Punch, Shave, Excise, Freeze? When to Do What, Where!

Home , Actinic keratosis, Cryosurgery, Dermatofibroma, Keratosis, Scar, Seborrheic keratosis

Punch, Shave, Snip, Excise, Freeze, Desiccate? When and How….to do What, Where!

Ted Rosen, MD Professor of Dermatology Baylor College of Medicine Houston, Texas Conflict of Interest Disclosure: NONE Which procedure is best….

•What’s your goal? •To remove •To destroy •To biopsy Which procedure is best….

•What’s your goal? •To remove: Always send to pathology •To destroy: Blind procedure (no histology) •To biopsy: Adequate width and depth Width Depth Cryosurgery None None Electrodesiccation None None Snip Yes Maybe Shave Yes Maybe Punch Maybe Maybe Excise Optimum Optimum Width Depth Cryosurgery None None Electrodesiccation None None Snip Yes Maybe Shave Yes Maybe Punch Maybe Maybe Excise Optimum Optimum Designed to destroy things Blind procedures: No histological confirmation (unless prior biopsy) Painful, Potential cosmetic abnormality as residual (dyschromia) Particularly difficult in skin of color Cryosurgery and Electrodesiccation

• Real life examples of how a blind procedure can lead to disaster! Repeated Cryosurgery as Warts (Both SCCA) Repeated Cryosurgery as Wart (Both Melanoma) Width Depth Cryosurgery None None Electrodesiccation None None Snip Yes Maybe Shave Yes Maybe Punch Maybe Maybe Excise Optimum Optimum Designed to remove things, completely or partially Histological confirmation, but may be insufficient Painful, Potential cosmetic abnormality as residual (depression) Less difficult in skin of color Snip or Shave May Be Insufficient Snip or Shave May Be Insufficient

Cutaneous horn may be sign of seborrheic keratosis or wart AND actinic keratosis and squamous cell carcinoma NEED DEPTH to discern nature of underlying pathology Width Depth Cryosurgery None None Electrodesiccation None None Snip Yes Maybe Shave Yes Maybe Punch Maybe Maybe Excise Optimum Optimum Designed to sample (biopsy) or remove things Histological confirmation, occasional sample error with punch Painful, Potential cosmetic abnormality as residual (depression) Best in skin of color Punch Biopsy: Sampling Error Width and Depth

Lentigo Atypical lentiginous proliferation Lentigo maligna melanoma Cryosurgery

• Almost always done with liquid nitrogen (about -196oF) • Almost always done with hand-held sealed canister (vrs Q-tip) • Warts • Seborrheic keratoses • Actinic keratosis • Adjunct with: keloids, dermatofibroma

Cryosurgery for Actinic Keratoses

Medically appropriate? Risks: Pain, AEs • Spray until lesion solid white • Continuous (wider) vrs Intermittent (deeper) spray • Should take ~20-30 seconds to thaw • How long to freeze? (EU: 20-40sec; USA much less) • Thick lesions: 2 freeze-thaw cycles Cryosurgery

• ADVANTAGES • DISADVANTAGES • Rapid • “Blind” procedure • Inexpensive • Pain and blistering • Prolonged healing time • Easy to learn and perform • Wound care may be required • No local anesthesia • Dyschromia • “Good” cosmesis • Atrophic scar formation • Scar improves with time Cryosurgery “Checkerboard” Cryosurgery Blistering Cryosurgery Dyschromia Hemostatic Cryosurgery

Immerse hemostat or needle holder Grasp skin tag (filiform wart) x 10-20 seconds Electrodesiccation

• Electric current dehydrates tissue • May use thick or very thin needle • Small facial lesions: syringoma, DPN, sebaceous hyperplasia, spider/cherry angioma, telangiectasia, venous lake • Small flat or filiform warts, Skin tags • Use with curettage: Seborrheic keratosis (before), NMSC (after) Electrodesiccation

• ADVANTAGES • DISADVANTAGES • Rapid and Inexpensive • “Blind” procedure • Easy to learn and perform • Pain and crusting • Long healing time occasional • Inherent hemostasis • ?Problematic with pacemaker • Local anesthesia optional • Dyschromia potential • “Good” cosmesis • Atrophic scar formation • Scar improves with time Examples of Electrodesiccation

Seborrheic keratosis

Facial warts Then removal of charred lesion by curettage Examples of Electrodesiccation

Venous Lake Cherry Angioma Pacemaker

Thermal Cautery “Snip” Biopsy

Useful for exophytic lesions, especially if on a stalk Skin tags, filiform warts, some bulky nevi Snip: Skin Tags!

