Sample - Common Office Procedures
overview
Learn to perform the top dermatologic office procedures to diagnose and treat numerous skin conditions, featuring detailed instructional videos.
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Introduction
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General Information
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Cryosurgery
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Dermatologic Procedure Videos #9–#14: Cryosurgery
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Dermatologic Procedure Video #18: Incision & Drainage of Cyst-Abscess
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Local Anesthesia
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Biopsy Consideration & Technique
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Surgical Biopsies
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Clinical Problems
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Wart Paring & Freezing
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Dermatologic Procedure Videos #1-#8: Skin Biopsy & Lesion Removals
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Dermatologic Procedure Videos #15–#17: Intralesional Kenalog Injection for Keloids
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Dermatologic Procedure Video #19: Unna Boot Application
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Procedure photos: Additional Dermatologic Procedures
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Introduction
-
General Information
-
Cryosurgery
-
Dermatologic Procedure Videos #9–#14: Cryosurgery
-
Dermatologic Procedure Video #18: Incision & Drainage of Cyst-Abscess
-
Local Anesthesia
-
Biopsy Consideration & Technique
-
Surgical Biopsies
-
Clinical Problems
-
Wart Paring & Freezing
-
Dermatologic Procedure Videos #1-#8: Skin Biopsy & Lesion Removals
-
Dermatologic Procedure Videos #15–#17: Intralesional Kenalog Injection for Keloids
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Dermatologic Procedure Video #19: Unna Boot Application
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Procedure photos: Additional Dermatologic Procedures
Quizzes
Put what you’ve learned to the test – take the quizzes below.
Quick Facts
Common Office Procedures
Local Anesthetics
2 Classes. Amides-Xylocaine (Lidocaine), Bupivacaine (Marcaine) widely used; allergic reactions rare.
Xylocaine- rapid onset of action, shorter duration adequate for most skin procedures.
Marcaine- longer duration, slower onset.
If (?) allergy to local anesthetic do not use; allergy referral
Reducing pain with injection:
1) Reassurance
2) Skin stretched taunt
3) Pressure on skin surface around site
4) 30 gauge needle
5) enter @ 90 degrees
5) Aspirate plunger-avoid intravascular placement
6) Slow injection
7) Superficial placement 1st
8) Allow to “set”. Avoid needle placement in suspected malignancies
Epinephrine use: Avoid if (+) history tachyarrhythmia, vasospastic disease (Raynaud’s). Avoid use distal to wrist, ankle and male genitalia.
Buffering Xylocaine with epinephrine- Mix 10:1 Xylocaine with epi: HCO3— from multi-dose 8.4% vial. (e.g. Add 5 cc HCO3-- to 50 cc multi-dose stock vial of Xylocaine with epi).
Skin Biopsy
Performed for diagnostic or therapeutic reasons.
Two types: Shave & Punch.
Shave- for exophytic lesions
Punch- rashes and endophytic lesions
Pre Procedure Antibiotics
Indications: 1) Prosthetic heart valve 2) Joint replacement in 2 years 3) History of endocarditis 4) Symptomatic valvular heart disease. Also, consider if biopsy lower extremity in elderly, debilitated, or institutionalized patient.
Antibiotic choice: Amoxicillin 2 grams PO 1 hour before. If PCN allergic- Clindamycin 300-600 mg. If in doubt- consult your physician.
Cryosurgery- use of liquid nitrogen (LN2) for selected viral (warts) or precancerous (actinic keratosis). Cry-AC Spray: Use “C” tip. Hold 1-2 cm away. Produce ice ball including 1-2 mm halo. Can use 2.5mm disposable otoscope speculum, trim as needed, place on surface reduce collateral spray.
Cotton tip applicator with added cotton for direct contact for sensitive areas.
Post treatment expectations: Immediate post sting gives way to throbbing then swelling and possible blister formation.
Contraindications:
1) Raynaud’s phenomenon or disease
2) Pyoderma gangrenosum
3) Cold urticaria
4) Cryoglobulinemia or cryofibrinogenemia
5) Cold intolerance
6) Connective Tissue Disease
Wart paring- use topical salicylic acid 18-40% topical @hs until dead white skin noted. Pare away with either surgical #15 blade or use rough file to remove dead skin; reapply salicylic acid, repeat.
Appendix
Pre-Procedure Antibiotic Use
All doses shown below are administered once as a single dose 30-60 min before the procedure.
Standard general prophylaxis
- Amoxicillin
- Adult dose: 2 g PO
- Pediatric dose: 50 mg/kg PO; not to exceed 2 g/dose
Unable to take oral medication
- Ampicillin
- Adult dose: 2 g IV/IM
- Pediatric dose: 50 mg/kg IV/IM; not to exceed 2 g/dose
Allergic to penicillin
- Clindamycin
- Adult dose: 600 mg PO
- Pediatric dose: 20 mg/kg PO; not to exceed 600 mg/dose
Allergic to penicillin
- Cephalexin or other first- or second-generation oral cephalosporin in equivalent dose (do not use cephalosporins in patients with a history of immediate-type hypersensitivity penicillin allergy, such as urticaria, angioedema, anaphylaxis)
- Adult dose: 2 g PO
- Pediatric dose: 50 mg/kg PO; not to exceed 2 g/dose
- Azithromycin or clarithromycin
- Adult dose: 500 mg PO
- Pediatric dose: 15 mg/kg PO; not to exceed 500 mg/dose
Allergic to penicillin and unable to take oral medication
- Clindamycin
- Adult dose: 600 mg IV
- Pediatric dose: 20 mg/kg IV; not to exceed 600 mg/dose
- Cefazolin or ceftriaxone (do not use cephalosporins in patients with a history of immediate-type hypersensitivity penicillin allergy, such as urticaria, angioedema, anaphylaxis)
- Adult dose: 1 g IV/IM
- Pediatric dose: 50 mg/kg IV/IM; not to exceed 1 g/dose
References: Medscape, Antibiotic Prophylactic Regimens for Endocarditis- AMA guidelines, updated May 14, 2013
Wright,T,et al: Antibiotic Prophylaxis in Dermatologic Surgery Advisory Statement 2008 JAAD 59:3;464-473,2008
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