Procedures to Treat Benign Conditions

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33 Procedures to Treat Benign Conditions

Daniel Stulberg, MD, Robert Fawcett, MD, Rebecca Small, MD, and Richard P. Usatine, MD

Many skin tumors and growths are benign and can be diagnosed based on their clinical appearance and history. These lesions can arise from the epidermis, the dermis, or the subcutaneous tissues. This chapter provides a detailed discussion of the most common benign skin lesions and their treatment options. Chapter 12 covered epidermal cysts, lipomas, digital mucous cysts, and hydrocystomas so these will not be covered here.

Acne Surgery

Acne surgery is the name given to the removal of open comedones (blackheads) with a comedone extractor in the clinician’s office. It can also be performed on actinic comedones or senile comedones. It is often performed for cosmetic reasons, but can also decrease pain around a comedone that is under pressure. Large inflammatory nodules and cysts are best treated with intralesional steroids rather than acne surgery (see Chapter 16, Intralesional Injections).

After informed consent, the comedones are cleaned with alcohol. No anesthesia is needed. The comedone is nicked with a No. 11 blade, a sterile needle, or the sharp end of a comedone extractor. Sebum, cells, and other debris are expressed out using pressure from a comedone extractor (Figure 33-1). If a comedone extractor is not available, one can be fashioned from a small paperclip bent to produce a homemade device. Clean the paperclip with an alcohol wipe before using it. Bill using acne surgery CPT code = 10040.

image

FIGURE 33-1 Acne surgery: (A) Pierce the comedone with the sharp side of the comedone extractor. (B) Press the comedone extractor against the skin and until the pilosebaceous material comes out. (C) The comedone extractor can be used multiple times and can be cleaned between uses with a 21-gauge needle.

(Copyright Richard P. Usatine, MD.)

Acrochordons (Skin Tags)

Diagnosis

• Flesh-colored, raised lesions, often pedunculated.
• Common on the neck, axillae, inguinal regions, and under the breasts.
• More common in persons with obesity, diabetes, or impaired glucose tolerance.
• Some persons develop hundreds of skin tags in conjunction with acanthosis nigricans (Figure 33-2).
image

FIGURE 33-2 Multiple skin tags (acrochordons) on the neck of a man with acanthosis nigricans.

(Copyright Richard P. Usatine, MD.)

Treatment

Treatment is done for cosmetic reasons or if the skin tags are getting caught in or irritated by clothing or jewelry.

Snip with Iris Scissors (Figure 33-3)

• Simple and quick with immediate results.
• Use lidocaine with epinephrine if skin tags have a wide base.
• Minimal bleeding for small lesions.
• Direct pressure, aluminum chloride for hemostasis if needed.

 

Cryo Tweezers

• Freeze with Cryo Tweezer down to normal tissue (Figure 33-4).
• Tags will necrose and fall off over 1 to 2 weeks.
• Works better for smaller skin tags and some will not fall off.
• Clean procedure, no bleeding or anesthetic.
• Great for skin tags on eyelids or around the eyes (Figure 33-4).

 

Electrosurgery

• Electrodesiccate to destroy or use radio-frequency (RF) loop to cut through base of lesion.
• Local anesthetic unless very small. Patients report that this hurts more without anesthesia than snipping or freezing.
• Also good for skin tags on eyelids or around the eyes because the electrosurgery minimizes bleeding and avoids the use of caustic hemostatic chemicals near the eye (Figure 33-5).
image

FIGURE 33-3 Snip excision of a pedunculated acrochordon.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-4 Cryosurgery using the Cryo Tweezer on a skin tag located on the eyelid. Grasp the acrochordon and pull the eyelid away from the globe.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-5 Removing a skin tag from the eyelid using an electrosurgical loupe. This requires local anesthetic.

(Copyright Richard P. Usatine, MD.)

Special Considerations/Billing

• Cosmetic and not covered by insurance. Some but not all insurance will cover removal when irritated by clothing or jewelry.
• Treated lesions can recur and new ones will form.
• No need to send for pathology unless diagnosis is uncertain.
• Code 11200 once for the first 1–15 lesions destroyed by any method.
• Code 11201 in addition for each additional 10 lesions beyond 15.

Angiomas/Angiokeratomas/ANGIOFIBROMAS

Diagnosis

Cherry Angiomas

• Red papules that appear with aging.
• Dermoscopy shows red lacunae (see Figure 32-9).
• Found most commonly on the trunk.
• Benign and can be treated if they are bleeding or for cosmetic reasons.
• Shave biopsy if diagnosis is not certain or a malignancy such as angiosarcoma is suspected.

 

Angiokeratomas

• Red to dark red or purple papules that appear with aging.
• Dermoscopy shows red and black lacunae (see Figure 32-10).
• Found most commonly on the scrotum or vulva.
• Benign and can be treated if they are bleeding or for cosmetic reasons.
• Shave biopsy if diagnosis is not certain or a malignancy is suspected.

 

Angiofibromas

• Skin-colored to pink papules found around the nose (Figure 33-6).
• Referred to as adenoma sebaceum when found in clusters around the nose in patients with tuberous sclerosis.
• Shave biopsy if diagnosis is not certain or a malignancy is suspected.
image

FIGURE 33-6 Multiple angiofibromas on the face of a young child.

(Copyright Richard P. Usatine, MD.)

Treatment

The following treatments are used for angiomas, angiokeratomas, or angiofibromas:

Electrodesiccation for Small Lesions

• Low power setting 2 to 3 on Hyfrecator (or similar instrument) without anesthesia. Start at 2 and only increase power if needed.
• Consider using lidocaine and epinephrine for larger angiomas, angiokeratomas in the genital area, or by patient preference (Figure 33-7).

 

Shave Excision with Electrodesiccation of the Base for Larger Lesions

• Start with lidocaine and epinephrine and send specimen for histology if diagnosis is in doubt.

 

Cryosurgery

• An alternative that works best if the vascular lesion is compressed with a probe during the freeze time. Liquid nitrogen spray is not useful for cherry angiomas but may have some benefit for angiofibromas.

 

Lasers

• The 532-, 595-, and 980-nm lasers and intense pulsed light (IPL) devices used for treatment of red vascular ectasias are effective for angiomas (see Chapter 27, Photorejuvenation with Lasers).1
• Angiomas will darken, turning blue or black in color after a single treatment, and then regress, fading to the background skin color.
image

FIGURE 33-7 Multiple angiokeratomas on the scrotum. The patient requested removal, so after obtaining consent, lidocaine with epinephrine was injected for local anesthesia. The Hyfrecator was used to electrocoagulate the angiokeratomas.

(Copyright Richard P. Usatine, MD.)

Chondrodermatitis Nodularis Helicis

Diagnosis

• Skin-colored or erythematous firm nodule of the helix of the ear (Figure 33-8).
• Frequent shallow central scale or crust.
• Usually very tender to palpation or when trying to sleep on the affected ear.
• More common in men, and prevalence increases with age over 40. When women get this, the nodule may be on the antihelix.
• May actually be a SCC so it is best to get a tissue diagnosis with a shave biopsy or elliptical excision.
image

FIGURE 33-8 (A) 1% lidocaine with epinephrine was injected into the helical rim to excise chondrodermatitis nodularis helicis. (B) A 15c blade was used to cut the ellipse. (C) A sharp iris scissor was used to cut off the bottom of the ellipse. (D) A curette was used to curette away the affected cartilage. (E) 5-0 polypropylene was used to close the defect. (F) Three interrupted sutures produced an excellent closure.

