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Dermatologic surgery need not be complex


San Francisco — Learning a variety of safe and relatively simple procedures can help medical dermatologists expand their practices into the surgical arena, according to Robert T. Brodell, M.D.

"I don't believe dermatologists are famous because of Mohs surgery or hair transplants, which we invented. Nor is our fame rooted in flaps, grafts, complex surgical procedures, chemical peels or lasers," Dr. Brodell, professor of internal medicine, dermatology section, Northeast Ohio Universities College of Medicine, Rootstown, Ohio, says.

"Virtually all dermatologists are already doing many things in their practices that are simple, easy, reproducible and failsafe," he says.

But medical dermatologists should embrace newer treatments that address problems ranging from sebaceous hyperplasia and xanthelasma to warts and ingrown nails, Dr. Brodell says.

Sebaceous hyperplasia

To treat sebaceous hyperplasia, some practitioners freeze the lesions with liquid nitrogen cryotherapy.

However, he says, "When one freezes these lesions, sometimes that can lead to dyspigmentation. And the procedure stings a lot, especially when many lesions are treated."

There's also significant variation in how long dermatologists freeze these lesions, which leads to variation in efficacy and side effects, he adds.

In contrast, Dr. Brodell says that with bichloracetic (dichloracetic) acid, one merely "paints" the lesions using a pointed toothpick, then waits until the acid dries and turns frosty white as protein is denatured. After treatment, he recommends applying bacitracin ointment twice daily for seven to 10 days.

He says, "The acid falls down through the fat that composes the bulk of sebaceous gland lobules. When it hits the dense protein in the dermis underneath it, the remaining acid is neutralized, and the penetration of the dermis ceases. The treatment is engineered to accomplish the desired result, and the patients uniformly heal with excellent cosmetic results, though I warn patients not to expect perfection."

Although he says he routinely treats patients with 10 to 15 sebaceous hyperplasias this way in one session, Dr. Brodell recommends that practitioners who are learning this procedure start with a small number of lesions to gain confidence.

Xanthelasma on the eyelids

To treat xanthelasma on the eyelids, he says plastic surgeons typically choose excision. However, Dr. Brodell says, "if one is going to excise a lesion from the eyelids, there are all sorts of potential problems associated with that." Examples include wound healing issues and scarring that can lead to ectropion. Instead of surgery, he says he uses bichloracetic acid in the same way it's used for sebaceous hyperplasia. Patients treated in this manner tend to heal very well, he adds.

"Every once in awhile," Dr. Brodell says, "we see a few milia that form, which is a sign that some scarring results from the procedure."

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