Tag: Integrative Medicine El Paso

Skin Health & Inflammation Solutions Using Functional Medicine

Learn about effective strategies in functional medicine for managing inflammation and promoting skin health and wellness.

Abstract

In this educational post, I walk you through a real-world clinical demonstration of a shave skin biopsy performed on a middle-aged male patient with an inflamed seborrheic keratosis on the lateral aspect of his right hip. The lesion became progressively noticeable over about four weeks, with inflammation, pain, and enlargement. This post covers the full procedural journey—from initial patient presentation and clinical assessment, through topical and injectable local anesthesia, to the execution of the shave biopsy technique and post-procedural hemostasis with aluminum chloride. I also discuss the physiological reasoning behind each step, the evidence base that supports these methods, and how integrative, multidisciplinary care at Injury Medical Clinic PA in El Paso, Texas — led by me alongside Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine and our Medical Director — shapes how we approach even seemingly straightforward dermatological procedures within the broader context of a patient’s overall health and wellness. Whether you are a clinician, a student, or a curious patient, this post is designed to take you on a clear, comprehensive, and evidence-supported journey through the science and practice of minor dermatological surgery.

---

Introduction: Why Minor Dermatological Procedures Matter in Integrative Care

When most people think about integrative or chiropractic-based clinics, they often imagine spinal adjustments, soft tissue therapies, and rehabilitation exercises. While those are foundational pillars of what we do at Injury Medical Clinic PA, comprehensive, patient-centered care extends far beyond the spine. As a clinician with dual credentials in chiropractic medicine and advanced practice nursing—and who works every day alongside an experienced internist—I have come to understand that skin health is not a peripheral concern. In many ways, it is a window into the patient’s overall physiological state.

The skin is the body’s largest organ. It is a dynamic, metabolically active tissue that reflects immune function, hormonal balance, inflammatory status, nutritional sufficiency, and circulatory integrity. When a patient presents with a new, enlarging, inflamed skin lesion, this is not merely a cosmetic inconvenience. It is a clinical signal that deserves careful, evidence-based evaluation and, when appropriate, procedural intervention.

In this post, I describe a clinical procedure I performed: a shave skin biopsy of a clinically suspected inflamed seborrheic keratosis on the lateral aspect of the right hip of a middle-aged male patient. The lesion had been present for approximately four weeks before becoming noticeable and symptomatic, and it showed signs of active inflammation, pain, and progressive enlargement. I walk through every step of the procedure, from the rationale for performing it to the anesthetic technique used, the mechanics of the shave biopsy itself, and the hemostatic methods employed at the conclusion.

But I do more than describe what happened. Throughout this post, I integrate the underlying physiology, evidence-based research, and clinical reasoning that guide every decision. I also explain how this type of minor surgical procedure fits within the broader framework of integrative, multidisciplinary care that defines our practice. My goal is to give you — whether you are a fellow clinician, a student, or a patient — a thorough and deeply informative understanding of what happened, why it happened, and what it means in the context of modern, integrative medicine.

---

Meet the Team: Dr. Alex Jimenez and Dr. Maria Guadalupe Cardenas

Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST

I am Dr. Alex Jimenez. My clinical journey has taken me through chiropractic medicine, advanced practice nursing, functional medicine, integrative medicine, and injury care — among other disciplines. I hold the following credentials: Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), Family Nurse Practitioner Board Certified (FNP-BC), Certified Functional Medicine Practitioner (CFMP), Institute for Functional Medicine Certified Practitioner (IFMCP), Advanced Triage Nurse (ATN), and Certified Chiropractic Sports Therapist (CCST). This breadth of training reflects my deep commitment to understanding the human body from multiple clinical perspectives and providing care that addresses the root causes of illness and injury, not merely the surface symptoms.

My clinical observations and ongoing educational work are available at chiromed.com and on my LinkedIn profile. I have spent decades building a practice grounded in evidence-based, patient-first principles, integrating chiropractic care with functional medicine, nursing practice, and collaborative medical oversight.

