Angioma (Hemangioma)

If the angiomas are small, use a ball electrode to cauterize them lightly. If larger than 2 mm, local anesthesia may be needed. Tissue should be wiped away and the process repeated until no vessel is seen (Fig. 12-1). Focal cryotherapy or sclerotherapy will also work. If the angiomas are large, a superficial shave excision or curettement followed by light cautery of the base works best.

Figure 12-1 A, Hemangioma. B, Cautery of hemangioma. C, Hemangioma after cautery.

Acrochordon (Skin Tag)

Although many physicians prefer to use electrosurgery or cryotherapy to remove acrochordons, the most direct and simple approach is to elevate the tag with pickups and excise it with sharp tissue scissors at the level of the surrounding skin (Fig. 12-2). If it has a broad base, a local anesthetic may be required. Monsel’s solution (ferric subsulfate) or aluminum chloride may be used for hemostasis. It is essential to have good-quality scissors so the lesion is cut, not “pinched.”

Figure 12-2 Acrochordon removal with sharp tissue scissors.

If the tag is small enough, a ball electrode can be used to lightly and quickly cauterize the tag. It is then simply “wiped away,” similar to the treatment of a small angioma (see earlier).

Cryocautery can be effective, but it is difficult to limit the freeze solely to the tag. A unique method with liquid nitrogen is to use the Styrofoam cup method, dipping the flat pickups in the liquid, and then grasping the tag with the cooled metal. The tag usually necroses off. The tag should be frozen twice in the same visit. Special thickened metal forceps are available from Brymill Cryogenic Systems (Ellington, Conn) that stay colder longer and can be used to treat multiple lesions without having to dip into the liquid nitrogen repeatedly (Fig. 12-3).

Figure 12-3 Special cryosurgical forceps (Brymill Cryogenic Systems) with extra mass at tips to allow freezing of multiple lesions before needing recooling. No anesthesia is needed.

Actinic Keratoses

Actinic keratoses (Fig. 12-4) are sun-induced, premalignant lesions. Single lesions can be shaved, cauterized, or, most commonly, treated with cryotherapy. When multiple lesions are present, they can be treated with 5-fluorouracil (5-FU, Efudex), masoprocol (Actinex) cream, imiquimod (Aldara) cream, or photodynamic therapy with δ-aminolevulinic acid (Levulan) in conjunction with light therapy (e.g., blue light, intense pulsed light [IPL]). Lesions that do not resolve require surgical sampling for histology. They are then frequently squamous cell carcinomas (SCCs; see treatment methods, later). The risk that actinic keratoses will progress to SCC is probably less than 1% in early lesions, and as high as 10% to 20% for persistent hypertrophic lesions. The patient should be counseled that both 5-FU and masoprocol cause significant erythema and tenderness in the areas treated. For 5-FU and masoprocol, the medication is applied twice a day for 3 to 4 weeks to the face and three to four times per day on the arms. (See patient education form online at www.expertconsult.com. The manufacturer will also provide a patient education videotape.) Treatment with imiquimod is significantly more expensive, with less efficacy (Table 12-2). Steroid creams may be used to reduce the inflammatory response. Alternatively, daily application of retinoic acid (Retin-A) 0.025% or 0.05% may resolve early lesions and prevent new ones. Protection from the sun is essential.

Figure 12-4 Advanced actinic keratosis of the right cheek.

TABLE 12-2 Comparison of Costs for Topical Treatment of Actinic Keratoses

Basal Cell Carcinoma

Basal cell carcinomas (BCCs) characteristically have small, centrally ulcerated depressions and raised, pearly borders (nodular-cystic type; (Fig. 12-5A and B). However, their actual appearance can vary markedly from the classic description. Sclerosing (or morpheaform; Fig. 12-5C) BCCs may manifest as flat lesions with nondescript borders. Others are nonhealing ulcerations that never do become elevated. Some are pigmented (Fig. 12-5D) and may be confused with seborrheic keratoses (SKs), nevi, or even melanomas. They may appear erythematous and bleed easily, mimicking a pyogenic granuloma. Superficial (Fig. 12-5E) BCCs commonly occur on the back and are flat and scaly. They may look like an SCC, actinic keratoses, eczema, or even tinea. A biopsy should be taken of all nonhealing, changing, or enlarging skin lesions. Once a diagnosis is made, proper treatment can be planned. Chronic sun exposure, chronic irritation, and the human papillomavirus appear to be the most common causative factors.

Figure 12-5 Basal cell carcinoma. A, Nodular; B, nodular ulcerative; C, morpheaform; D, pigmented; E, superficial.

