biopsy Indications
Inflammatory disorders Suspected fungal Suspected bacterial
The Incisional Biopsy Procedure
Anesthesia and prep Incision
perpendicular Counter traction on
skin, full thickness incision
Second cut parallel Elliptical result Suture
The Excisional Biopsy Fusiform or elliptic Procedure of choice
for melanoma Length:width = 3:1 Long axis parallel to
skin tension or wrinkle lines
The Excisional Biopsy Procedure
Mark excision margins Three point traction Begin at one pole Incise vertically, full
thickness, into subQ fat Stay vertical as excision
continues Repeat on opposite side Grasp with forceps and
cut through fat as lifting Electrocautery
Surgical Margins Margins fit lesions Benign lesions = narrow 1-2mm Malignant
Basal cells 3-4mm Squamous cell 5mm Melanoma = narrow margin with axis toward
draining lymph node. If positive, refer to surgeon.
Undermining If edges invert when
pushed together, undermining is necessary
Used to avoid wound tension and dehiscence
Done with blunt scissors Scalp = midfat or
fatgalea junction Face = subq fat Small torso or extremity
= upper subq Large = deep fascia
Danger Zones in Undermining Motor nerves lie superficially
Later zygoma – temporal branch of facial nerve
Posterior triangle of neck Lateral popliteal space
Processing the Biopsy Sample For light microscopy, each specimen
should be placed in a separate bottle of 10% buffered formalin solution.
Specimens smaller than 1cm in 30ml sol. Bacterial of fungal cultures in sterile
container with NS. Viral specimens in viral sol.
Questions?