Dr. Maria Guadalupe Cardenas, MD

Working alongside me every day at Injury Medical Clinic PA is Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine, with over 40 years of experience as an internist. Dr. Cardenas holds NPI #1164426749 and a Texas MD License #J2933. In our practice, she serves as Medical Director and Collaborative Physician. This designation reflects both the depth of her clinical expertise and the regulatory framework governing multidisciplinary integrative clinics in Texas.

Dr. Cardenas brings an extraordinary wealth of internal medicine knowledge to our team. As an internist, her training encompasses the prevention, diagnosis, and treatment of adult diseases across virtually every organ system—including the skin, cardiovascular system, endocrine system, gastrointestinal system, and more. Her presence in our clinic ensures that every patient who comes through our doors receives not only the benefits of chiropractic and functional medicine care but also the rigorous medical oversight that complex cases require.

The collaboration between a Doctor of Chiropractic/Advanced Practice Nurse and a Board-Certified Internist is the very essence of what makes our clinic exceptional. This multidisciplinary model is increasingly recognized in the evidence-based literature as the gold standard for integrative and injury care, allowing patients to receive comprehensive, coordinated, and truly holistic treatment under one roof.

---

Understanding the Clinical Setting: Injury Medical Clinic PA

Injury Medical Clinic PA, also known as Mission Plaza Injury Medical Clinic, is located in El Paso, Texas. Our clinic is a multidisciplinary integrative care facility that provides a wide spectrum of services, including:

• Chiropractic care and spinal manipulation
• Advanced practice nursing and family medicine
• Internal medicine oversight and medical direction
• Functional medicine and nutritional therapy
• Personal injury care and accident rehabilitation
• Minor surgical procedures and dermatological care
• Diagnostic imaging and laboratory services
• Physical rehabilitation and corrective exercise

The multidisciplinary model we operate under is not merely administrative convenience — it is a clinically superior approach to patient care. Research consistently shows that patients who receive care from coordinated, multidisciplinary teams experience better outcomes, shorter recovery times, lower rates of chronic pain progression, and higher patient satisfaction than those who receive siloed, single-discipline care (Körner et al., 2016; Stochkendahl et al., 2017).

In the context of the procedure described in this post, the clinical setting matters profoundly. A minor dermatological procedure like a shave skin biopsy is performed not in isolation, but within a broader clinical picture. Dr. Cardenas’s medical oversight ensures that any systemic conditions — such as diabetes, autoimmune disorders, coagulopathies, or medication interactions — that might affect wound healing or anesthetic response are carefully considered before the procedure begins. My training as an APRN and FNP-BC means I can assess, diagnose, and treat conditions across multiple body systems, ensuring the dermatological finding is evaluated in the context of the whole patient.

---

Patient Presentation: The Middle-Aged Male with a Lateral Hip Skin Lesion

The patient who came to us on this occasion was a middle-aged male presenting with a skin lesion over the lateral aspect of his right hip. He reported that the lesion had become significantly noticeable over the preceding four weeks. During that time, he observed progressive enlargement, local inflammation, and the onset of pain in the area.

Key Clinical Features at Presentation

• Location: Lateral aspect of the right hip
• Duration of noticeable change: Approximately four weeks before the visit date of September 1, 2026, meaning symptoms began around early August 2026
• Symptoms: Inflammation, pain, and enlargement of the lesion
• Clinical appearance: Consistent with an inflamed seborrheic keratosis

Why the History and Timeline Matter

The four-week timeline matters for several reasons. Seborrheic keratoses are benign epidermal tumors that typically grow slowly over years. When a patient reports a sudden increase in size, inflammation, and pain over a period of weeks, this raises the clinical question of whether the lesion has become irritated or inflamed due to friction, trauma, or clothing contact — all of which are common at the lateral hip — or whether the clinical picture warrants concern for a more serious pathology, such as squamous cell carcinoma, basal cell carcinoma, or melanoma.

The principle here is the “ABCDE” rule for skin lesion evaluation: Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolution (change over time). The “E” — evolution — is arguably the most clinically alarming feature, because change in a skin lesion is always a reason to investigate further (Abbasi et al., 2004). In this case, the rapid change over four weeks, combined with inflammation and pain, was the primary driver for proceeding with a biopsy.

