Chapter 3: Treatment of Lumps and Bumps

Skin tags (fibroepithelial polyps) are very benign tumours, and can safely be left. However, patients often request their removal for cosmetic reasons. There are several ways to remove skin tags. These include:

• simple excision (see also Perianal skin tags for elliptical excision)

• cutting with scissors

• electrocautery (to base); a very effective method

• tying a fine thread around the base

• crushing with bone forceps

• liquid nitrogen therapy.

Liquid nitrogen therapy

1. Use a pair of forceps (dissecting or artery) to grasp the skin tag, preferably on the base or stalk.

2. Holding the skin tag upright and taut, apply a liquid-nitrogen-soaked cotton bud to the forceps close to the tumour (Fig. 3.1).

3. Apply for several seconds to freeze the tumour. It can be left or cut off with scissors.

A variation

The tips of the forceps can be dipped directly into the liquid nitrogen and then clamped onto the base of the skin tag. Multiple tags can be frozen rapidly in this way.

Bone forceps method

A simple procedure is to crush the base of the skin tag flush with the skin using bone forceps (Fig. 3.2a). The advantages are that:

• no local anaesthetic is required

• the procedure is relatively painless

• the procedure is very quick

• immediate haemostasis is achieved (Fig. 3.2b).

There are several methods for removal of epidermoid cysts after infiltration of local anaesthetic over and around the cyst. They are the most common cutaneous cysts, which have a cheesy keratin material (not sebum). They can occur anywhere but most commonly on the face, scalp and trunk. These include the following methods.¹

Incision into cyst

Make an incision into the cyst to bisect it, squeeze the contents out with a gauze swab and then avulse the lining of the cyst with a pair of artery forceps or remove with a small curette.

Punch biopsy method

Use a 5 mm punch biopsy to punch a hole into the apex of the cyst. Squeeze vigorously to express the contents. Look for the cyst wall, grasp it with forceps and carefully enucleate it. A suture is not necessary.

Incision over cyst and blunt dissection

Make a careful skin incision over the cyst, taking care not to puncture its wall. Free the skin carefully from the cyst by blunt dissection. When it is free from adherent subcutaneous tissue, digital pressure will cause the cyst to ‘pop out’.

Standard dissection

Incise a small ellipse of skin to include the central punctum over the cyst (Fig. 3.3a). Apply forceps to this skin to provide traction for dissection of the cyst from the adherent dermis and subcutaneous tissue. Ideally, forceps should be applied at either end. The objective is to avoid rupture of the cyst. Insert curved scissors (e.g. McIndoe’s scissors) and free the cyst by gently opening and closing the blades (Fig. 3.3b). Bleeding is not usually a problem. When the cyst is removed, obliterate the space with subcutaneous absorbable sutures. The skin is sutured with a vertical mattress suture to avoid a tendency to inversion of the skin edges into the slack wound. Send the cyst for histopathology.

Electrocautery method

On the first visit, inject LA into the overlying skin. Insert a heated electrocautery needle in the cyst and cauterise the contents for several seconds (Fig. 3.4).

On the second visit, 7 to 10 days later, inject LA, then make a small incision in the cyst and express the contents.

Treatment of infected cysts

Incise the cyst to drain purulent material. When the inflammation has resolved completely, the cyst should be excised as outlined above.

Simple deroofing method

This method simply unroofs the cyst and allows healing by dressings over an open area. It should be avoided on the face or other areas where a puckered scar is unacceptable. It is very useful for an infected cyst.

Method

1. Infiltrate the skin over the cyst with local anaesthetic.

2. Unroof the cyst by removing a disc of skin with scalpel or scissors. This disc should be slightly smaller than the diameter of the cyst (Fig. 3.5).

3. Evacuate the contents of the cyst and pack with paraffin gauze.

4. Apply pressure if bleeding is a problem.

5. Apply non-adherent dressings daily.

When an infected cyst is encountered, it is appropriate to open it and drain the pus through a cruciate incision or a 4–6 mm punch biopsy (under local anaesthetic). Evacute the contents with sterile gauze and determine if it is possible to avulse the cyst wall. Usually it heals, often definitively, through open healing.

Sebaceous hyperplasia presents as a single or multiple nodules on the face, especially in older persons. The nodules are small, yellow-pink, slightly umbilicated and are found in a similar distribution to basal cell carcinoma, for which they may be mistaken. There is no need for surgical excision.

Subcutaneous dermoid cysts arise from a nest of epidermal cells in the subcutaneous tissues. There are two forms.

Developmental (inclusion) dermoid cyst

The most common is the external angular dermoid, which lies at the junction of the outer and upper margins of the orbit, in the line of fusion of the maxilla and frontal bones (Fig. 3.6). It is usually fluctuant and transilluminable. It should not be treated in the office as an excision of a simple cyst, but referred for expert dissection under general anaesthetic, as it can extend into the cranium. Imaging such as a CT scan or MRI is advisable.