“Snip” Removal

• ADVANTAGES • Rapid and Inexpensive • Easy to learn and perform • DISADVANTAGES • Local anesthesia optional • Need for hemostasis afterward (Recommended) • May miss diagnostic base of • Specimen available for the lesion histologic examination • “Good” cosmesis Shave Biopsy

Useful for exophytic lesions, especially if on a stalk Skin tags, filiform warts, bulky nevi (removal) Sample: almost any lesion with thickness

Shave Removal

• DISADVANTAGES • ADVANTAGES • Need for local anesthesia • Rapid and Inexpensive • Need for hemostasis afterward • Easy to learn and perform • May miss diagnostic base of • Specimen available for the lesion histologic examination • May be unable to judge depth • “Good” cosmesis or thickness of lesion** Snip or Shave May Be Insufficient Need to Obtain Depth for Diagnosis Use Shaving Blade, Bent, to “Scoop” Shave “DermaBlade” Where a Shave Biopsy is NOT Optimum

Nodular Melanoma Intradermal Injection

x x x x x Ring Block Anesthesia

• TIPS TO REDUCE PAIN • Small bore needle (30g) • Inject slowly • Warm local anesthetic to near skin temperature • Buffer with 8.4% sodium bicarbonate (9:1 ratio) • This reduces shelf life • Ann Emerg Med 21:16, 1992 Ann Emerg Med 26:121, 1995 Anesthesia • TOXICITY • Rare with small procedures • Most common: vaso-vagal rxn (diaphoresis, bradycardia) • CNS (accidental intravascular) • Metallic taste, tinnitus, confusion • Systemic vasoconstriction: BP • Excess local vasoconstriction • Warm area • Arrhythmia • Allergic rxn: diphenhydramine and/or steroids Milia (Tiny Cysts) Milia: Removal

Punch Biopsy (Excision)

May obtain hemostasis: Pressure Drysol Monsel’s solution Suture (Punch > 3mm) • Use 6-0 Nylon • 1 suture 3mm • 2 sutures 4mm Pinching stops bleeding! Punch Biopsy: Size Varies Larger size: Wider and Deeper Specimen

3.5mm 4mm

3mm 4.5mm

2mm 5mm

1mm 10mm Punch Biopsy: Size Varies But….Larger size: Harder to create elipse Left with circle to close!

3.5mm 4mm

3mm 4.5mm

2mm 5mm

1mm 10mm Post-Biopsy Instructions

• Place Bandaid + Ointment • Vaseline is likely sufficient • Antibiotic ointment: OTC sufficient (Ear, Nose, Mouth, Eye) • Bacitracin®, Polysporin® • Avoid Neosporin® (neomycin sensitivity) • Latex-free bandaid available • Wear bandage for first 24-48 hours • Replace with new cover + ointment daily for one week • Report: bleeding, pain, swelling, pus • Then may wash with soap and water, but clean gently BID • RTC as appropriate for suture removal Punch Biopsy or Removal

• DISADVANTAGES • ADVANTAGES • Need for local anesthesia • Rapid and Inexpensive • Need for hemostasis afterward • Easy to learn and perform • May miss diagnostic base of • Specimen available for the lesion unless punch to hilt histologic examination • Risk of hemorrhage, infection • “Good” cosmesis • Risk of scar formation Punch Biopsy: WHERE? Where to Perform the Biopsy

• Tumor: thickest or most atypical appearing area of lesion • Annular patch or plaque: active or advancing edge of lesion • Blister: blister and rim of normal skin • Vasculitis: newest lesion • Other plaque lesions: older or most representative portion • Everything else: right from middle! A

C ANOTHER GOOD OPTION

C Where Would You Biopsy? A B

C What’s The Problem With This Biopsy? What’s The Problem With This Biopsy? What’s The Problem With This Biopsy?

Bisect biopsy! All “cuts” will be parallel to your bisection What’s The Problem With This Biopsy?

Bisect biopsy! All “cuts” will be parallel to your bisection A

C A B

C Additional Considerations

• Multiple biopsies? (multiple morphologies) • Immunofluorescence needed? • Special media needed for preservation of specimen? (IF, culture) • Special stains required? (ASK for them) • Is a culture being sent as well? You can “split” a specimen (> 4mm)

Multiple Biopsies Reasonable

MULTIPLE MORPHOLOGIES Surgical Excision Relaxed skin tension lines Dimensions

• Length to width ratio: 3:1 to 4:1 • Apical angles = 300 Elliptical Excision (Biopsy)

• ADVANTAGES • DISADVANTAGES • Specimen available for • Requires more skill histologic examination • Need for local anesthesia • May allow total removal in one surgical session • Need for hemostasis before closure is accomplished • Can check for clear margins • Risk of hemorrhage, infection • Facilitates good functional outcome • Risk of scar formation Selection of Procedure: Summary • Cryosurgery or Electrodesiccation • Diagnosis is not in doubt • Superficial destruction is goal • Shave or Snip biopsy • Lesion elevated above skin surface • Punch biopsy • Lesion has depth: dermal, subcutaneous • Need precise depth of lesion • Excisional biopsy • When more than a punch biopsy is needed • Remove lesion entirely • Obtain multiple areas (pathology + nearby)