The Role of Pain and Inflammation

Pain in a seborrheic keratosis is noteworthy. Most seborrheic keratoses are entirely asymptomatic. When a patient reports pain, this typically indicates one of the following:

1. Mechanical irritation — repeated friction against clothing, a waistband, or a belt, which is particularly common at the lateral hip
2. Secondary inflammation — the body’s immune response to an injured or irritated keratinocyte population
3. Secondary infection — less common but possible if the surface of the lesion has been broken
4. Underlying epidermal or dermal pathology — warranting biopsy to rule out malignancy

Regardless of the underlying cause, the combination of enlargement, inflammation, and pain in a skin lesion over four weeks establishes a clear clinical indication for tissue sampling and histopathological analysis — in other words, a biopsy.

---

What Is Seborrheic Keratosis? A Deep Dive into the Pathophysiology

Seborrheic keratosis (SK) is one of the most common benign epidermal neoplasms encountered in clinical practice. Understanding the pathophysiology of SK is essential for appreciating why it can become inflamed, painful, and enlarged, and why biopsy is sometimes necessary to confirm the diagnosis.

Epidemiology and Prevalence

Seborrheic keratoses affect individuals of all races and ethnicities, but they are most prevalent in adults over the age of 50. By the seventh decade of life, virtually all adults have at least one seborrheic keratosis (Gill et al., 2000). They can appear anywhere on the body except the palms and soles, with the trunk, face, scalp, and extremities being the most common locations. The lateral hip — the location of our patient’s lesion — is a clinically plausible site, particularly given the mechanical friction to which this area is routinely subjected.

Histopathological Features

At the microscopic level, seborrheic keratoses are characterized by:

• Acanthosis — thickening of the epidermis due to proliferation of keratinocytes and basaloid cells
• Hyperkeratosis — an excess of keratin on the surface of the lesion
• Papillomatosis — irregular upward projections of the epidermal surface
• Horn cysts — invaginations of keratin-filled cysts within the lesion
• Flat base — the lesion grows upward from the skin surface, not downward into the dermis, which is why it appears “stuck on” clinically

These histopathological features explain the characteristic clinical appearance of SK: a waxy, “stuck-on” lesion with a rough, warty texture, ranging in color from light tan to dark brown or black.

Molecular Pathogenesis

The molecular underpinnings of seborrheic keratosis have been increasingly well characterized in recent years. Research has identified somatic mutations in the FGFR3 (Fibroblast Growth Factor Receptor 3) and PIK3CA genes as the most frequently implicated genetic alterations in SK development (Hafner et al., 2007). These mutations constitutively activate cell proliferation pathways—specifically the RAS/MAPK and PI3K/AKT signaling cascades—resulting in the uncontrolled but benign proliferation of keratinocytes that defines the lesion.

Importantly, these are somatic mutations, meaning they arise in individual skin cells over a lifetime and are not inherited. This explains why SK prevalence increases dramatically with age: over decades, accumulating UV radiation exposure, oxidative stress, and DNA repair inefficiencies contribute to the accrual of these mutations in keratinocytes (Hafner et al., 2009).

Why Does Seborrheic Keratosis Become Inflamed?

Inflammation in a seborrheic keratosis is not uncommon and can arise through several mechanisms:

1. Mechanical Irritation and the Koebner Phenomenon

The Koebner phenomenon refers to the development of new skin lesions at sites of trauma or mechanical irritation in individuals who are predisposed to certain skin conditions. In the context of SK, repeated mechanical friction — particularly from clothing, waistbands, or physical activity — can trigger an inflammatory cascade within the lesion. The keratinocytes within the SK release pro-inflammatory cytokines, including interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α), which recruit immune cells to the area and produce the classic signs of inflammation: redness, swelling, warmth, and pain (Baroni et al., 2012).

2. Immune Cell Infiltration

Histopathological studies of inflamed seborrheic keratoses have demonstrated significant lymphocytic infiltration — an influx of T lymphocytes into the lesion — which can lead to what is sometimes called “irritated seborrheic keratosis” or “inflamed SK”. In some cases, this lymphocytic infiltration can actually lead to partial regression of the lesion, a process that mirrors the immune-mediated destruction of neoplastic tissue (Yeh et al., 2000).

