Basal cell carcinoma

WARTS

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Warts are simple raised lesion on the skin caused by the Human Papilloma Virus.  It is one of the most common sexually transmitted infection.

The different types of warts are:

  • Common wart (verucca vulgaris)
  • Flat warts
  • Palmoplantar warts
  • Anogenital warts (condyloma acuminata)

Presenting symptoms:

  • Generally asymptomatic
  • Pain
  • Itching
  • Skin coloured flat lesions
  • Condyloma acuminata can be raised, exophytic or pedunculated papule or plaque in the anogenital region.

Treatment options:

  • Could resolve spontaneously
  • Cryotherapy
  • Imiquimod
  • Curettage
  • Scissor or shave excision
  • Home therapy with salicylic acid covered by silver duct tape
  • Intralesional Bleomycin

Precautions to be taken before and after treatment

  • Good local hygiene
  • Refrain from high risk sexual behaviour
  • Treatment for the partner with regular follow up with PAP smear

NEVUS(Moles)

A nevus is defined as any pigmented lesion on the surface of the skin.  The pathology leading can range from congenital, developmental, raditation induced, auto immune and viral. Nevus can be of various types as follows:

 

  • Melanocytic nevus: May be present at birth. But generally development. Hormonal causes have been implicated. Sun exposure may also have a role. All nevi should be evaluated for asymmetry, border irregularity, variable color, diameter > 6 mm, evolution, and a family history of melanoma. Benign nevus are generally asymptomatic. Treatment of benign nevus is conservative. The long standing naevus/mole can turn into a basal cell carcinoma (BCC).The atypical ones need evaluation like biopsy.  The dysplastic nevus is treated with a wide local excision.

 

 

  • Halo nevus: It appears like a pigmented centre with a depigmented or hypo-pigmented periphery, giving it a halo like appearance. Halo nevi present as single lesions, but there may be multiple lesions. They can be seen in patients with malignant melanoma, multiple dysplastic nevi, and vitiligo. Therefore, the identification of a halo nevus should prompt a thorough skin examination for these additional lesions.  The are often asymptomatic. Benign looking ones need close observation.  Atypical one require excision.

 

 

 

  • Becker’s melanosis: They are generally seen in adolescent females.  Estrogen has been implicated as a cause for the lesion, and hence, may respond to androgens.   There could be hypertrichosis in the lesions. Treatment is not necessary, as they are benign. However, if bothersome to the patient, waxing, electrolysis, and laser therapy may be used to treat the hypertrichosis.

TATTOO

Tattoo is a mark or a design made on the skin by inserting pigment into the dermis causing dermal pigmentation.  They have been a part of many cultures for centuries and hold a place of importance in many of them.  They are thought to be a form of quest for personal identification.  However, some of the tattoos represent poor decision making and become the bane of the youth as one ages.  Tattoo removal as a procedure has been on the rise in the recent times.

The various methods of tattoo removal can be classified as follows:

  • Mechanical methods
  • Chemical methods
  • Thermal methods
  • Others

Mecahnical methods:

  • Salabrasion : This includes mechanically abrading the superficial skin and dermis using common table salt and moist gauze pad. They are most effective in removing the amateur tattoos. However scarring in a major side effect.
  • Dermabrasion: A rapidly spinning diamond fraise wheel or a wire brush abrades the skin that is usually prepared with a skin refrigerant to produce a hard surface. Traumatic tattoo are superficial and can be removed by this technique in one session.  However, professional tattoos are deeper and may require multiple sessions.  It may have to be combined with a formal surgical removal.  Scarring is a risk involved in this technique as well
  • Surgical removal : This means excision of the skin containing the tattoo pigment followed by suture closure. In areas of skin laxity, the scar may be fine but this may not be the case in areas of tissue tightness.  Tissue expansion may circumvent this problem.
  • Superficail tangential excision with a Brown dermatome: Ideal for small amateur tattoo. Minimal scarring is an advantage of the procedure. 

All mechanical methods lead to some degree of scarring and must be used with caution.

 

Chemical methods:

Chemicals like tannic acid and silver nitrate is applied over the tattoo after breaking the epidermal continuity (French technique).  The chemical forms an eschar and removes the tattoo.  Ideal of amateur tattoo.  Advantage being larger area can be covered. The results and complication risks are comparable to cryotherapy, infrared coagulation, and focal salabrasion. However, the process of removal in time consuming taking upto 2 to 3 weeks to show results. 

 

 

Thermal methods:

Thermal methods involve removal of tattoo using LASER, infrared coagulator etc.  The most common methods are :

  • Q switched LASER: Q-switched ruby (QSR) laser (694 nm); Q-switched Nd:YAG laser (532 and 1064 nm); and the Q-switched alexandrite laser (755 nm). They generally cause fading of the tattoo pigment by causing selective photothermolysis.  A select LASER may be effective only against a particular pigment.  They form the standard of care for LASER therapy in the current scenario.  The advantages is effective removal, minimal scarring and ability to address larger surface area.  Disadvantages are, need for multiple sessions, partial results and cost.  Acute events include purpura, crusting, blistering, infection, and oxidative darkening of pigment may also occur.  They may also cause transient hypo pigmentation of the area.  Hyperpigmentation may also occur in certain individuals. 
  • Carbon dioxide LASER: Non selective laser affecting superficial structures. The advantage of the laser includes high precision and may be effective in areas of the face, lips and eyelids.  However, it is impractical for areas off the face or for large, extensive tattoos, where tattoo pigment deposition is deeper, and risks of postoperative scarring and long-term hypopigmentation are high.
  • Infrared coagulator: It uses a noncoherent, multispectral light source. They are effective in treating amateur superficial tattoos.  Disadvantages include, deep collagen necrosis and scarring.  Due to these reason, they are not popular anymore.

Other methods:

  • Imiquimod creams: They help in fading of tattoos is certain cases.
  • Camouflaging : They are effective in people who want to hide the tattoos for professional reasons and do not wish to get them removed completely. Concealing creams can be used to this effect.