Traumatic (implantation) dermoid cyst

This is a common lesion of the fingers and palms in adults. It is lined by squamous epithelium and contains sebum, degenerate cells, mucus and occasionally hair. It is caused by implantation of epithelial cells from repeated occupational trauma (puncture wounds) and may be seen in tailors, wire workers and hairdressers. It initially presents as a small (< 1 cm) cystic nodular swelling beneath the skin surface, and attached to it, commonly on the finger pulp (Fig. 3.7). There may be an overlying puncture wound or scar. It is often painful and tender and should be removed by a simple incision removal under local anaesthetic (deroof the cyst and enucleate its contents by curette or scraping). If asymptomatic, it can be left.

Acne cysts can be treated by an injection of a long-acting corticosteroid preparation in such a way as to flush out the follicular contents and subdue the sterile inflammation. The treatment is suitable for small numbers of cysts.

Equipment

You will need:

• 25-gauge needles

• small syringe

• 1 mL long-acting corticosteroid (e.g. triamcinalone acetonide, methylprednisolone acetate)

Method

1. Introduce a 25-gauge needle into one side of the cyst and inject a small quantity of steroid. Remove the needle (Fig. 3.8a).

2. Introduce a needle into the opposite side of the cyst. Inject steroid so that material is flushed out through the initial entry point (Fig. 3.8b). This removes the follicular material and leaves residual amounts of steroids in a depot form.

There are various methods for taking biopsies from skin lesions. These include scraping, shaving and punch biopsies, which are useful but not as effective or safe as excisional biopsies.

Shave biopsies

This simple technique is generally used for the tissue diagnosis of premalignant lesions and some malignant tumours, but not melanoma.

Method

1. Infiltrate with LA.

2. Holding a no. 10 or 15 scalpel blade horizontally, shave off the tumour just into the dermis (Fig. 3.9).

3. Diathermy may be required for haemostasis.

The biopsy site usually heals with minimal scarring.

Punch biopsy

This biopsy has considerable use in general practice, where full-thickness skin specimens are required for histological diagnosis. (Good-quality disposable punch biopsies are available from Dermatech.)

Method

1. Clean the skin.

2. Infiltrate with LA.

3. Gently stretch the skin between the finger and thumb to limit rotational movement.

4. Select the punch (4 mm is the most useful size) and hold it vertically to the skin.

5. Rotate (in a clockwise, screwing motion) with firm pressure to cut a plug about 3 mm in depth (Fig. 3.10). Remove the punch.

6. Use fine-toothed forceps or a tissue hook to grip the outer rim of the plug.

7. Exert gentle traction and undercut the base of the plug parallel to the skin surface using fine-pointed scissors or a scalpel.

8. Place the specimen in fixative.

9. Secure haemostasis by firm pressure or by diathermy.

10. Apply a dry dressing or a single suture to the defect.

Ganglions have a high recurrence rate after treatment, with a relapse of 30% after surgery. Most ganglions are around the dorsal area of the wrist and associated with the scapulolunate joint, while about 25% are volar (palmar).

A simple, relatively painless and more effective method is to use intralesional injections of long-acting corticosteroid, such as methylprednisolone acetate.²

Method 1

1. Insert a 19- or 21-gauge needle attached to a 2 mL or 5 mL syringe into the cavity of the ganglion.

2. Aspirate some (not all) of its jelly-like contents, mainly to ensure that the needle is in situ.

3. Keeping the needle exactly in place, swap the syringe for an insulin syringe containing up to 0.5 mL of steroid.

4. Inject 0.25–0.5 mL (Fig. 3.11).

5. Rapidly withdraw the needle, pinch the overlying skin for 1 to 2 minutes and then apply a firm dressing.

6. Review in 7 days and, if still present, repeat the injection using 0.25 mL of steroid.

Up to six injections can be given over a period of time, but 70% of ganglions will disperse with only one or two injections.

Method 2

Insert a larger gauge catgut suture through the middle of the ganglion and firmly tie it over the ganglion. Side pressure may express the contents through the needle holes. Remove the knot 12 days later.

Simple aspiration–injection technique

Chronic recurrent traumatic olecranon or pre-patellar bursitis with a synovial effusion may require surgery, but most cases can resolve with partial aspiration of the fluid and then injection of LA corticosteroid through the same needle.

Lipomas are benign fatty tumours situated in subcutaneous tissue. They are common on the back, but can occur anywhere. Ultrasound imaging is useful for gauging the depth of a lipoma.