(Copyright Richard P. Usatine, MD.)

Treatment

Injection

• Use this treatment method only if you are certain of the diagnosis clinically or by previous biopsy.
• Triamcinolone acetonide 10 to 40 mg/mL injected into lesion can reduce the size and tenderness.
• Injections may be repeated at 2- to 4-week intervals but the overall success rate is low.

Elliptical Excision

• Elliptical excision around the lesion has a high success rate (Figure 33-8).
• Draw the ellipse around the nodule and follow ear anatomy.
• Anesthetize with 1% lidocaine and epinephrine (epinephrine is not contraindicated and helps to produce a visible field).
• Curette the underlying diseased cartilage with a 3-mm curette or snip it off with a sharp scissor.
• Close the defect with a few simple interrupted sutures using 5-0 polypropylene on a small plastics needle (13 to 16 mm).
• Bill for excision of benign growth on the ear based on size.

 

Electrodesiccation and Curettage

• Do a shave biopsy for diagnosis (if not already done).
• Scrape off abnormal tissue with 3-mm curette.
• Use electrodesiccation to destroy any remaining abnormal tissue.
• Repeat for another cycle if needed.
• Cover with petrolatum and let heal by secondary intention.
• The remaining scar may be less cosmetic than the sutured closure done with the ellipse.
• Can only bill for destruction of a benign growth (no more than freezing a seborrheic keratosis).

 

Cryosurgery

• This method can be attempted but is not very effective.

 

Laser

• Ablate with CO2 laser and leave open to granulate in.

Cutaneous Horn

Diagnosis

• Thickened keratin that grows from the skin like an animal’s horn (Figure 33-9).
image

FIGURE 33-9 A cutaneous horn turned out to be a wart when it was biopsied and sent to pathology.

(Copyright Richard P. Usatine, MD.)

Treatment

• Shave off the horn including tissue at the base using a blade (razor or scalpel). Use electrodesiccation or aluminum chloride for hemostasis. Always send for pathology because the underlying lesion may be a skin cancer such as a SCC.
• The thick keratin itself is difficult to cut, but the biopsy should always be below the horn itself.
• Cryosurgery of the base may be performed as a second step if the original shave showed a wart, SK, or AK and some tissue is remaining.

Dermatofibromas

Diagnosis

• Firm nodular thickening of the dermis that may have a hyperpigmented halo (Figure 33-10). It can be hypopigmented, hyperpigmented, or pink.
• Most commonly found on the legs, particularly in women (Figure 33-11). Not unusual to see them on the arms or trunk.
• Displays retraction sign (i.e., Fitzpatrick’s sign). Lesion seems to retract or dimple downward when pinching around lesion (Figure 33-12).
• Dermatofibromas have a specific dermoscopic pattern that helps with the diagnosis (see Chapter 32, Dermoscopy).
• Most often a clinical diagnosis.
image

FIGURE 33-10 Typical dermatofibroma with a hyperpigmented halo and a white and pink scar at the center.

(Copyright Daniel L. Stulberg, MD.)

image

FIGURE 33-11 Large dermatofibroma on the leg that was not dermatofibrosarcoma protuberans.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-12 Positive pinch test showing how the dermatofibroma dimples down when pinched from the sides.

(Copyright Richard P. Usatine, MD.)

Treatment

Discuss with the patient that a dermatofibroma is not dangerous and can be left alone. The scar from treatment may be more unsightly and more uncomfortable than the original DF. If patient insists on treatment the options consist of the following:

• Punch excision if smaller than 6 mm.
• Elliptical excision (full thickness down to SQ fat) for larger lesions (Figure 33-13).
• Always send tissue to confirm diagnosis and rule out a dermatofibrosarcoma protuberans (DFSP) (see Chapter 34, Diagnosis and Treatment of Malignant and Premalignant Lesions).
• A shave biopsy can be combined with cryosurgery, but this is not as effective as a complete full-thickness excision.
• Cryosurgery is less effective than surgery but can shrink the lesion if that is what the patient desires. Using liquid nitrogen (spray or probe), create a 2-mm freeze margin for a 15-second freeze time. Allow to thaw completely and consider a second freeze for another 15 seconds. Regrowth is not uncommon with this method. A closed probe may allow a deeper freeze.
image

FIGURE 33-13 Elliptical excision of a dermatofibroma on the arm.

(Copyright Richard P. Usatine, MD.)

Special Considerations/Billing

• Recurrence is possible.
• Send for pathology if excised.
• Bill for the excision of a benign lesion based on the size of the excision.
• If cryosurgery is used, bill for the destruction of a benign lesion.

Keloids and Hypertrophic Scars

Diagnosis

• Thickened, dense proliferation at site of trauma may be pink, red or brown.
• May itch or be irritated.
• Keloids extend beyond extent of scar site in contrast to hypertrophic scar.
• More common in black skin and other dark skin types.
• More common on ear, midchest, and back.

Treatment

Cryosurgery

• Use a 20- to 30-second freeze with 1-mm freeze margin, then thaw. Repeat one time. In one study this was performed every 20 to 30 days until flattening with a 73% success rate.2
• As an adjunct before intralesional injection, wait 10 to 15 minutes to allow softening of keloids then inject.
• Cryosurgery and intralesional steroids can be combined.
• May cause hypopigmentation in addition to pain.

 

Injection

• Inject triamcinolone acetate 10 to 40 mg/mL infiltrated with a 27-gauge needle into keloids until tissue blanches (Figure 33-14).
• Start at 10 mg/mL and titrate up to 40 mg/mL as needed if no effect and no atrophy.
• Repeat every 2 to 4 weeks until nearly flat.
• May cause telangiectasias and atrophy.

 

Excision of Keloid

• Results in a high rate of recurrence, so this method should not be used as sole therapy.
• After excision, inject with triamcinolone 10 to 40 mg/mL into wound margins at time of surgery and every 2 to 4 weeks for 6 months. Or one reinjection at 4 weeks only.
• Earlobe keloids (Figure 33-15) can be shaved off, injected with triamcinolone and allowed to heal by second intent (Figure 33-16). If possible, have the patient return in 1 month for a second triamcinolone injection to prevent regrowth.
• Large keloids on the ear can be excised and sutured (Figure 33-17).
• After a keloid excision in any location (Figure 33-18), consider injections with triamcinolone to prevent keloids from recurring.

 

Lasers

• Ablative devices, including erbium and CO2 lasers, and nonablative devices, including pulsed dye (585- and 595-nm) and fractional (1550-nm) devices, can reduce the thickness and texture of scars.3
• Nonablative lasers and IPL devices for treatment of red vascular ectasias can reduce the erythema associated with scars.

 

Other Treatments

• Use silicone sheeting or other occlusive dressings for up to 1 year.
image

FIGURE 33-14 Injecting an acne keloid with triamcinolone using a 27-gauge needle.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-15 Keloids formed on both sides of the earlobe secondary to ear piercing.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-16 The front side of an earlobe after a keloid was excised. The base was electrocoagulated and steroid suspension was injected at the base.