When a biopsy is taken of a suspected BCC, almost any area of the lesion is appropriate for sampling. If the lesion is ulcerated, it is best to sample the nonulcerated portion because the ulcer may show only necrotic changes if enough depth is not included in the sample. Normal skin from the margin is not needed in the specimen.

The treatment of BCCs is rather straightforward. No one dies from BCCs unless there is long-term total neglect, and they almost never metastasize, so failure of treatment will generally lead only to recurrence, which then may need referral or more aggressive treatment. They can be difficult to treat, with higher recurrence rates in the nasolabial folds and the preauricular areas. The inner canthal area can be an especially difficult area to excise and treat because of tear duct involvement. Careful follow-up is needed to detect early recurrences. Any lesion that is less than 5 to 6 mm in any location generally has an excellent response to almost any treatment modality.

There are many approaches to the treatment of BCCs. Radiation therapy is rarely used, but it may be necessary when the lesions are located in areas such as the lid margins, and in large lesions found on elderly patients. It is usually not recommended for sclerotic/morpheaform types, around the tear ducts where there can be scarring, or in young people when there can be long-term sequelae from the radiation.

BCCs usually involve the upper portions of the skin and, again, very rarely metastasize. Deaths are extremely rare and reportable. For the majority of lesions that are smaller than 1 cm, treatment with cautery and curettement (electrodesiccation and curettage [ED&C]) is a rapid and effective solution. Cure rates approach 95% to 98%, and scarring is usually minimal (Figs. 12-6 and 12-7). The technique is as follows:

Figure 12-6 Electrodesiccation and curettage for a basal cell carcinoma. Sequence is repeated a total of three times. A, Dermal curette (available as disposable and reusable). Generally, for cancers, the reusable curettes are used because they are not as sharp and are less likely to penetrate the dermis. B, Lesion is curetted away. This tissue is sent to pathology for histologic diagnosis. C, Cautery of curetted area.

Figure 12-7 A, Basal cell carcinoma of right nose. B, After administration of local anesthetic, the lesion is curetted. C, Cautery of the base with a ball electrode. Repeat curettement and cautery for a total of three times. D, Appearance of wound after completion of treatment.

(Courtesy of The Medical Procedures Center P.C., Midland, Mich.)

Encourage the patient to gently wash the area three or four times a day with soap and water to prevent an eschar from forming. Immediately after washing, have the patient apply an antibiotic ointment to keep the area moist. The ointment can be applied six or eight times a day, not so much to prevent infection but to aid the reepithelialization of the wound. Petroleum jelly may work as well. Allow the wound to be open unless it is under clothing. Cover it at night if necessary to keep it moist.

Lesions in younger patients, larger-sized (>1 cm) lesions, lesions in more aggressive locations (nasolabial folds, preauricular areas, eyelids), sclerosing-type BCC lesions, recurrent lesions, and lesions with ill-defined margins may require complete excision to enable the pathologist to examine the margins. Remove 3 to 4 mm of normal skin around all edges (Table 12-3). Margins can be marked to aid in the histologic evaluation. Some physicians believe that excision is more cosmetically acceptable than cautery and curettement. An advantage of ED&C over cryotherapy is that the necrotic lesion can be “felt” with the curette, so the surgeon knows how far and deep to proceed with the scraping. If properly cared for, most lesions treated with ED&C will only have some mild depigmentation after 4 to 6 months. Although cryotherapy reportedly is very successful, the surgeon cannot often “feel” or see the margins of the tumor. All the various clinical factors should be weighed when selecting the method for lesion removal.

TABLE 12-3 Excisional Margins of Normal Tissue for Various Skin Lesions

Laser therapy can be used to ablate the lesions. Topical 5-FU and imiquimod have been approved to treat superficial BCCs. Cryotherapy has excellent results for lesions less than 1 cm wide. A good freeze 5 mm past the lesion is required, followed by thawing, then a repeat freeze (see Chapter 14, Cryosurgery). It is critical to note the thaw time. Cure rates of 98% are reported (see caveat previously).

Follow-up 3 months after treatment to ensure success of treatment is recommended. The patient must be followed closely because 30% of patients will develop new BCCs somewhere within 3 years (Table 12-4).

TABLE 12-4 Follow-up of Various Skin Cancers after Treatment (Nonmetastatic)

Mohs chemosurgery is not indicated for routine treatment of BCCs. Consider it for recurrent, morpheaform-type, or very large lesions. It may also be used for larger lesions in high-risk sites. The cost does not justify routine use because cure rates are so good with the other methods discussed here.