Lipomas rarely require removal, but removal may be desired for cosmetic reasons or to relieve discomfort from pressure. Many lipomas can be simply enucleated using a gloved finger, but there are a few traps: some are deeper than anticipated, and some are adjacent to important structures such as large nerves and blood vessels. Others are tethered by fibrous bands, and recurrence can occur if excision is incomplete. Beware of lipomas on the back that can be difficult to remove and in the axilla and supraclavicular areas where they can be misleadingly extensive.

Larger lipomas (> 5 cm) may require referral.

Method

The principle is CUT, SQUEEZE, POP.

1. Outline the extent of the lipoma and mark it with a ballpoint pen. Note its anatomical relationships.

2. Infiltrate the area with 1% lidocaine with adrenaline. (Include the deepest part of the lipoma.)

3. Make a linear incision (Fig. 3.12a) in the overlying skin, preferably in a natural crease line, for about three-quarters of its length. The lipoma should bulge through the wound. For large lipomas, incise an ellipse of skin (Fig. 3.12b).

4. Deepen the incision until the lipoma can be seen.

5. Insert a gloved finger between the skin and fatty tumour to find a plane of dissection and to determine whether it will shell out.

6. It is important to seek the outer edge of each lobule, dissect it and bring it to the wound surface (Fig. 3.12c). If necessary, insert curved scissors and use a blunt opening action to free any fibrous bands tethering the lipoma (Fig. 3.12d).

   Note: The best way to prevent bleeding is not to dissect around the fatty tissue but to incise it, invert the tumour through the wound and then remove it.

7. Ensure that all the fatty tissue is removed. Send it for histological examination. Clipping and ligation of persistent bleeding vessels may be required. Haemostasis should be meticulous.

8. Use a gauze swab to control bleeding and remove debris from the dead space.

9. Close the dead space with interrupted catgut sutures. Consider a small suction drain tube if oozing persists in an extensive dissection area.

10. Close the skin with interrupted or subcuticular sutures.

    Note: A punch biopsy method can be used to remove a lipoma.

Most keratoacanthomas (KAs) occur singly on light-exposed areas. They are regarded as a variant of squamous cell carcinoma and should be treated as such.

Although KAs can be treated by curettage and cautery, the recommended treatment is surgical excision and histological examination. Ensure a 2–3 mm margin for excision. Most patients will not tolerate a tumour on an exposed area such as the face for 6 months while waiting for a spontaneous remission to confirm the clinical diagnosis.

Note: SCCs on the ear metastasise 15 times more rapidly than elsewhere. The relative growth rates of SCC, KAs and basal cell carcinomas (BCCs) are shown in Figure 3.13.

BCCs are the most common type of skin cancer. They can occur on any part of the body, but the most common site is on the face, especially next to the eyes or nose. It is useful to think of it as the area covered by an eye mask (Fig. 3.14). Another common area is the neck, and the upper back and chest are becoming more common sites.

Increased risk occurs with:

• age over 50 years

• exposure to excessive sunlight

• fair complexion

• lack of sun protection.

Treatment guidelines

• Surgery is the primary treatment: use a simple ellipse (where possible) under local anaesthetic with a 3 mm margin (in most cases).

• Cryotherapy is suitable for primary, well-defined, histologically confirmed superficial tumours, at sites away from the head and neck. Contraindicated for morphoeic or ill-defined tumours. Good results are obtained for small BCCs (< 1 cm) with sharply demarcated borders.

• Superficial X-ray therapy is an option in larger tumours in older people. Use with discretion and infrequently.

• Imiquimod: Suitable for biopsy-proven superficial BCC, but not on nose or around eyes. Treatment Monday to Friday, 5 times weekly for 6 weeks.

• Curettage and electrodissection: A curette is first used to remove friable tumour tissue, leaving firm normal tissue. Electrodesiccation of the margins of the defect is then performed. Careful follow-up is essential.

SCCs usually develop in skin exposed to the sun, in particular the face (especially the lower lip), ears, neck, forearm, back of the hands and lower legs (Fig. 3.15). A special trap is on the scalps of men who are bald or have thin scalp hair.

Increased risk occurs with:

• age over 60 years

• fair complexion

• outdoor occupations

• development of sunspots (solar keratoses).

Treatment guidelines

• Surgery is the treatment of choice—use a simple ellipse under LA with a 4 mm margin (in most cases).

• Superficial X-ray therapy is an option in a primary untreated tumour when surgery is not feasible. Cryotherapy and curettage are not treatments of choice.

These solitary, raised, bright red tumours (granuloma telangiectaticum) tend to bleed profusely. The most effective treatment is curettage and electrocautery under local anaesthesia.

However, it must be stressed that histological confirmation of the diagnosis is essential to exclude anaplastic squamous cell carcinoma or amelanotic melanoma. Thus, after the tumour has been shaved off or curetted it should be sent for examination.

Regular applications of liquid nitrogen may remove these benign skin tumours, or at least decolourise them.