(Copyright Richard P. Usatine, MD.)

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FIGURE 33-17 A large keloid developed at the site of an upper ear piercing. This was excised and the helix was sutured with an excellent cosmetic result.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-18 (A) Keloid on the neck. (B) Keloid excised and defect closed with 6-0 Prolene. The incision site was injected with triamcinolone to prevent recurrence.

(Copyright Richard P. Usatine, MD.)

Special Considerations/Billing

• Recurrence and future lesions are common.
• Bill for cryosurgery or intralesional injections based on treatment.
• If excised bill for the excision of a benign lesion.

Lentigines (Solar)

Diagnosis

• Pigmented macules in sun-exposed distribution (Figure 33-19).
• Increased number of melanocytes.
• Single or multiple starting in adulthood and increase with age and sun exposure.
• Do not regress with sun avoidance.
image

FIGURE 33-19 Large solar lentigo on the face of a 54-year-old Hispanic woman.

(Copyright Richard P. Usatine, MD.)

Treatment

• Sunscreen and sun avoidance may decrease occurrence.
• Use makeup to cover lentigines.
• Depigmentation with cryosurgery with short superficial freezing. Warn patients that this may make the solar lentigo darker rather than produce the intended depigmentation.
Lasers and IPL devices used for treatment of benign pigmented lesions are effective for solar lentigines (see Chapter 27).4,5

• In general, devices with shorter wavelengths (e.g., 532- and 755-nm lasers and IPLs with lower cutoff filters) and Q-switched lasers are most effective for lentigines, where melanin is located superficially in the skin.
• Lentigines typically darken immediately after treatment and spontaneously exfoliate over a few weeks.
• One to three treatment sessions are typically needed.
• Topical retinoids may lighten lesions.

• Tretinoin (Retin-A) nightly.
• Adapalene 0.1% to 0.3% gel (Differin) nightly.

• Light chemical peels (see Chapter 22, Chemical Peels).
• Topical skin lightening agents including hydroquinone 4% to 8% (multiple brands and combinations), kojic acid, and peptides (see Chapter 24, Skin Care Products).

Special Considerations/Billing

• Treatment for lentigines is cosmetic, so insurance may not cover.
• Consider lentigo maligna and lentigo maligna melanoma in the differential diagnosis. Use dermoscopy to help with this differential diagnosis and if still uncertain, perform a shave biopsy.

Milia

Diagnosis

• Superficial 1- to 3-mm white keratinized cysts (Figure 33-20).
• Common in the normal newborn, but usually regresses spontaneously.
• May occur later in children and adults where they are more persistent.
• Most common on the face and genital region.
image

FIGURE 33-20 (A) Milia on the lower eyelid. (B) Milium incised with a No. 11 blade. (C) Milia within comedone extractor. (D) Milia removed.

(Copyright Richard P. Usatine, MD.)

Treatment

• Nick top of lesion with a No. 11 blade, sterile needle, or the sharp end of a comedone extractor (Figure 33-20B).
• Express white keratin contents by pressure with comedone extractor or paperclip (Figure 33-20C).
• This is performed without anesthesia to avoid obscuring the milia and because the small cut should be less painful than the anesthetic.
• If this does not work the first time, make a slightly larger incision. Some comedone extractors work better than others depending on the size and location of the milia. It is therefore good to have a few types of comedone extractors in the office.

Special Considerations/Pathology/Billing

• Bill using the CPT code for acne surgery = 10040.

Molluscum Contagiosum

Diagnosis

• Molluscum contagiosum virus infection is seen commonly in children.
• Seen as a sexually transmitted infection in adults.
• Clustered, flesh-colored epidermal papules; dome shaped often with central umbilication.

Treatment

• Spontaneous resolution, but may take months to years.
• Cryosurgery to a 1-mm freeze margin, approximately 5- to 10-second freeze, thaw, and repeat (Figure 33-21).
• Curette the papules off with a skin curette (or scrape with an 18-gauge needle).

• Pretreat with topical anesthetic in children (EMLA or others).
• Any bleeding may be stopped with aluminum chloride.

• Cantharidin (blister beetle extract) topically applied in office once. This method does not hurt when initially applied so it is easier to use for children who are afraid of liquid nitrogen. Apply with the wooden end of a cotton-tipped applicator (CTA). If applied carefully it can be well tolerated and effective.
• Trichloroacetic acid 20% to 30% applied in office once.
• Tretinoin (Retin-A) nightly (off label).
• Imiquimod 5% (Aldara) topically QHS three to four times per week for 2 to 4 weeks (off label). Currently relatively expensive, but less painful than destructive methods, so useful in younger children.
• Electrodesiccation lightly performed, no need to destroy entire lesion. The risk of scarring is probably greatest with electrodesiccation.
image

FIGURE 33-21 Molluscum contagiosum receiving cryosurgery with a bent tip spray.

(Copyright Richard P. Usatine, MD.)

Billing

• 17110 used once for treatment of 1 to 14 lesions.
• 17111 used once for treatment of 15 or more lesions and these codes are mutually exclusive.

Mucocele

Diagnosis

• Bluish to clear or mucosal colored fluid collection, not a true cyst with epithelial lining.
• Most common on inner lower lip (Figure 33-22).
• Mucin collection due to disruption of minor salivary duct.
• Most common in children and young adults.
• Often due to biting inner lip.
image

FIGURE 33-22 Mucocele on the inner lip.

(Copyright Richard P. Usatine, MD.)

Treatment

Cryosurgery

• This is an especially good technique for children old enough to permit this procedure.6
• Freeze the closed probe and then apply to the mucocele with pressure. A second treatment may be needed.
• Alternatively, aspirate the mucin contents and then freeze using CTAs or cryoprobe pressed against the base of the mucocele.

Shave Excision

• If the mucocele protrudes above the lip, a shave excision may be performed (Figure 33-23A). Then the base may be destroyed with cryosurgery or electrosurgery (Figure 33-23B).

Elliptical Excision

• Suture with absorbable suture or silk. Consider using buried absorbable sutures so that the ends of the sutures do not irritate the patient.7 If a deep excision is performed be careful to not cut a labial artery. If so, ligate the artery on both ends.7

image

FIGURE 33-23 (A) Mucocele shaved off with scalpel. (B) Mucocele being frozen with liquid nitrogen spray.

(Copyright Richard P. Usatine, MD.)

Nevi

Diagnosis

The three most common acquired nevi are junctional, compound, and intradermal nevi. Some nevi evolve over time from junctional to compound to intradermal nevi.

Junctional Nevi

• Flat, pigmented brown to black with nevus cells at the dermal epidermal junction.

 

Compound Nevi

• Have nevus cells in the epidermis and dermis.
• Slightly raised and pigmented brown to black.
• Slightly irregular surface.

 

Intradermal Nevi

• Raised, flesh-colored; pink or brown to black.
• Often cerebriform/variegated surface especially on scalp. The nevus cells are in the dermis.

 

Dysplastic Nevi (Atypical Moles)

• Have atypical features similar to an early melanoma clinically and dermoscopically.
• Based on the history and physical exam a biopsy may be needed.