3. Secondary Infection

If the surface of the seborrheic keratosis is disrupted—through scratching, friction, or minor trauma—bacteria can colonize the damaged keratin layer, triggering a secondary infectious inflammatory response. This is more common in lesions located in areas of high friction or moisture.

4. The Sign of Leser-Trélat

In rare cases, the sudden onset of multiple new seborrheic keratoses — or the rapid enlargement of existing ones — is associated with internal malignancy, a phenomenon known as the Sign of Leser-Trélat (Schwartz, 1996). While this sign is uncommon and its clinical reliability has been debated in the literature, it underscores the importance of evaluating rapidly changing seborrheic keratoses in the context of the patient’s overall health. Dr. Cardenas’s internist oversight at our clinic is particularly valuable in these cases, as an experienced internist is well positioned to evaluate for systemic signs of malignancy.

---

Clinical Evaluation and Differential Diagnosis of Skin Lesions

Before proceeding to any skin biopsy, a thorough clinical evaluation is essential. The differential diagnosis for an inflamed, enlarging skin lesion at the lateral hip in a middle-aged male is broad and includes both benign and malignant entities.

Benign Differential Diagnoses

• Seborrheic keratosis (inflamed) — the leading clinical diagnosis in this case
• Dermatofibroma — a benign fibrous nodule of the dermis, often found on the lower extremities
• Epidermoid cyst (inflamed) — a cystic structure containing keratin, which can become inflamed or infected
• Lipoma — a benign subcutaneous tumor composed of mature adipocytes
• Verruca vulgaris (common wart) — caused by Human Papillomavirus (HPV), can occur at any site
• Sebaceous hyperplasia — an overgrowth of sebaceous glands, more common on the face
• Pigmented nevus (mole) — a benign melanocytic lesion that may enlarge and become inflamed

Malignant and Pre-Malignant Differential Diagnoses

• Actinic keratosis — a pre-malignant lesion caused by chronic UV exposure, which can progress to squamous cell carcinoma
• Squamous cell carcinoma (SCC) — a malignant tumor of keratinocytes; can mimic an inflamed seborrheic keratosis clinically
• Basal cell carcinoma (BCC) — the most common skin cancer; can present as a pearly, raised nodule with surface changes
• Melanoma — the most dangerous skin cancer; can present as a changing pigmented lesion
• Merkel cell carcinoma — a rare but aggressive neuroendocrine skin tumor
• Cutaneous lymphoma — lymphomatous infiltration of the skin

The clinical appearance — a “stuck-on,” waxy, hyperpigmented lesion with a rough surface — strongly suggests seborrheic keratosis in this case. However, the recent rapid change, including enlargement, inflammation, and pain over four weeks, means that clinical diagnosis alone is insufficient. The gold standard for definitive diagnosis of any skin lesion is histopathological examination of a tissue specimen — which is exactly why the shave biopsy was performed.

Dermoscopy as a Complementary Tool

Modern clinical practice increasingly employs dermoscopy (also called dermatoscopy) as a non-invasive adjunct to clinical evaluation of skin lesions. Dermoscopy uses a handheld polarized light microscope to visualize subsurface skin structures that are invisible to the naked eye. In seborrheic keratosis, dermoscopic features include milia-like cysts, comedo-like openings, fissures and ridges, and cerebriform patterns (Braun et al., 2005). The absence of these features — or the presence of melanoma-associated features — would strengthen the case for urgent biopsy and potential oncological referral.

---

Indications for Shave Skin Biopsy

A shave biopsy is one of several biopsy techniques used in dermatological practice. Understanding when and why a shave biopsy is the appropriate choice — rather than a punch biopsy, excisional biopsy, or incisional biopsy — is essential for appreciating the clinical reasoning in this case.

