Curettage and Electrodessication

Curettage and electrodessication (C&D or ED&C) is a basic skin procedure in which the technique of curettage, using a sharp curette, is followed by electrodessication. The technique is often performed by dermatologists, family medicine physicians, and general surgeons in their offices on a regular basis.

For many indications, C&D has been replaced by curettage alone, as it yields similar cure rates and a better cosmetic outcome.

Curettage and electrodessication (C&D) may be used for small benign skin lesions and tumors, including warts, seborrheic keratosis, pyogenic granuloma, granulation tissue, and genital warts.[1] C&D may also be used to treat some skin cancers, including superficial basal or squamous cell carcinomas; however, primary excisional approaches are frequently required to achieve maximum cures and to obtain complete histopathologic diagnosis.[2, 3]

Cosmetic results may be better with other procedures such as shave removal or simple curettage. Seborrheic keratosis and genital warts may be treated with cryotherapy with superior cosmetic results. Lesions such as skin tags that have a narrow stalk may be better treated with snip excision to avoid channeling of the electric current into the underlying tissue.

C&D used to treat cancerous basal cell lesions less than 1 cm (< 0.4 in) in diameter yields an excellent cure rate, but similar results may be achieved with curettage alone. C&D should not be used for basal cell lesions larger than 2 cm, tumors with poor definitive edges, recurrent basal cells, or sclerosing basal cells.[1]

C&D is most effective on new skin cancers and is less successful for recurrent skin cancers when scar tissue has developed.[4]

Suspected malignant lesions larger than 2 cm and those in the "H" zone of the face are best removed using excisional technique or Mohs micrographic surgery (MMS).

The American Academy of Dermatology has established appropriate use criteria for MMS. These guidelines represent the most up-to-date evidence-based recommendations for the use of MMS.[5] MMS is a microscopically controlled method of cutaneous neoplasm removal with complete tumor eradication at the surgical borders in an area where retained carcinoma cells are often left using C&D alone.

Other contraindications to curettage and electrodessication (C&D) include obviously infected lesions, fibrotic lesions, and lesions believed to extend into the subcutaneous fat.

Curettage and electrodessication (C&D) requires minimal equipment and operator time for the physician.

In some cases, planning for C&D includes scheduling adequate surgical time in an appropriately sized room with the needed equipment and wound care materials. However, in many situations, small lesions can be treated during a regular office visit.

For appropriately chosen lesions, curettage and electrodessication (C&D) provides good results with few complications.

Possible complications of C&D include pain, hypertrophic scarring, hyperpigmentation, and wound infections.[1]

Superficial multifocal basal cell carcinoma involving the temple has a high rate of recurrence following C&D, so other modalities may be more appropriate in this setting. In addition, with large basal cell cancers, C&D can leave scars larger that the tumor being removed,[5] although the technique is often useful in patients at high risk for more invasive surgical procedures.

17110 Benign other than skin tags or cutaneous vascular lesions, 14 or fewer

17111 Benign other than skin tags or cutaneous vascular lesions, 15 or more

17000 Destruction, premalignant, 1st

17003 Destruction, premalignant, 2-14 (use only conjunction with 17000)

17004 Destruction, premalignant, 15 or more (do not use conjunction with 17000, 17003)

17260 Destruction, malignant; trunk, arm or leg, 5 mm or smaller

17261 Destruction, malignant; trunk, arm or leg, 6-10 mm

17262 Destruction, malignant; trunk, arm or leg, 11-20 mm

17270 Destruction, malignant; scalp, neck, hand, foot, or genitalia, 5 mm or smaller

17271 Destruction, malignant; scalp, neck, hand, foot, or genitalia, 6-10 mm

17272 Destruction, malignant; scalp, neck, hand, foot, or genitalia, 11-20 mm

17280 Destruction, malignant; face, 5 mm or smaller

17281 Destruction, malignant; face, 6-10 mm

17282 Destruction, malignant; face, 11-20 mm

Table. ICD-10CM (Open Table in a new window)

Anesthesia

Injectable lidocaine is administered before most destruction techniques. Lidocaine plus epinephrine prolongs the anesthetic effect and further reduces blood loss.

An alternative for small lesions is to use a eutectic mixture of local anesthetics (EMLA) cream, which contains 2.5% lidocaine and 2.5% prilocaine. EMLA cream under occlusion should be applied to the skin at least one hour before the procedure to achieve topical anesthesia.

In patients who are allergic to "caine," diphenhydramine (25 mg/mL) solution is diluted in 1-5 mL of sterile normal saline and injected intradermally. This is effective for most small skin lesions.

Gentle daily washing of the wound with mild soap and water is recommended. The wound may be left exposed to air or covered with a light bandage for comfort.

Larger-area wounds that require more prolonged healing by secondary intention may benefit from application of a topical antibiotic such as neomycin or mupirocin to prevent infection.

Careful chart notes regarding the location of the lesion allow for periodic re-examination of the area to observe for signs of any recurrence.

When evaluating lesions for treatment with curettage and electrodessication (C&D), the size of the lesion should be considered. In addition to avoiding lesions larger than 2 cm in diameter, pigmented lesions with irregular borders or rapidly changing appearance should be referred for full-thickness excisional biopsy.

The location of lesions should also be considered; lesions that involve the embryotic fusion lines such as the nasal labial folds or inner canthal regions or lesions in the postauricular folds (the so called "H" zone of the face) should be avoided.[6]

Subtypes of basal cell carcinoma that are not suitable for C&D include nodular, infiltrative, morpheaform, and micronodular types.

The lesion is prepared with alcohol or topical cleansing agents such as Hibiclens or Betadine.

Once dried, the area may be marked (according to surgeon preference) with a small surgical pen, outlining the tissue to be removed.

Anesthesia is typically performed by raising a wheal of anesthetic with a small No. 30- or 25-gauge needle with 1% lidocaine plus epinephrine to assist with hemostasis.[1]

A Fox dermal curette (size 3, 4, or 5 mm) is the most commonly used metal curette.

With the sharp side of the curette touching the skin, the lesion is scraped to its base, where a “gritty” feeling of the dermis is obtained.

In suspected basal cell or squamous cell lesions, this scraping is repeated in various directions in a checkerboard pattern with firm counterpressure and until all the tissue feels firm and gritty.

Most cancers have been described as having a softer feel than normal tissue.

Electrodesiccation is then applied to the area after it is blotted to a dry base with gauze.

Depending on the electrocautery unit (whether spark gap hyfrecator or Bovie), the current settings vary for achieving adequate heat-induced coagulation of bleeding.

Light application of the electrical current, creating a visible spark and instant coagulation of the lesion base, is accomplished with a smooth backward and forward motion with the cautery tip.

Patients should experience no discomfort during this procedure if adequate anesthesia and grounding has been secured.

A second approach recommended for any lesions suspected of malignant potential includes the initial procedure described above repeated 3 separate times.[7]