 

There are many other types of nevi including epidermal nevi, speckled nevi, nevus sebaceous, Becker’s nevi, halo nevi, Spitz nevi, nevus depigmentosus, and nevus anemicus. The most important issue is to recognize melanoma and to biopsy any suspicious nevus in a timely fashion. See Chapter 34 for further information on biopsy techniques for lesions suspicious for melanoma.

Treatment

Do not perform cryosurgery or electrodesiccation on nevi—you may be treating a melanoma inadvertently. Also if a nevus that was benign grows back a biopsy may show histology suggestive of a melanoma (pseudomelanoma). Pigmented lesions are best sent for diagnosis to avoid missing a melanoma or other skin cancer.

Shave

• Intradermal nevi are easily shaved flat with the surrounding surface to provide good cosmesis and adequate tissue for diagnosis (Figure 33-24). These may have features suggestive of a BCC such as telangiectasias, so a shave biopsy is a good technique to differentiate between these diagnoses.
• Scalp nevi that appear benign can easily be removed with a shave excision.
• Nevi may recur but if the pathology was normal it need not be removed again unless the patient wants it done for cosmetic reasons.
• Shave biopsy/excision may be performed with electrosurgery using an RF loop electrode (Figure 33-25)

image

FIGURE 33-24 (A) Benign intradermal nevus that looks like a BCC because of its pearly nature and telangiectasias. (B) Intradermal nevus after a simple shave excision.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-25 Excising an intradermal nevus with a radio-frequency loop.

(Copyright Richard P. Usatine, MD.)

• Dysplastic nevi may be removed with a deep shave (also called saucerization). Shave deep enough to remove all pigmentation and a 1- to 2-mm margin. It helps to mark around the pigmented lesion before cutting (Figure 33-26).

 

Punch Excision

• If the nevus is less than 6 mm, it is small enough to be removed completely with a punch excision (Figure 33-27). If greater than 6 mm, an elliptical excision is preferred.
• A full-thickness excision is good for pathology and diagnostic depth if melanoma.
• Use of a VisiPunch allows the surgeon to check for good margins before starting the cutting (Figure 33-28).
• Junctional nevi are flat and if not suspicious for melanoma, these are best left alone. If a patient insists on removal for cosmetic purposes, a punch biopsy will give a good cosmetic result if the nevus is less than 6 mm.

 

Elliptical Excision

• Use for lesions greater than 6 mm when a full thickness excision is preferred.
• Nevi with hair will do better cosmetically with a full-thickness excision because most shave biopsies will not be deep enough to remove the hair follicles.
• A full-thickness excision is good for pathology and diagnostic depth if melanoma.
• Usually heals well with linear scar.
• Takes more time than other techniques.

 

Dysplastic Nevus (Atypical Mole)

• Dysplastic nevi are markers for an increased risk of melanoma and if one is stable and not evolving and not suspicious for melanoma, the doctor and patient may choose to monitor it rather than excise it.
• Dysplastic nevi may be biopsied and excised using a deep shave, a punch, or an elliptical excision.
• Figure 33-29 shows how a dysplastic nevus can be fully removed with a deep shave biopsy.
• If the pathology shows severe dysplasia and the margins were not clear, it is best to go back and excise with clear margins.
image

FIGURE 33-26 Physician has pinched the skin for stabilization before cutting this possible dysplastic nevus off with a shave biopsy to pathology.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-27 Punch biopsy done of a pigmented lesion. Note the elongated ellipse achieved on purpose through pulling this can away from the biopsy site using a perpendicular approach.

(Copyright Daniel L. Stulberg, MD.)

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FIGURE 33-28 Punch biopsy of a dark congenital blue nevus on the dorsum of the hand of an 18-year-old girl. VisiPunch allows the surgeon to check for good visible margins.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-29 (A) 2-mm margins drawn around a dysplastic nevus prior to scoop shave biopsy. (B) Scoop shave being performed. (C) Specimen with adequate margins. (D) There is no remaining pigment at the depth of the shave biopsy.

(Copyright Richard P. Usatine, MD.)

Studies show that 20% to 50% of melanomas appear to arise from a preexisting nevus. The annual risk of an individual nevus transforming into a melanoma is estimated to be only 1 in 200,000.8 The annual risk for an individual dysplastic nevus (DN) is extremely low as well but estimates are higher: 1 in 10,000 may transform into a melanoma in 1 year.9 This raises the question of whether incompletely removed DN should be re-excised with clear margins to prevent potential evolution into melanoma. Although most physicians would agree that DN demonstrating severe dysplasia should be re-excised given the risk of early or evolving melanoma, management of incompletely excised DN demonstrating mild or moderate dysplasia has remained an open question.10

In one study, 271 possible DN were biopsied using the shave technique in 163 (60%), punch technique in 74 (27%), and elliptical excision in 34 (13%).10 The authors found very low (3% to 4%) recurrence rates for both benign nevi and DN after biopsy, regardless of margin involvement, nevus subtype (junctional, compound, intradermal), or the presence of congenital features. The recurrence rates were lower than those seen in previous studies even though the follow-up period was greater than that in most of the other studies.10 A likely explanation is that they performed deeper and broader shave biopsies of clinically atypical nevi, whereas earlier studies primarily examined recurrence of benign nevi removed for cosmetic purposes, where a more superficial shave biopsy may have been done to minimize scarring. Failure of nevi with positive margins to recur suggests that in most cases, residual nevus cells in the biopsy wound are not of sufficient number (or do not have the capacity) for regeneration and pigment production.10

The only statistically significant association found with nevus recurrence was the biopsy method, with the shave technique being significantly associated with recurrence.10 One explanation for a higher recurrence rate with shave biopsies compared with punch biopsies is that nevus recurrence may be more likely to originate from a deep rather than lateral margin—which was observed in most recurrent nevi in this study.10 Another explanation for the association between shave technique and recurrence is that lesions that are shaved tend to be much larger than those selected for punch biopsy. Larger lesions may contain more proliferative cells or be more likely to recur from residual cells for other reasons that are presently unclear.10

Goodson et al.’s results10 are consistent with those of Kmetz et al.,11 who found that no melanomas developed during a 5-year period after biopsy of 55 atypical nevi (26 lesions with at least one positive margin and 29 with clear margins) that were not re-excised.11 Both studies suggest that lesions that demonstrate only mild or moderate dysplasia may not need to be re-excised given their low likelihood of recurrence, and can be followed clinically for evidence of recurrence or development of any concerning features.10,11

Congenital Nevi

Congenital nevi are frequently large and can meet all five ABCDE criteria (see page 434) as a potential melanoma. The clinical diagnosis of congenital nevus is made based on history because they have been present since birth or occurred within the first month or two of birth. Biopsy is indicated if a congenital nevus changes in color, there is a new growth within the nevus, or bleeding without trauma occurs within the nevus. It was long taught that all congenital nevi should be removed because of the potential for malignancy. Large lesions have the greatest potential to become malignant, but they may be so large as to cause major scarring if removed (>20 cm). So, they will need to be watched closely or excised by a plastic surgeon in multiple procedures. With very dark, almost black lesions, early changes will be difficult to detect. The most recent approach recommends following these lesions as with any other nevus and removing them for any observed changes or concerns.

