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.)

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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

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