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Moles, Warts and Skin Tags Removal

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2. Punch biopsy: A round "cookie-cutter" knife that obtains tissue specimen. Usually 3 to 5 mm is taken. Usually 1 to 2 sutures are required.

3. Incisional biopsy ("wedge"): An elliptical partial removal of a lesion down to fat. Useful, for example, when a malignancy is too large to remove by simple surgery, in scleroderma, panniculitis, and pyoderma gangrenosum. Requires layered closure with sutures.

4. Excisional biopsy: An elliptical complete removal of lesion down to fat. Useful in completely removing skin cancers. Requires layered closure with sutures.

5. Curettage: For hyperkeratotic lesions (e.g., SK, warts, BCC); often accompanied by cautery.

6. Snip (scissors): Skin tags, filiform warts

RIGHT

WRONG

RIGHT

Relaxed skin tension lines

Margin of normal skin

Relaxed skin tension lines

Margin of normal skin x1

Epidermis Dermis Fat

Epidermis Dermis Fat ffe^H

Examples of excision ellipses on facial crease lines

A biopsy is warranted in:

1. Skin neoplasms.

2. Bullous disorders (with immunofluorescence simultaneously).

3. Autoimmune connective tissue diseases — lupus, dermatomyositis.

4. Skin disorders in which clinical exam is insufficient for diagnosis.

DERMOSCOPY A hand lens with built-in lighting and magnification (10-30X). It allows for the noninvasive inspection of deeper layers of the skin (dermal-epidermal junction and beyond). This is especially useful in distinguishing benign and malignant growth patterns in pigmented lesions.

DIASCOPY A microscope slide or magnifying glass is pressed against lesion.

■ Blanching: Dilated capillaries (erythema)

■ Nonblanching: Extravasated blood (purpura)

■ "Apple-jelly" color (yellow-brown): Granulomas as seen in sarcoidosis, necrobiosis lipoidica, tuberculosis of skin, and granuloma annulare

IMMUNOFLUORESCENCE Tissue is transported in liquid nitrogen or Michel's media (most commonly). 1. Direct immunofluorescence (DIF): A histologic stain for antibodies or other tissue proteins. Useful in bullous pemphigoid, cicatricial pemphigoid, dermatitis herpetiformis, epidermolysis bullosa acquisita, Henoch-Schönlein purpura, herpes gestationis, linear IgA bullous disease, lupus erythematosus, and pemphigus

2. Indirect immunofluorescence (IIF): Examines the presence of circulating autoantibodies in the serum. Can give titers that are useful in pemphigus and other diseases to determine disease activity.

KOH (POTASSIUM HYDROXIDE) Scrape presumed derma-tophyte infection with an alcohol pad or water and scrape with a #15 blade onto a slide. Then apply 2 drops of 10% to 20% KOH on slide to dissolve keratin for fungal elements. Heating accelerates the process. May have to wait several minutes to visualize.

MAGNIFYING LENS Handheld magnifier or dermatoscope, or loupes, provide enhanced morphologic detail; should be carried around at all times.

PATCH TESTING: The test of choice for diagnosing allergic contact dermatitis. Patch test allergens are usually purchased prepared, but can be prepared individually. Allergens are placed in special wells (e.g., Finn chambers®) and applied to the back for 48 hours using Scanpor tape® and then removed; they are interpreted at 48 hours after first application, and then again at 96 hours. Contact hypersensitivity will show as a papular-vesicular reaction.

Finn Chamber Scanpor

A. Patch tests are prepared

B. Patches are affixed to upper back

C. Hypersensitivity is determined

Patch testing methodology

A. Patch tests are prepared

B. Patches are affixed to upper back

C. Hypersensitivity is determined

+/-

= Macular erythema only

+

= Weak reaction: erythema, infiltration, papules (no

vesicles)

+ +

= Strong reaction: edema, vesiculation

+ + +

= Extreme reaction: spreading, bullous, ulcerative

IRR

= Irritant morphologic appearance

-

= Negative reaction

NT

= Not tested

TZANCK SMEAR Quickly diagnoses HSV and VZV (doesn't distinguish between them). Scrape the base of an early blister, air dry or fix with ethanol, stain with Giemsa or Wright's stain. Look for multinucleated giant cells or atypical keratinocytes with large nuclei.

WOOD'S LAMP A 360-nm light source useful in localizing the site of melanin in Caucasian skin, diagnosing infections and porphyria. Specifically, it is useful in diagnosing disorders of pigmentation such as vitiligo; erythrasma; porphyria cutanea tarda; pseudomonas infection of the skin; tinea capitis; and tinea versicolor.

■ Dull yellow: Tinea versicolor

■ Yellow-green: Some Dermatophytes (esp. Microsporum species; audounii, canis, distortum, ferrugineum, gypseum, & T. schonleinii)

■ Coral red: Erythrasma

■ Pale blue-green: Pseudomonas

■ Dark pink urine: Porphyria cutanea tarda

■ Completely white: Vitiligo

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