In a prospective study of 230 medium-sized congenital melanocytic nevi (CMN) (1.5 to 19.9 cm) in 227 patients from 1955 to 1996 with average follow-up period being 6.7 years to an average age of 25.5 years, no melanomas occurred in these nevi. The authors concluded that the results of this follow-up study do not support the view that there is a clinically significantly increased risk for malignant melanoma arising in banal-appearing medium-sized CMN or that prophylactic excision of all such lesions is mandatory. Lifelong observation seems a reasonable alternative for medium-sized CMN without unusual features.12 With the affordability of digital cameras, careful lifelong follow-up with photographs should be easy to accomplish.

Bathing Trunk Nevi

Bathing trunk nevi are very large CMN at higher risk of becoming melanoma. According to Habif,13 50% of the melanomas in bathing trunk nevi develop before age 5. There is a risk of neurocutaneous melanoma, which requires an MRI for diagnosis. Melanomas in these large congenital nevi can be missed by observation because they may have nonepidermal origins. In a systematic review, the risk of developing melanoma and the rate of fatal courses were by far highest in CMN ≥40 cm in diameter.14 Although there are no evidence-based data to support this, surgical excision of bathing trunk nevi is recommended by some experts.13 This requires multiple stages and the use of tissue expanders. This is done by plastic surgeons and the financial cost is great. The pain and suffering to the child is substantial and needs to be weighed in the decision of whether or not to recommend surgery.

Spitz Nevus

In 1947, Sophie Spitz described “juvenile melanoma” in which prognosis was frequently excellent. However, Spitz reported one patient with “juvenile melanoma” that had a fatal metastases. Currently there is still a lack of consensus about Spitz nevi but pathologists no longer use the term juvenile melanoma. Some experts recommend that all Spitz tumors be completely excised with clear margins.15 Atypical Spitz nevi should be excised with wider margins up to 1 cm.15 All patients with a history of a Spitz nevus should be carefully monitored by regular examinations for recurrence and metastasis. See Chapter 32 for dermoscopic features of the Spitz nevus.

Neurofibromas

Diagnosis

• Neurofibromas are soft fleshy papules that can feel like pushing tissue through a buttonhole when compressed downward.
• Persons without neurofibromatosis can have a few isolated neurofibromas.
• Neurofibromatosis type 1 (NF1) is associated with multiple neurofibromas.

 

Diagnosis of NF1 is made if an individual has two or more of the seven National Institutes of Health criteria present:

1. Multiple café au lait macules (6 or more)
2. Axillary or inguinal freckling
3. Multiple neurofibromas
4. Characteristic skeletal disorders
5. Family history of NF1
6. Iris hamartomas (Lisch nodules)
7. Optic gliomas.

Treatment

• Individual lesions can be removed if desired by the patient.
• Elliptical incision around the lesion is not usually necessary.
• Shave across the base with razor, scalpel, or electrosurgical cutting electrode (Figure 33-30A).
• Often the underlying tissue will elevate above the skin surface (pouch out).
• Cut the remaining tissue flat with the surrounding skin using a forceps to stabilize it and cut with a blade or scissors (Figure 33-30B).
• If the defect is small and flat, allow it to heal by second intention. Otherwise suture the defect with a single-layer closure. Use deep sutures only if there is tension.
• Convert to an ellipse if there are standing cones (dog ears) (see Chapter 11, The Elliptical Excision).
image

FIGURE 33-30 (A) Shave excision of a neurofibroma revealed an outpouching of soft tissue. (B) The remainder of the neurofibroma was excised with a sharp iris scissor.

(Copyright Daniel L. Stulberg, MD.)

Pilomatricoma

Diagnosis

• Dermal or subcutaneous nodule containing calcium (also known as calcifying epithelioma of Malherbe) (Figure 33-31).
• Usually found on the head, neck or upper extremities.
• Firm to palpation.
image

FIGURE 33-31 Pilomatricoma on the left arm of a 17-year-old girl. (A) The nodule is tender and she requests it to be resected. (B) After elliptical excision the pilomatricoma was analyzed by cutting the specimen in half. Note the white calcium granules within the tissue.

(Copyright Richard P. Usatine, MD.)

Treatment

• Elliptical excision is the treatment of choice (Figure 33-31).

Pyogenic Granuloma (Lobular Capillary Hemangioma)

Diagnosis

• Glistening, friable, easily bleeding vascular tissue often with a narrowed base (Figures 33-32 and Figure 14-19 in Chapter 14, Electrosurgery).
• Initial rapid growth and failure to heal.
• Often at site of trauma or irritation.
• Common on extremities, especially fingers.
• May occur as an umbilical granuloma of the newborn or on gums of pregnant woman.
image

FIGURE 33-32 Shave excision of a pyogenic granuloma using a DermaBlade. The base was then curetted and electrodesiccated.

(Copyright Richard P. Usatine, MD.)

In a randomized controlled trial that compared cryotherapy with liquid nitrogen versus curettage and electrodesiccation of patients with pyogenic granuloma, the curettage and electrodesiccation had the advantage of requiring fewer treatment sessions to achieve resolution and better cosmetic results.16 Treatment of the pyogenic granulomas resulted in complete resolution of all lesions after one to three sessions (mean 1.42) in the cryosurgery group and after one to two sessions (mean 1.03) in the curettage group (P < 0.001). Twenty-three patients (57.5%) in the cryotherapy group and 25 patients (69%) in the curettage group had no scar or pigmentation abnormality. From this study and personal experience, we conclude that curettage and electrodesiccation is the preferred treatment option over cryosurgery.

Treatment

Shave, Curettage, and Electrodesiccation

• Use lidocaine with epinephrine and wait at least 10 minutes for the epinephrine to work. Shave off the abnormal tissue and send this for pathology. This can be done with a razor blade, scalpel, or electrosurgical loop (Figure 33-32).
• Curette the base and use electrodesiccation to stop the bleeding (Figure 14-19 in Chapter 14). The curettage and desiccation may need to be repeated until all abnormal tissue is destroyed. If not, these have a tendency to recur.

 

Elliptical Excision

• Pyogenic granulomas (PGs) on the lips or face may not be adequately treated by the above method and the scarring may be unacceptable. Another option is to elliptically excise the PG. Figure 33-33 shows how the PG on the lip is excised with the ellipse running vertically for the best cosmetic result.

 

Cryosurgery

• Children may be afraid of needles and may not allow one to anesthetize the skin to cut off their PG. In Figure 15-26 of Chapter 15, Cryosurgery, a young child has a PG on the face and allowed the physician to use a Cryo Tweezer to treat her. While it is best to obtain tissue for pathology in most cases, it is safe to treat a benign-appearing PG in a child with cryotherapy.

 

Silver Nitrate

• Silver nitrate may be used to treat umbilical granulomas. Be careful, however, because excessive application of silver nitrate can burn and/or tattoo the surrounding skin of an infant.17
image

FIGURE 33-33 (A) Suspected pyogenic granuloma on the lip. (B) Pyogenic granuloma excised elliptically with direction of the ellipse being perpendicular to the vermilion border. The swelling is secondary to the anesthesia and the cosmetic result looked great the following week.

(Copyright Richard P. Usatine, MD.)

