Chapter 39

Surgical Office Procedures

Glen Blair

The skin is the largest organ of the human body and the only organ that is nearly completely visible to examination by the naked eye. Cutaneous diseases such as rashes, infections, benign and malignant tumors, and lesions represent a sizeable portion of the skin complaints of patients seen in primary care, yet many providers are not comfortable with diagnosis or treatment of cutaneous disease.¹

Concurrently, multiple forces are at work that will influence the provision of dermatologic care in the future. Demand for dermatology services is predicted to increase but the supply of dermatology providers is predicted to remain low, despite the influx of nonphysician providers.²^,³ The need to restrain the growth of health care spending is likely to place greater pressures on primary care providers to treat common dermatologic issues in the office rather than to refer patients for more expensive specialty services. Providers of primary care services will be challenged to be selective in which patients to refer and which patients to treat. Dermatologists delivering telemedicine can work with primary care providers to determine whether dermatology services are needed or to assist with diagnosis. Education of primary care providers to perform skin biopsies for diagnosis in primary care could conceivably help prioritize requests for high-demand specialty services, especially in the early age of teledermatology.⁴^–⁶

Performance of office-based procedures for the treatment of benign lesions such as warts, skin tags, and irritated seborrheic keratoses is one way to try to meet this challenge while also reducing the cost to the patient. Cryosurgery, electrocautery, curettage, punch biopsy, shave biopsy, and scissor excision are common dermatology office procedures. Primary care providers can safely perform these procedures with proper education and training.

A note on the treatment of benign lesions: Patients may request treatment of benign lesions that are painful or irritating, such as plantar warts, but at times they may seek treatment because they find the lesion unattractive. Although treatment of benign lesions that are causing physical discomfort is usually a covered expense, patients are often distressed to discover that many insurance carriers do not cover dermatology treatment performed for cosmetic concerns.

Cryosurgery

Cryosurgery or cryotherapy is the application of cold, such as nitrogen in its liquid state, to produce therapeutic tissue necrosis. Liquid nitrogen is the most common cryogenic agent because of its low boiling point (−196° C). It is administered with a cryosurgical canister with a spray tip attachment or sometimes manually with a cotton-tipped applicator. Tissue injury results from the direct effects of the freeze on intracellular and extracellular components and from vascular stasis.⁷ Further destruction occurs during the thaw phase. Maximum destruction occurs with repeated freeze-thaw cycles.

Cryosurgery is indicated in the treatment of myriad skin conditions, and its use is ubiquitous in dermatology. In primary care, it is used typically in the destruction of benign lesions that are easily recognizable, such as acrochorda (skin tags), warts, and seborrheic keratosis. It is also used for the treatment of actinic keratosis—gritty, erythematous patches on typically sun-exposed surfaces that are considered precancerous. Cold intolerance, cold urticaria, and cryoglobulinemia are relative contraindications to cryosurgery, as is treatment of digits in patients with a history of Raynaud disease. Patients who are darkly pigmented are at risk for depigmentation resulting from destruction of melanocytes or postinflammatory hyperpigmentation after tissue injury. Alternative treatments should be considered. Use at the vermilion border of the lips, oral commissures, eyebrows, canthi, and nasal ala is avoided because of the risk of scarring.⁷

Freeze time, the duration of cooling, varies from lesion to lesion. For some lesions, complete freezing may take only a few seconds; but for mosaic-type plantar warts, freeze time may be considerably longer. The freeze should spread laterally 2 to 3 mm from the edge of the lesion. For skin tags, flat warts, genital warts, and molluscum contagiosum, one freeze-thaw cycle is generally sufficient. For thicker, more keratotic lesions such as plantar warts and large seborrheic keratosis, two freeze-thaw cycles are recommended.

Patients are counseled to expect some redness and swelling during the healing process. Bullae, sometimes hemorrhagic, can develop; patients should be advised to protect the bullae from trauma until healing is complete, but they can be drained if uncomfortable.⁸ Scarring can occur if damage is sustained in the dermis. Post-treatment care includes keeping the area clean with soap and water and using petrolatum if the patient desires. Unless patients use them routinely and without issue, topical antibiotic ointments such as bacitracin should be avoided owing to the high incidence of contact dermatitis.⁹

Electrocautery

Electrocautery is the delivery of direct current through a heated metal wire to cause local tissue destruction or hemostasis. Small wall-mounted units (hyfrecators) are available that deliver variable amounts of electricity. The electrode used for electrocautery is monopolar, meaning that it has only one tip to make contact with the skin, and no indifferent electrode (ground plate) is required.⁷ Bipolar or biterminal electrodes are used in electrosurgery when deeper levels of tissue destruction are needed; this procedure is not discussed here.

In primary care, electrocautery can be used for the treatment of acrochorda, actinic keratosis, small angiomata, compound nevi, warts, and seborrheic keratoses. There are no absolute contraindications to the use of electrocautery, and it can be used in patients with pacemakers or implantable cardioverter-defibrillators when appropriate precautions are taken (i.e., lower voltage, shorter bursts).

The area to be treated is cleaned with a non–alcohol-based skin cleanser. Alcohol wipes are avoided because of concerns of the alcohol’s igniting on the skin.⁷ One percent or 2% lidocaine, with or without epinephrine, can be used in those cases when significant pain is anticipated. Treatment of small lesions without anesthesia is often preferable to the discomfort of the anesthesia itself. Vascular lesions may become less identifiable because of the vascular effects of the anesthetic agent, so they are best treated without local anesthesia. Electrodesiccation is the direct application of the tip to the skin or lesion surface to deliver the current and is the preferred method for treatment of most lesions. Electrofulguration, the delivery of the current from a small distance above the surface, is used for very small, superficial lesions. Current and power settings are determined by the lesion to be treated and the specifications of the device being used and are influenced by the knowledge that deeper tissue injury results in greater risk of scarring. When it is ready, the tip is passed lightly and repeatedly over the treatment surface until the degree of desired tissue destruction has been achieved.

Electrocautery is an attractive alternative to cryotherapy when pigmentation issues are of concern and is more useful in the treatment of vascular lesions. Complications are rare. In combination with curettage (i.e., electrodesiccation and curettage), it is one of several standard treatment options available for nodular basal cell and invasive squamous cell carcinomas.

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