Immediately after freezing you can use a scalpel (e.g. size 15 blade) to scrape off the lesion at skin level.

Another method is to apply carefully concentrated phenol solution. Repeat in 3 weeks if necessary.

Yet another method is to apply trichloroacetic acid to the surface and instil it in gently by multiple pricks with a fine gauge needle. Perform twice weekly for 2 weeks.

Stucco keratoses

This subtype of seborrhoeic keratoses are multiple non-pigmented small friable keratoses over the lower legs. They can be treated with a topical keratolytic such as 3–5% salicyclic acid in sorbolene.

This lump, which is not an SCC or other neoplasm, presents as a painful nodule on the most prominent part of the helix or antehelix of the ear (Fig. 3.16). It is seen more often on the helix in men, while it is found more often on the antehelix in women. It is caused by sun damage and pressure degeneration from excessive sleeping on the affected side. It causes pain at night.

Histologically, a thickened epidermis overlies inflamed cartilage. It looks like a small corn, is tender, and affects sleep if that side of the head lies on the pillow. The first line treatment is cryotherapy. If that fails, wedge resection (see ‘Wedge resection of ear’) with a minimal border or a simple superficial elliptical excision (Fig. 3.17) under local anaesthesia is an effective treatment. Send the specimen for histological examination.

Rapid healing of the skin lesion orf can be achieved by injecting corticosteroids into the pustular nodule.

Precautions

• Ensure that the diagnosis of orf is correct.

• Warn the patient of likely increased discomfort for 24 hours.

Method

• Mix 0.5 mL of 1% plain lidocaine with 0.5 mL of long-acting corticosteroid, e.g. triamcinolone. Use more solution for a larger lesion.

• Infiltrate the solution into the lesion, around its margins and into its base.

• The lesion is left to heal without dressings.

Rapid healing occurs within 5 to 10 days. Otherwise it takes 3 to 4 weeks.

These nodules can heal more rapidly if the same intralesional corticosteroid injection is given as for orf.

Attempted excision of these common lesions should be avoided because of bleeding. Perform a mental nerve block (preferable to local infiltration) and insert the needle of the electrocautery or hyfrecator into the centre of the haemangioma. More than one treatment may be necessary.

A distended tender popliteal cyst (Baker cyst) of the knee is really a bursa that communicates with the knee joint. It may be associated with rheumatoid arthritis, osteoarthritis, traumatic knee disruption or a normal joint.

Aspiration and injection may alleviate the symptoms of swelling and tenderness.

Method

1. The patient should be prone, with a small pillow under the knee to produce slight hyperextension of the joint and obvious distension of the bursa.

2. Using a sterile, no-touch technique, insert a 21-gauge 38 mm needle attached to a 20 mL syringe into the bursa.

3. Completely aspirate the fluid, which is usually a clear yellow.

4. Leave the needle in situ and exchange the 20 mL syringe for a 2 mL syringe containing 1 mL of long-acting corticosteroid, which is then injected (Fig. 3.18).

5. Recurrence is common. An alternative treatment is to inject 5 mL of 2.5–3% aqueous phenol or 3% STD (sodium tetradecyl sulfate) solution instead of corticosteroid.

Aspiration, followed by an injection of dilute aqueous phenol or STD, can be a very useful treatment technique for primary hydroceles—especially where definitive surgery is inappropriate. Aspiration alone rarely corrects a hydrocele, but the aspiration/injection combination performed 2 or 3 times can often cure the problem.

Method

1. Inject LA into the scrotal skin down to the sac.

2. Insert an 18- or 19-gauge intravenous cannula through this site into the sac and remove the stilette, leaving the soft cannula in the sac (Fig. 3.19).

3. Remove the serous fluid initially by free drainage, possibly aided by manual compression on the sac and then by aspiration with a 20 mL syringe.

4. Record the volume.

5. Inject 2.5–3% sterile aqueous phenol into the empty sac (10 mL for 200 mL of fluid removed, 15 mL for 200–400 mL and 20 mL for over 400 mL). An alternative and simpler solution is to use 3% STD. Use 2–5 mL. Phenol: In Australia phenol can be ordered from Briggate Medical Company (www.briggatemedical.com).

The procedure can be repeated after 6 weeks.

The same method as for hydroceles can be used. Aspirate and then inject sclerosant.

It has been shown that scrotal needling such as for needle biopsy of testicular tumours has the potential risk of implanting malignant cells in the scrotal wall. The same applies to a scrotal incision to remove testicular cancer. For this reason, incisions to remove testicular cancer are made in the inguinal area. Testicular cancer is spread by the lymphatics to the para-aortic nodes, and not to the inguinal nodes.

• Follow the 4 to 6 hour intervention rule.

• Don’t waste time with investigations, such as ultrasound.