Squamous Cell Carcinoma

Squamous cell carcinoma (Fig. 12-8) often appears as a diffuse, nonhealing, crusted lesion. It frequently occurs at the base of an actinic keratosis or cutaneous lesion. The lesions may be multifocal in origin and, as with actinic lesions, are due to solar damage. SCCs are more aggressive than BCCs and can metastasize. Because the margins of these lesions are often not very clear, many clinicians prefer to excise all invasive SCCs. If 5-FU (Efudex) or masoprocol (Actinex) creams or cryotherapy are used to treat diffuse actinic changes, any post-treatment residual lesions (after 6 to 8 weeks) should be removed for biopsy to rule out SCC. When a biopsy is performed on a suspected SCC, try to include portions of the central area. A deep punch biopsy into subcutaneous fat is preferred by many pathologists, but a deep saucer-type shave is adequate, with definitive therapy after pathology results. Early or small lesions can be treated with cautery and curettement (see Figs. 12-6 and 12-7) or with cryotherapy, with excellent results (see earlier). If the lesion is excised, remove at least 5 mm of normal tissue to be sure all margins are clear (see Table 12-3).

Figure 12-8 Squamous cell carcinoma.

SCC in situ (Bowen’s disease) is a severely dysplastic lesion that has not yet invaded beyond the epidermis. This lesion should be treated similarly to SCC, although excision is rarely needed.

Lesions (especially the more invasive ones) should be reevaluated in 3 and 6 months to document cure. Evaluation of the lymph nodes draining the area is also prudent (see Table 12-4).

Coding for skin cancer treatment is complicated. The biller must know the size, location, and method of removal to bill correctly.

Condylomata Acuminata

Many therapeutic interventions are available to treat condylomata acuminata. See Chapter 155, Treatment of Noncervical Condylomata Acuminata.

Dermatofibroma

Dermatofibromas (Fig. 12-9) often occur on the anterior surface of the lower leg. The etiology is unknown, but dermatofibromas may represent a fibrous reaction to trauma, viral infection, or insect bites. They are often confused with verrucae or nevi. Dermatofibromas do not progress to cancers, and once the diagnosis of dermatofibroma is confirmed, the physician often can merely observe the lesion. However, until the lesion is sampled, only an educated guess is possible. Many BCCs of the lower extremities mimic dermatofibromas. A rapidly growing lesion could be a dermatofibrosarcoma. Dermatofibromas are generally deep-seated and require excision if complete removal is desired. Cryotherapy can be attempted but dermatofibromas are generally quite cryoresistant. Because the lesions are often on the legs and are cut while shaving, the most judicious approach is to shave the lesion flat, which provides tissue for confirmatory diagnosis and reduces the likelihood of further trauma. A pigmented spot may remain, but at least it will be flat. If final results are not satisfactory, it can still be excised or cryotherapy can then be attempted.

Figure 12-9 Dermatofibroma.

Cutaneous Horn

A cutaneous horn (Fig. 12-10) is a type of actinic keratosis. Use caution to rule out an early SCC at the base. Usually a deep saucer-type shave is performed, followed by cautery. Tissue should be sent to pathology for verification.

Figure 12-10 Cutaneous horn.

Keratoacanthoma

Keratoacanthoma (Fig. 12-11) is a common, “benign” epithelial tumor found in elderly patients. This lesion may have a viral etiology. Keratoacanthoma often is confused with SCC, but it is a distinct entity and often considered an “SCC variant” because it cannot be differentiated histologically from SCC. The history of rapid growth is critical for the pathologist to make the proper diagnosis.

Figure 12-11 A–C, Keratoacanthomas.

The lesion begins as a dome-shaped papule that continues to enlarge rapidly. A fully developed tumor is a round, dome-shaped mass with a central keratin-filled crater often 1 to 2 cm in size. The lesion may stop growing after 6 weeks, and then it may slowly regress over the next 12 months. These lesions often occur on the dorsum of the hands, ears, and neck. Clinically they often appear to be BCCs, but if curettement is attempted they are much more sclerotic and fibrous, unlike the classic BCC.

Because these lesions grow rapidly, most physicians do not advocate simple observation. Cryotherapy (small lesions only), a deep saucer-type shave, ED&C (×3), or conventional excision with 3- to 5-mm free margins provides acceptable treatment. Keratoacanthomas can recur, and patients should be followed closely during and after treatment. The major differential diagnoses for the clinician include BCC and SCC. Because of the rapid growth and high numbers of mitotic cells, even pathologists experience difficulty and often will report that they “cannot rule out SCC” at the base. Subsequently, the therapeutic approach is essentially the same as for an SCC.