Types of Skin Biopsy Techniques

1. Shave Biopsy

A shave biopsy uses a surgical blade or razor to horizontally “shave” the lesion from the skin surface. It is ideally suited for:

• Exophytic lesions — lesions that project above the skin surface, such as seborrheic keratoses, viral warts, and skin tags
• Superficial lesions — where the pathology is confined to the epidermis and superficial dermis
• Lesions where full excision is not necessary — particularly when the primary goal is diagnosis rather than complete removal

2. Punch Biopsy

The punch biopsy uses a circular cutting tool to remove a cylindrical core of full-thickness skin. It is preferred for:

• Inflammatory dermatoses — conditions like psoriasis, lichen planus, or eczema, where the pathology spans the full thickness of the skin
• Lesions where dermal involvement needs to be assessed
• Alopecia and scalp conditions

3. Excisional Biopsy

The excisional biopsy removes the entire lesion with a margin of normal tissue. It is indicated when:

• Complete removal is both diagnostic and therapeutic — as in suspected melanoma, where complete excision with margins is the standard of care
• The lesion is small enough to excise completely

4. Incisional Biopsy

The incisional biopsy removes only a portion of a large lesion. It is used when:

• The lesion is too large to excise completely
• A representative sample is needed for diagnosis

Why a Shave Biopsy Was Appropriate in This Case

For the patient described — with a clinically suspected inflamed seborrheic keratosis that was exophytic (projecting above the skin surface) and located in a non-cosmetically critical area — the shave biopsy was the ideal technique for the following reasons:

• The lesion is epidermal in origin — seborrheic keratoses are confined to the epidermis and do not invade the dermis, making a superficial shave technique sufficient to obtain a diagnostic sample
• The technique allows for rapid removal with minimal tissue trauma and a small, cosmetically acceptable wound
• The exophytic nature of the lesion means that a horizontal cut at the base of the lesion will capture the entire pathological tissue.
• The intradermal wheal technique (described below) physically elevates the lesion, making it easier to perform a clean, complete shave with precise margins.
• The hemostatic properties of aluminum chloride make this technique safe and efficient in an outpatient setting without the need for sutures.

---

The Science of Local Anesthesia: Pain Ease Mist and Lidocaine with Epinephrine

One of the most important aspects of any minor surgical procedure is pain management. The goal of local anesthesia is to render the procedural site completely insensate — free from pain — without affecting the patient’s consciousness or systemic physiology. In this procedure, two anesthetic agents were used complementarily: Pain Ease mist (a topical cryogenic spray) and 1% lidocaine with epinephrine (an injectable local anesthetic).

Pain Ease Mist: Topical Cryotherapy for Needle Phobia and Surface Anesthesia

Pain Ease Mist is a commercially available topical cryogenic spray (also known as a “vapocoolant spray”) that works by rapidly cooling the skin surface through the evaporation of a volatile liquid — typically a mixture of 1,1,1,3,3-pentafluoropropane and 1,1,1,2-tetrafluoroethane. The rapid evaporation of these compounds extracts heat from the skin surface, producing a brief but intense cooling sensation that temporarily numbs the superficial nerve endings.

Mechanism of Action

Cryogenic sprays produce surface anesthesia by thermally modulating cutaneous nociceptors. Pain is transmitted from the skin to the central nervous system via nociceptive afferent nerve fibers — primarily A-delta fibers (which transmit sharp, fast pain) and C-fibers (which transmit slow, burning, or aching pain). Both of these fiber types are exquisitely sensitive to temperature changes.

When skin temperature drops rapidly below about 10°C, voltage-gated sodium channels in nociceptive nerve endings become transiently inactivated. These sodium channels are essential for the generation of action potentials — the electrical signals that carry pain information along the nerve fiber. When cold blocks them, the nociceptive fiber cannot fire, and the sensation of pain is temporarily abolished (Bleakley et al., 2012).

Clinical Application in This Procedure

In this procedure, the Pain Ease mist was applied to the skin before needle insertion to blunt the pain of the initial puncture. This is a particularly thoughtful approach to patient care. Needle phobia — technically termed trypanophobia — is one of the most common procedural fears among patients, and even in patients who do not have a formal phobia, the anticipation of needle pain can trigger significant anxiety, which in turn increases pain perception through central sensitization mechanisms (Taddio et al., 2009).