• Consider manipulation from the horizontal position, although it is painful.

Indications

Suitable lesions for steroid injections are:

• granuloma annulare

• hypertrophic scars (early development)

• keloid scars (early development)

• alopecia areata

• lichen simplex chronicus

• necrobiosis lipoidica

• hypertrophic lichen planus

• plaque psoriasis.

Triamcinolone is the appropriate long-acting corticosteroid (10 mg/mL). It may be diluted in equal quantities of saline.

Method

1. The steroid should be injected into the lesion (not below it).

2. Insert a 25- or (preferably) 27-gauge needle, firmly locked to a small insulin-type 1 mL syringe, into the lesion at the level of the middle of the dermis (Fig. 3.20).

3. High pressure is required with some lesions (e.g. keloid).

4. Inject sufficient steroid to make the lesion blanch.

5. Several sites will be needed for larger lesions, so preceding LA may be required in some instances. Avoid infiltration of steroid in larger lesions: use multiple injections.

An excellent method of effective treatment of small to moderately sized plaques of psoriasis is by intralesional infiltration using a long-acting corticosteroid.

Requirements

• Triamcinolone 10 mg/mL solution (or other corticosteroid)

• 1% (plain) lidocaine (or similar local anaesthetic)

• 25-gauge needle (or 23-gauge if larger plaque)

Method

1. Mix equal parts of corticosteroid and local anaesthetic.

2. Swab the lesion.

3. Insert the needle at the margin of the plaque and infiltrate the lesion at an intradermal level, avoiding going deep into the subcutaneous tissue.

4. Infiltrate the whole plaque.

5. A larger plaque may require needle insertion at two sites (Fig. 3.21).

This treatment, which is ideal for a persistent elbow or knee plaque, is rapidly effective and tends to induce a long remission.

Hypertrophic scars are usually treated by multiple intradermal injections of long-acting corticosteroids. The injections are not normally painful, but the procedure can be distressing, particularly to children.

It is possible to achieve the same results without ‘an injection’, delivering the steroid by the multiple-pressure technique used for smallpox vaccinations.

Method

1. The patient is positioned so that the scar to be treated is in the horizontal plane.

2. Cleanse the skin thoroughly with an alcohol swab and allow it to dry.

3. Draw injectable corticosteroid up into a syringe, preferably before the patient enters the treatment room.

4. Spread a film or layer of the steroid aseptically over the scar.

5. Make multiple pressures through the solution into the scar, using a 21-gauge needle held tangentially to the skin. The point of the needle should just penetrate the epidermis and not be deep enough to cause bleeding.

6. There should be approximately 20 pressures per cm².

7. Allow the steroid to dry and cover the area with a dressing if desired.

Treatment can be repeated every 6 weeks if necessary; most simple hypertrophic scars, however, settle after one treatment.

Silicon adhesive gel/dressings

Silicon sheet dressings (e.g. Cica-Care^®) worn continuously over a wound may prevent hypertrophy of the wound. An adhesive gel sheet can be purchased and a piece cut out to fit the wound. The gel sheet should be re-applied daily for 12 weeks.

Alternatively, silicon gels massaged firmly into the wound each day after the wound has re-epithelialised may help.

Elastoplast^® Scar Reduction Patch

These patches can be used to treat or prevent hypertrophic scars. The patch is applied over the scar and changed every 24 hours. It should not be applied to open wounds or burns.

Methods

• Multiple puncture method.

• Inject long-acting corticosteroid, e.g. triamcinolone 10 mg/mL (usually three treatments, 6 weeks apart).

• Apply liquid nitrogen, then inject with corticosteroid about 5 to 15 minutes later—the softer oedematous tissue is easier to inject.

• Radiotherapy.

Prevention of keloids (in susceptible patients)

• Apply high-potency topical corticosteroid with occlusive dressing for 2 to 3 days.

• Inject long-acting corticosteroid into the recess of the wound immediately following suture of the wound (Fig. 3.22).

• Inject long-acting corticosteroid immediately following suture removal.

If the palmar nodule is growing rapidly, an injection of long-acting corticosteroid or collagenase (e.g. Xiaflex^®) into the cord or nodule may be very effective. It can be repeated in 6 weeks, but surgical intervention is indicated for a significant flexion deformity.

Acute bacterial mastitis

Resolution without progression to an abscess will usually be prevented by antibiotics (e.g. flucloxacillin 500 mg 4 times a day orally or cephalexin 500 mg 4 times a day orally). In addition, therapeutic ultrasound (2 W/cm² for 6 minutes) daily for 2 to 3 days will assist resolution.

The breast abscess

If an abscess develops, repeated aspiration or occasionally incision and drainage will be required.