Special Considerations/Billing

• Differential diagnosis includes amelanotic melanoma, so send tissue for pathology.
• Bill for a skin neoplasm (ICD-9 238.2) because the diagnosis is not completely certain until the pathologist reviews the slides.
• Recurrence is common so aggressive removal is prudent.

Sebaceous Hyperplasia

Diagnosis

• Flesh-colored to slightly pale papular clusters of enlarged sebaceous glands (Figure 33-34).
• Usually multiple lesions on forehead and face help to differentiate them from BCC.
• Often doughnut shaped without ulceration or bleeding.
• Telangiectasias may be present but tend to be symmetrically aligned around the doughnut like the jewels in a crown (see page 394).
image

FIGURE 33-34 Blunt electrode about to electrodesiccate sebaceous hyperplasia.

(Copyright Richard P. Usatine, MD.)

Treatment

Electrodesiccation

• This is done without anesthesia using low settings as for cherry angiomas and telangiectasias (Hyfrecator 2 to 3 joules). Start at 2 and only increase power if needed.
• Lightly electrodesiccate the rim of abnormal tissue around the central pore. Using the blunt electrode can be easier than using the sharp-tipped electrode (Figure 33-34).
• Results can be seen immediately and within 1 month (Figure 33-35).
• Many lesions (especially larger lesions) will need retreatment after 1 to 2 months.
• Consider local anesthesia if lesions are large or if patients request it. Use a surgical marker before administering the anesthesia because the sebaceous hyperplasia may be hard to see afterward.

 

Shave Excision

• If the diagnosis is not clear and a BCC is in the differential diagnosis, a shave biopsy is a good method medically and cosmetically. Do not forget to mark the lesion with a surgical marker before administering the anesthesia.
• For sebaceous hyperplasia that has not cleared with electrosurgery, shave excisions can provide long-lasting results. The most common complication of this method is to leave a divot at the site of removal so care is needed to not shave too deeply.

 

Lasers

• Ablative lasers (e.g., 2940 nm and CO2) can be used.18,19 Certain ablative devices have microtips used for precision ablation, which is very effective for these types of small lesions.20
• Nonablative 1450-nm diode lasers can also be used.22
• A series of four to six treatments is usually necessary with nonablative lasers, whereas ablative lasers require only one or two treatments.
• Photodynamic therapy utilizes topical photosensitizing medication activated by light (lasers, LEDs, and IPL devices).21
image

FIGURE 33-35 (A) Sebaceous hyperplasia prior to electrosurgical treatment. (B) Clearance of sebaceous hyperplasia after treatment.

(Copyright Daniel L. Stulberg, MD.)

Special Considerations/Billing

• Often appears similar to BCC; if any question, perform the shave and send to pathology. Code these as skin neoplasms ICD-9 238.2.
• May leave depressed area/scar that over time will usually partially fill in, but may not.
• Initial diagnostic E&M (evaluation and management) service and shave biopsy if needed to rule out BCC should be covered.
• Electrosurgery or laser for cosmesis is often not covered by insurance.

Seborrheic Keratoses and Dermatosis Papulosa Nigra

Diagnosis

• Benign stuck-on tumors with tan, brown, or black colors
• Dermatosis papulosa nigra (DPN) is a collection of seborrheic keratoses (SKs) found on the cheeks and face—most commonly on the face of women of color and bilaterally distributed (Figure 15-22 in Chapter 15).
• Verrucous or smooth surface, often with keratin pearls (horn cysts, comedo-like openings, and milia cysts) and crevices seen on magnification and dermoscopy (see Chapter 32).
• Sharply demarcated, stuck-on appearance.
• Superficial layers peel away easily, leaving capillary bleeding at base.

Treatment

• No treatment necessary if classic appearance and asymptomatic.
Cryosurgery of SK (Figure 33-36)

image

FIGURE 33-36 Cryosurgery of a seborrheic keratosis using an open spray approach with a bent-tip. The comedo-like openings can be seen.

(Copyright Richard P. Usatine, MD.)

• No anesthesia required.
• Use a 1- to 2-mm freeze margin, 10- to 20-second freeze, thaw; consider repeating.
• May be erythematous for weeks.
• Can cause hypo or hyperpigmentation (especially hypopigmentation in persons of darker color).
• Quick and clean.

Alternative treatment methods that require local anesthesia include the following:

• Shave excision with blade and aluminum chloride or electrosurgery for hemostasis (Figure 33-37). This allows tissue to be sent for pathology if diagnosis is uncertain. Even if a SK is most likely, send for pathology to avoid missing a melanoma.
• Shave excision with electrosurgical loop.
• Curettage followed by electrodesiccation or aluminum chloride for hemostasis (Figure 33-38). It may help to apply the electrodesiccation first because that will make the curettage step easier.
Electrodesiccation with local anesthesia.

• Desiccate the raised tissue.
• Wipe off destroyed tissue with moistened gauze.
• Repeat as needed until lesion is removed and flat skin remains.

• Ablative lasers (e.g., 2940 nm and CO2) can be used.18,19 Certain ablative devices have microtips used for precision ablation, which is very effective for SKs.20
• Nonablative lasers and IPL devices used for treatment of benign pigmented lesions (see Chapter 27) will remove the pigmentation of SKs and DPN but not reduce lesion thickness.
image

FIGURE 33-37 Shave excision of a suspicious looking seborrheic keratosis to send to pathology.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-38 Curettage of a seborrheic keratosis.

(Copyright Richard P. Usatine, MD.)

Special Considerations/Billing

• Consider malignant melanoma in differential diagnosis if atypical appearance.
• Be careful when freezing SKs or DPN on the face of a darkly pigmented person—hypopigmentation can be permanent.
• 17110 used once for treatment of 1–14 lesions.
• 17111 used once for treatment of 15 or more lesions. These codes are mutually exclusive.

Syringomas

Diagnosis

• Benign periorbital adnexal tumors commonly seen on both lateral lower eyelids.
• Diagnosis is clinical based on appearance (Figure 33-39).
• Only of cosmetic concern and not a sign of any underlying illness.
image

FIGURE 33-39 (A) Electrodesiccation of syringomas. (B) Cryosurgery of syringomas.

(Copyright Richard P. Usatine, MD.)

Treatment

Treatment may be reassurance in many patients. If the patient insists on treatment, electrosurgery or laser treatments are most effective.

Electrodesiccation

• Apply a topical anesthetic such as EMLA. Wait for it to take effect.
• Use a Hyfrecator or other electrosurgical device using 2 to 3 W (Figure 33-39A). Use the ball electrode with the Surgitron.
• Deliver short bursts with standard electrodes or an epilation needle.23

 

Laser

• Ablative lasers (e.g., 2940 nm and CO2) can be used.18,19

 

Cryosurgery

• This method can be used to treat syringomas without anesthesia (Figure 33-39B). It is possible that multiple sessions will be needed to produce the desired results.

Telangiectasias and Spider Angiomas

Diagnosis

• Telangiectasias are frequently found on the nose as patients age. Persons with rosacea may have many telangiectasias on the nose and face.

Treatment

Telangiectasias may be treated for cosmetic reasons using electrosurgery or laser treatments.

