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?