Aspiration drainage

This is the preferred treatment and best performed under ultrasound guidance. However, if US is unavailable it can be drained with an 18- to 21-gauge needle under local anaesthetic every second day until resolution.

Surgical drainage under general anaesthesia

The surgical incision should be placed as far away from the areola and nipple as possible and the dressings kept clear of the areola to allow breastfeeding to continue. The incision is best placed in a radial orientation (like the spoke of a wheel) to minimise the risk of severing breast ducts or sensory nerves to the nipple.

Method

1. Make an incision over the point of maximal tenderness, preferably in a dependent area of the breast (Fig. 3.23a).

2. Use artery forceps to separate breast tissue to reach the pus.

3. Take a swab for culture.

4. Introduce a gloved finger to break down the septa that separate the cavity into loculations (Fig. 3.23b). Flush the cavity with sterile saline solution.

5. Insert a corrugated drainage tube into the cavity. Fix it to the skin edge with a single suture (Fig. 3.23c).

Remove the tube 2 days after the operation. Change the dressings daily until the wound has healed. Continue antibiotics until resolution of the inflammation. Continue breastfeeding from both breasts, but if breastfeeding is not possible because of the location of the incisions and drains, milk should be expressed from that breast.

This simple technique is very helpful, especially if the lump is a cyst, and will have no adverse effects if the lump is malignant. If so, the needle biopsy will help with the pre-operative cytological diagnosis.

Clues to diagnosis of breast cysts

• Sudden onset; past history at surgery

• Discrete breast mass, firm, rarely fluctuant, relatively mobile

Method of aspiration and needle biopsy

1. Avoid LA; use an aqueous skin preparation.

2. Use a 21-gauge needle and a 5 mL sterile syringe.

3. Identify the mass accurately and fix it by placing three fingers of the dominant hand firmly on three sides of the mass (Fig. 3.24a).

4. Introduce the needle directly into the area of the swelling, and once in subcutaneous tissue apply gentle suction as the needle is being advanced (Fig. 3.24b).

5. If fluid is obtained (usually yellowish green), aspirate as much as possible.

6. If no fluid is obtained, try and get a core of cells from several areas of the lump in the bore of the needle.

7. Make several passes through the lump at different angles, without exit from the skin and maintaining suction.

8. Release suction before exit from the skin so as to keep the cells in the needle (not in the syringe).

9. After withdrawal, remove the syringe from the needle, fill with 2 mL of air, reattach the needle and produce a fine spray on two prepared slides.

10. Fix one slide (in Cytofix™) and allow one to air dry, and forward to a reputable pathology laboratory.

Indications for biopsy of lump

• The cyst fluid is bloodstained

• The lump does not disappear completely with aspiration

• The swelling recurs within 1 month

Recurrent cysts

After aspiration, leave the needle in situ and inject 2–5 mL of air. This method reduces the recurrence rate.

Bartholin cyst presents as a swelling at the posterior end of the labium majus, close to the fourchette. The correct treatment of both cyst and abscess is marsupialisation, not excision (which is difficult, bloody and leads to scarring) or incision (which is usually followed by recurrence).

The procedure can be carried out on an outpatient, preferably using local anaesthesia.

Method

1. With the patient in the lithotomy position, swab and drape the vulva.

2. Infiltrate the skin over the medial part of the cyst with 1% lidocaine with adrenaline, using a fine needle and a slow injection.

3. Make a narrow elliptical incision over the medial part of the cyst, at least 3 cm in length (Fig. 3.25a). (As this ostium later contracts, it is a fault to make it too small.)

4. Excise the ellipse of skin, then open the wall of the cyst in the same line, and carefully grasp its edges with mosquito forceps.

5. After the contents of the cyst escape, wash out the cavity with saline, and inspect it then dry it carefully. Any deep loculi must be opened widely. On the postero-inferior cyst wall it is usual to find a punctum leading into the proximal remnant of the duct.

6. Suture the cyst wall to the skin edge at four points using fine catgut, thus creating a pouch (Fig. 3.25b). No dressing is applied and the patient is instructed to take a sitting bath twice a day for a week. Healing is rapid, without pain, and the result is a permanent ostium close to the hymen which delivers free-draining secretion close to the normal site (Fig. 3.25c). If this ostium is too lateral, the woman may complain of discharge and wetness of the skin.

With this technique, even the inexperienced operator will have no difficulty achieving good results with Bartholin cysts. Abscesses can be more difficult if the lining is friable or necrotic. For this reason, early operation should be advised in the presence of inflammation.

Women presenting with small cervical polyps can be readily and simply treated in the office with sponge-holding forceps and a silver nitrate stick. Patients with large polyps require a different approach and referral may be appropriate.