• Electrodesiccation is performed without anesthesia using a Hyfrecator or other electrosurgical device set at 2 to 3 W (Figure 33-40).
• Short bursts of energy are delivered with a standard electrode or epilation needle. Enough electricity should be delivered to see the vessel blanch, but to avoid leaving a burn on the skin. Epilation needles are inserted into the vessel to avoid skin scarring and provide electrodesiccation to the blood vessel.
• Telangiectasias on the legs do not respond well to electrosurgery and are best treated by lasers or sclerotherapy.
• Spider angiomas are often larger than telangiectasias and have a central feeding vessel. These are seen more commonly in patients with liver disease from viral hepatitis or alcohol addiction. In Figure 33-41 a patient with a spider angioma on the face was treated with cryosurgery using a contact probe to compress the vessel while the liquid nitrogen was used to freeze the probe. Electrosurgery and lasers are options.
• Lasers (e.g., 532, 595, and 980 nm) and IPL devices used for treatment of red vascular ectasias are effective for facial telangiectasias (see Chapter 27).24
image

FIGURE 33-40 Electrosurgery of telangiectasias on the nose using the sharp tip electrode on the Hyfrecator.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-41 (A) Spider angioma on the face. (B) Cryosurgery of this angioma using the closed probe technique.

(Copyright Richard P. Usatine, MD.)

Trichoepithelioma

Diagnosis

• Papular lesions most commonly of the head and upper trunk.
• May be single or multiple and may occur in childhood (Figure 33-42).
• Shave biopsy to confirm suspected diagnosis because a single trichoepithelioma may resemble a BCC.
• Desmoplastic trichoepitheliomas are more aggressive and should be removed with clear margins. Consider Mohs surgery if this is on the face.25
image

FIGURE 33-42 Multiple trichoepitheliomas are seen around the nose of a 9-year-old girl. Treatment was initiated with cryosurgery and tretinoin.

(Copyright Richard P. Usatine, MD.)

Treatment

• Shave excision may be adequate.
• Punch or elliptical excision is an alternative.
• For multiple trichoepitheliomas on the face in children, the treatment choices include cryosurgery along with topical medications (Figure 33-42). Although no clinical trials have been done that could help guide treatment, topical imiquimod and topical tretinoin have been used alone or in combination for treatment.26

Warts, Common

Diagnosis

• Benign human papilloma virus (HPV) infection.
• Most common on extremities.
• Range from flat to dome shaped, smooth or rough surface.

Treatment

Topical Salicylic Acid

• These preparations are up to 75% effective.27
• Topical liquid 17% (Compound W, Duofilm, and others) or wax-based applicator (Wart Stick) applied nightly after soaking the wart in water and debriding loose skin.
• Topical 40% salicylic acid plasters applied before bed.
• May take weeks to months.

Cryosurgery

• Use a 1- to 2-mm freeze margin and a 10- to 20-second total freeze time (may be divided into a freeze-thaw-freeze if patient can’t tolerate one longer freeze).
• Repeat freeze or use longer total freeze time if warts are thick, large, or resistant to previous cryosurgery.
• Pain, erythema, possible blistering, and skin sloughing are expected.
• Damage to underlying tissues may cause hematoma or temporary local nerve damage on occasion.
• Hypopigmentation or hyperpigmentation is possible.
• Scarring is possible, but not common.

 

In-Office Topicals

• Cantharidin may be used as for molluscum (see page 412).
• Trichloroacetic acid 20% to 30% applied weekly after paring the wart down.
• Topical sensitizers can be used. They require inducing immune system sensitization and resultant local reaction before treatment. The dinitrochlorobenzene sensitizer has cure rates from 38% to 80%.27

 

Curettage and Desiccation

• In resistant warts, may curette or dissect out wart and electrodesiccate the base.
• Leaves large initial defect.
• Scarring is the norm.
• Electrodesiccation can aerosolize viral particles.

 

Immunotherapy

• Candida antigen is a useful method to treat recalcitrant warts. A detailed description of how to mix and inject candida antigen is given in Chapter 16, Intralesional Injections (pages 206–207).28

Special Considerations/Billing

• Biopsy if persistent or atypical appearance to rule out malignancy especially if patient is immunocompromised.
• 17110 used once for treatment of 1–14 lesions.
• 17111 used once for treatment of 15 or more lesions. These codes are mutually exclusive.

Warts, Filiform

Diagnosis

• Finger-like projection of warty tissue.
• Common on face.

Treatment

• Due to small base can snip or shave and electrodesiccate the base.
• Electrodesiccation can aerosolize viral particles.
• Cryosurgery with Cryo Tweezers down to normal skin; thaw and repeat.

Billing

• As above for common warts.

Warts, Flat

Diagnosis

• Slightly raised multiple flat flesh-colored lesions, 2 to 4 mm.
• Common on face, extremities of children, and legs (if shaving legs).

Treatment

• Imiquimod (Aldara).
• Tretinoin (Retin-A) nightly.
• Topical 5-fluorouracil (Efudex) in refractory cases in adults.
• Cryosurgery to a 1-mm freeze margin; approximately 5- to 10-second freeze.

• Electrosurgery with light fulguration (use topical anesthetic first).
• Light curettement with a disposable sharp curette is effective and can be performed either without anesthesia or after topical anesthetics have been applied.

Warts, Plantar

Diagnosis

• Warts on the sole of the foot (plantar surface) or palm of the hand.
• Pain with walking or pressure.
• Thickened, slightly raised.
• Differentiate from calluses by alteration of normal skin lines and thrombosed capillaries causing small black dots (Figure 33-43).
image

FIGURE 33-43 Plantar wart on the sole of the foot disrupting skin lines and showing black dots caused by thrombosed capillaries.

(Copyright Richard P. Usatine, MD.)

Treatment

• As above for common warts.
• Swelling of cryosurgery and tissue destruction may cause pain with walking.
• Consider longer trial of topical therapy before more aggressive treatment.

Special Considerations/Billing

• As above for common warts.
• Resistant and recurrent warts may respond to laser treatment.

Warts, Venereal (Condyloma Acuminata)

Diagnosis

• Fleshy, polypoid, or verrucous flesh-colored raised lesions of the genital region and perirectal areas caused by HPV.

Treatment

Imiquimod 5% (Aldara)

• Topically QHS three times per week; wash off after 6 to 10 hours.
• Use up to 16 weeks.

 

Podofilox 0.5% Solution or Gel (Condylox)

• Apply topically BID for 3 days to lesions; repeat weekly for 1 to 4 weeks.
• Gel for perianal lesions.

 

Cryosurgery

• Use a 1- to 2-mm freeze margin for a 5- to 20-second total freeze time (may be divided into a freeze-thaw-freeze if patient can’t tolerate one longer freeze) (Figure 33-44).

 

Excision

• Large lesions can be anesthetized and excised with dissecting scissors or a scalpel with suture repair of any large defect.
• Condyloma can be excised using electrosurgery and a loop electrode (Figure 33-45). See page 170.
• Scarring is possible.

 

Electrodesiccation or Laser

• Electrodesiccation or laser treatment can aerosolize viral particles; use a vacuum filter.
• Use local anesthetic; general if large areas.
• Results are immediate.
• Scarring is possible.
image

FIGURE 33-44 Cryosurgery of condyloma acuminata on the penis.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-45 Electrosurgical removal of condyloma on the penis using radiofrequency and a loop electrode. Note the excellent result on the proximal penile shaft where condyloma were already shaved off with the electrosurgical loop.