Method

1. Grasp the polyp with sponge-holding forceps and gently twist the polyp until it separates (Fig. 3.26a).

2. Place the polyp in a specimen bottle and send it for histological examination.

3. Cauterise the base of the polyp at the cervical os (Fig. 3.26b) with silver nitrate or by electrocautery.

Ideally, liquid nitrogen is stored in a special, large container and decanted when required into a small thermos flask or a spray device. The temperature is −193°C.

The easiest method of application to superficial skin tumours (see Table 3.1) is via a ball of cotton wool rolled rather loosely on the tip of a wooden applicator stick. This should be slightly smaller than the lesion, to prevent freezing of the surrounding skin.

Beware of application to the following:

• dark skin

• upper lips

• nerves

• eyelids

• nails (do not freeze over nail matrix).

Cotton wool application method (basic steps)

1. Inform the patient what to expect.

2. Pare excess keratin with a scalpel.

3. Use a cotton wool applicator slightly smaller (not larger—see Fig. 3.27a) than the lesion.

4. Immerse it in nitrogen until bubbling ceases.

5. Gently tap it on the side of the container to remove excess liquid.

6. Hold the lesion firmly between thumb and forefinger.

7. Place the applicator vertically (Fig. 3.27b, c) on the tumour surface.

8. Apply with firm pressure: do not dab.

9. Redip the applicator every 5 to 10 seconds.

10. Freeze until a 2–5 mm white halo appears around the lesion.

The appropriate length of application varies (see Table 3.2).

Explain likely reactions to the patient, such as the appearance of blisters (possibly blood blisters). The optimal time for retreatment of warts is at or soon after 3 weeks.

Spray ‘gun’ method

Spraying liquid nitrogen under high pressure is by far quicker and more effective than the topical method. It produces sufficient intense cold to treat deeper lesions. Spray until the white halo forms. If the spray is too diffuse for the lesion, you can place the opening of an otoscope earpiece over the lesion—then spray into the opening of the earpiece, but wear thick gloves for this manoeuvre. Another strategy is to apply a thick film of petroleum jelly or spray ‘plastic skin’ such as OpSite^® to protect the surrounding skin.

Carbon dioxide (CO₂), also known as dry ice, is an effective cryotherapy (freezing) agent for the treatment of warts and keratoses. The CO₂ snow is obtained by the rapid release of CO₂ gas from a cylinder.

Equipment

You will need:

• one sparklet cylinder of CO₂

• a chamois bag with a purse string around the edge

• a bottle of acetone

• a cotton wool bud (preferably on a long stick).

Method

1. Invert the cylinder and connect the chamois bag around the nozzle to collect a small amount of dry ice (snow). The CO₂ snow can be made into a slush by adding a few drops of acetone immediately before use. Alternatively, the cotton bud can be dipped in acetone and then introduced into the snow.

2. Roll the cotton wool bud firmly in this slush to collect an ‘ice ball’, which must be used immediately as it melts very rapidly. The ‘ice ball’ should be marginally smaller than the lesion to be treated.

3. Apply this ‘ice ball’ to the skin lesion for 10 to 15 seconds.

Post cryotherapy

The application of an alcohol swab to the site immediately after cryotherapy provides some immediate pain relief because of the evaporative effect.

Trichloroacetic acid, which should be readily available from pharmacies, has good use as a chemical ablative agent, but it requires careful application on skin lesions. It is usually applied twice weekly, and can be introduced into the lesions, e.g. seborrhoeic keratoses, with fine needle pricks.

Suggested uses

• Seborrhoeic keratoses

• Xanthelasma

• Other flat hyperpigmented lesions

General practitioners receive many requests to remove cosmetically unacceptable xanthomas (xanthelasmas) of the eyelid. A simple method of removal is described. It is suitable for most sizes, but works best for smaller nodular xanthomas that are bulging and ‘ripe’ for removal.

Equipment

• A 21-gauge sterile disposable needle

• Manicure tweezers (flat or slanted, not pointed)

Method

1. Explain the method to the patient, indicating that there is slight discomfort only.

2. Although it is not necessary for all patients, apply some ice or other surface ‘anaesthetic’ to the xanthoma to lessen the discomfort.

3. Stretch the overlying skin and make a small incision in the skin with the tip of the needle (or a fine scalpel) (Fig. 3.28a).

4. Compress the xanthoma along its axis with the tweezers. It is invariably easily expelled (Fig. 3.28b).

Infiltrative xanthelasmas

The flat yellowish xanthelasma around the eyes is difficult to treat surgically. The simplest method is to use ablative therapy, such as laser or careful application of trichloracetic acid.

Warts are skin tumours caused by the human papilloma virus that are transmitted by direct or fomite contact and may be autoinnoculated from one area to another. The various types include common warts, filiform warts (fine elongated growths usually on the face and neck), digitate warts (finger-like projections, usually on scalp), genital and plantar warts. We should keep in mind the fact that about 25% of warts resolve spontaneously in 6 months and 70% in 2 years.