(Copyright John L. Pfenninger, MD.)

Special Considerations/Pathology/Billing

• Viral infection is not cleared by removal of the condyloma. Recurrence is always possible.
• Caution to not miss cervical, penile, anal, and vulvar cancer, which is often caused by HPV.
• Caution to not miss syphilitic condyloma lata.
• Use site specific codes to bill for destruction of condyloma. See Table 38-6 on page 469.

Xanthelasma

Diagnosis

• Superficial lipid deposits around the eyes and eyelids (Figure 33-46).
• Pale, raised, rubbery.
• Fifty percent of patients have hyperlipidemia, so evaluate lipid levels and treat as appropriate.
image

FIGURE 33-46 Xanthelasma in a woman with cholesterol over 300.

(Copyright Richard P. Usatine, MD.)

Treatment

• Elliptical excision.
• Cryosurgery or electrosurgical destruction may be attempted.
• Ablative lasers, including erbium and CO2, and pulsed dye lasers (585 and 595 nm).18,29

Less Common Benign Adnexal Tumors

• Eccrine poroma (Figure 33-47).
• Spiradenoma (Figure 33-48).
image

FIGURE 33-47 Eccrine poroma on the abdomen.

(Copyright Richard P. Usatine, MD.)

image

FIGURE 33-48 Spiradenoma on the forehead.

(Copyright Richard P. Usatine, MD.)

These will most likely be diagnosed when an unusual growth is removed and the pathology report comes back with one of these descriptions. Their photos are included in this chapter just as an introduction to their existence. In most cases the definitive treatment involves complete excision with clear margins.

Conclusion

The clinician will see multiple benign skin tumors in practice. It is important to realize that many, once diagnosed, do not require treatment or intervention. If a patient desires to have the lesion removed, there are usually multiple techniques to achieve removal with reasonable cosmetic results. Clinicians should consider their array of instruments, equipment, and their own skills and practice flow to choose the appropriate technique for the individual situation. If the diagnosis is uncertain or malignancy is high in the differential diagnosis, do not hesitate to remove the lesion and send for pathology.

References

1. Goldberg DJ, Marcus J. The use of the frequency-doubled Q-switched Nd:YAG laser in the treatment of small cutaneous vascular lesions. Dermatol Surg. 1996;22:841-844.

2. Rusciani L, Rossi G, Bono R. Use of cryotherapy in the treatment of keloids. J Dermatol Surg Oncol. 1993;19:529-534.

3. Katz TM, Glaich AS, Goldberg LH, Friedman PM. 595-nm long pulsed dye laser and 1450-nm diode laser in combination with intralesional triamcinolone/5-fluorouracil for hypertrophic scarring following a phenol peel. J Am Acad Dermatol. 2010;62:1045-1049.

4. Ross EV, Smirnov M, Pankratov M. Intense pulsed light and laser treatment of facial telangiectasias and dyspigmentation: some theoretical and practical comparisons. Dermatol Surg. 2005;31:1188-1198.

5. Small R. Aesthetic procedures in office practice. Am Fam Physician. 2009;80:1231-1237.

6. Marcushamer M, King DL, Ruano NS. Cryosurgery in the management of mucoceles in children. Pediatr Dent. 1997;19:292-293.

7. Tran TA, Parlette HLIII. Surgical pearl: removal of a large labial mucocele. J Am Acad Dermatol. 1999;40:760-762.

8. Tsao H, Bevona C, Goggins W, Quinn T. The transformation rate of moles (melanocytic nevi) into cutaneous melanoma: a population-based estimate. Arch Dermatol. 2003;139:282-288.

9. Naeyaert JM, Brochez L. Clinical practice. Dysplastic nevi. N Engl J Med. 2003;349:2233-2240.

10. Goodson AG, Florell SR, Boucher KM, Grossman D. Low rates of clinical recurrence after biopsy of benign to moderately dysplastic melanocytic nevi. J Am Acad Dermatol. 2010;62:591-596.

11. Kmetz EC, Sanders H, Fisher G, et al. The role of observation in the management of atypical nevi. South Med J. 2009;102:45-48.

12. Sahin S, Levin L, Kopf AW, et al. Risk of melanoma in medium-sized congenital melanocytic nevi: a follow-up study. J Am Acad Dermatol. 1998;39:428-433.

13. Habif T. Clinical Dermatology, 4th ed. St. Louis: Mosby; 2004.

14. Krengel S, Hauschild A, Schafer T. Melanoma risk in congenital melanocytic naevi: a systematic review. Br J Dermatol. 2006;155:1-8.

15. Situm M, Bolanca Z, Buljan M, et al. Nevus Spitz—everlasting diagnostic difficulties—the review. Coll Antropol. 2008;32(Suppl 2):171-176.

16. Ghodsi SZ, Raziei M, Taheri A, et al. Comparison of cryotherapy and curettage for the treatment of pyogenic granuloma: a randomized trial. Br J Dermatol. 2006;154:671-675.

17. Daniels J, Craig F, Wajed R, Meates M. Umbilical granulomas: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed. 2003;88:F257.

18. Krupashankar DS. Standard guidelines of care: CO2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol. 2008;74(Suppl):S61-S67.

19. Riedel F, Bergler W, Baker-Schreyer A, et al. Controlled cosmetic dermal ablation in the facial region with the erbium:YAG laser. HNO. 1999;47:101-106.

20. Khatri KA. Treatment of cutaneous lesions using a novel 2.94 erbium laser with micron tips. Presented at American Society for Laser Medicine and Surgery, 2009, National Harbor, MD.

21. Richey D, Hopson B. Treatment of sebaceous hyperplasia with photodynamic therapy. Cosm Dermatol. 2004;17:525-529.

22. No D, McClaren M, Chotzen V, Kilmer SL. Sebaceous hyperplasia treated with a 1450-nm diode laser. Dermatol Surg. 2004;30:382-384.

23. Karam P, Benedetto AV. Syringomas: new approach to an old technique. Int J Dermatol. 1996;35:219-220.

24. Goldman MP, Bennett RG. Treatment of telangiectasia: a review. J Am Acad Dermatol. 1987;17:167-182.

25. Mamelak AJ, Goldberg LH, Katz TM, et al. Desmoplastic trichoepithelioma. J Am Acad Dermatol. 2010;62:102-106.

26. Urquhart JL, Weston WL. Treatment of multiple trichoepitheliomas with topical imiquimod and tretinoin. Pediatr Dermatol. 2005;22:67-70.

27. Gibbs S, Harvey I, Sterling JC, Stark R. Local treatments for cutaneous warts. Cochrane Database Syst Rev. 2003;CD001781.

28. Phillips RC, Ruhl TS, Pfenninger JL, Garber MR. Treatment of warts with Candida antigen injection. Arch Dermatol. 2000;136:1274-1275.

29. Karsai S, Czarnecka A, Raulin C. Treatment of xanthelasma palpebrarum using a pulsed dye laser: a prospective clinical trial in 38 cases. Dermatol Surg. 2010;36:610-617.

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