Treatment options

Topical applications

• Salicylic acid, e.g. salicylic acid 5–20% in flexible collodion (apply daily or bd), salicylic acid 16–17% + 16–17% lactic acid (apply once daily)

• Formaldehyde 2–4% alone or in combination

• Podophyllotoxin 0–5%, for warts on mucosal surfaces, e.g. anogenital warts

• Cytotoxic agents, e.g. 5-fluorouracil, very good for resistant warts such as plantar warts and periungual warts

• The immunomodulator, imiquimod

Cryotherapy

• Carbon dioxide (–56.5°C) or liquid nitrogen (–195.8°C)

• Excessive keratin must be pared before freezing

Curettage

A most common treatment, some plantar warts can be removed under LA with a sharp spoon curette. The problem is a tendency to scar.

Electrodessication

A high-frequency spark under LA is useful for small or digitate warts. A combination of curettage and electrodessication is suitable for large and persistent warts.

Vitamin A and the retinoids

• Topical retinoic acid (e.g. tretinoin 0.1% cream-Retin-A^®) for plane warts

• Systemic oral retinoid, acitretin (Neotigason^®) for recalictrant warts (with care)

Medication

Consider cimetidine for a large crop of warts.

Specialised treatments

Bleomycin, cantharidin, immunotherapy (e.g. topical diphenyl-cyclo-propenone [DCP]). Consider DCP treatment for recalcitrant warts.³

Specific wart treatment

The method chosen depends on the type of wart, its site and the patient’s age.

• Plane warts: liquid nitrogen (after paring) to each wart every 2 to 4 weeks; consider tretinoin 0.05% cream (once daily for face) or 5-fluorouracil cream

• Filiform or digitate warts: liquid nitrogen or electrodissection

• Plantar warts: refer to ‘Treatment of plantar warts’ in Chapter 7

• Periungual warts (fingernails): consider 5-fluorouracil or liquid nitrogen with care. Always use a paint rather than ointment or paste on fingers

• Common warts (see below)

Topical options for common warts: helpful hints

1. Soak the wart/s in warm soapy water.

2. Rub back the wart surface with a pumice stone.

3. Apply the anti-wart agent—options:

   • Adults: 17% salicylic acid, 17% lactic acid in collodion paint (Dermatech, Duofilm™), apply daily.

   • Children: 8% salicylic acid, 8% lactic acid in collodion.

   • Formulated paint: formalin 5%, salicylic acid 12%, acetone 25%, collodion to 100%; apply daily or every second day.

   • Salicylic 70% paste in linseed oil: leave 1 week then freeze with liquid nitrogen.

4. Consider protecting the surrounding skin with nail polish or Vaseline^®.

5. Remove dead skin between applications.

Maverick tip (from personal communications): Apply superglue weekly to stubborn common warts.

Individual lesions usually involute spontaneously over several months. There are several simple treatments available for this viral tumour of the skin, the choice being influenced by the person’s age. The great range of possible treatments reflects the difficulty of achieving rapid resolution.

Treatment choices are:

• liquid nitrogen (a few seconds)

• pricking the lesion with a pointed stick soaked in 1% or 3% phenol

• application of 15% podophyllin in Friar’s Balsam (compound benzoin tincture)

• application of 30% trichloroacetic acid

• application of 5% benzoyl peroxide

• application of 17% salicylic acid + 17% lactic acid in collodion (Dermatech or Duofilm™)

• application of wheatgrass topical cream or spray (a wheatgrain extract—see www.drwheatgrass.com.au)

• destruction by electrocautery or diathermy

• ether soap and friction method

• lifting open the tip with a sterile needle inserted from the side (parallel to the skin) and applying 10% povidone-iodine (Betadine^®) solution or 2.5% benzoyl peroxide (parents can be shown this method and continue it at home for multiple tumours)

• paint with clear nail polish

• cover with a piece of duct tape or Micropore™ (or similar paper-based tape) and change every day (may take a few months)

• inject a larger single lesion with corticosteroid, e.g. triamcinolone 10 mg/mL solution.

Most effective method

Extract the core with a curette or large needle, then apply 10% povidone-iodine solution.

Ether soap method

Soak the tumour or tumours for 1 to 2 nights in ether soap (now difficult to obtain), with a plastic covering over the soap-soaked swab. The tumours are then obliterated by rubbing with another damp swab.

For large areas of multiple molluscum contagiosum

Apply aluminum acetate (Burrow’s solution 1:30) twice a day.

New alternative treatments

• Extract of the Cantharis beetle (prepared as Cantharone^®) is reportedly very effective (if available).

• Imiquimod (Aldara™) cream, thrice weekly for 3 weeks.

• Diphenyl-cyclo-propenone (DCP) ointment.