By pre-treating the skin with a vapocoolant spray, I was able to:

1. Reduce the pain of the initial needle insertion
2. Reduce patient anxiety about the procedure
3. Create a more relaxed procedural environment, which itself reduces pain perception

This is an excellent example of how integrative, patient-centered care — which prioritizes the patient’s comfort and experience alongside clinical efficacy — shapes procedural decisions.

Lidocaine with Epinephrine: The Gold Standard Injectable Local Anesthetic

Lidocaine is the most widely used local anesthetic in clinical practice worldwide. It belongs to the amide class of local anesthetics, characterized by stability, low allergenic potential, and reliable onset of action.

Mechanism of Action of Lidocaine

Lidocaine produces local anesthesia by blocking voltage-gated sodium channels in the axonal membranes of peripheral nerve fibers. When these channels are blocked, the nerve cannot generate or propagate action potentials, and all sensory modalities — including pain, temperature, touch, and pressure — are temporarily abolished in the distribution of the affected nerve.

At the molecular level, lidocaine enters the sodium channel from the intracellular side of the nerve membrane — meaning it must first cross the nerve cell membrane to reach its binding site. It does this in its uncharged (base) form, which is lipid-soluble and can diffuse through the lipid bilayer. Once inside the cell, it becomes partially ionized (charged) at physiological pH and binds to the alpha subunit of the voltage-gated sodium channel in its open or inactivated state, preventing the channel from reopening and thus blocking nerve conduction (Catterall et al., 2005).

This mechanism explains an important clinical observation: lidocaine is less effective in infected or inflamed tissue, because the acidic environment of infected tissue (lower pH) favors the ionized form of lidocaine, which cannot cross the nerve membrane as easily. This is a critical consideration when anesthetizing inflamed lesions like the one in this case, and it reinforces the importance of using an adequate volume and correct placement to achieve reliable anesthesia despite potential local acidosis.

The Role of Epinephrine

The addition of epinephrine (adrenaline) to the lidocaine solution serves several important functions:

1. Vasoconstriction and Prolonged Anesthetic Duration

Epinephrine is a potent alpha-1 adrenergic receptor agonist that causes vasoconstriction — narrowing of local blood vessels — at the injection site. This vasoconstriction reduces systemic absorption of lidocaine, keeping the anesthetic concentrated at the site of action longer. The result is a significantly prolonged duration of local anesthesia — from approximately 30-60 minutes with plain lidocaine to 90-120 minutes or more with lidocaine-epinephrine (Becker & Reed, 2012).

2. Reduced Bleeding

Epinephrine-induced vasoconstriction also reduces bleeding at the procedural site. This is particularly beneficial during a shave biopsy, where a clean, blood-free operative field is essential for accurate margin assessment and specimen quality.

3. Reduced Systemic Toxicity

By slowing systemic absorption, epinephrine reduces the risk of local anesthetic systemic toxicity (LAST) — a rare but potentially life-threatening complication of local anesthetic administration that can cause cardiac arrhythmias and central nervous system toxicity when plasma lidocaine levels exceed a critical threshold (Neal et al., 2018).

Concentration and Volume

In this procedure, 1% lidocaine with epinephrine was used, and approximately 1 mL was injected. The 1% concentration means that the solution contains 10 mg of lidocaine per milliliter. Therefore, 1 mL delivers 10 mg of lidocaine — a dose well within the safe therapeutic range for a local infiltration in an adult patient. The maximum safe dose of lidocaine with epinephrine is generally cited as 7 mg/kg, meaning even a small adult patient would have a maximum dose of 350 mg or more, making a 10 mg dose extraordinarily safe (Becker & Reed, 2012).

---

Needle Selection and Injection Technique: The 30-Gauge Half-Inch Needle

Selecting a 30-gauge, half-inch needle for this procedure reflects a deliberate, evidence-informed clinical decision.

Understanding Needle Gauge and Length

Needles are classified by their gauge (a measure of diameter, where higher gauge numbers indicate thinner needles) and their length (expressed in inches or millimeters). A 30-gauge needle has an outer diameter of approximately 0.31 mm, making it one of the thinnest needles commonly used in clinical practice. A half-inch (12.7 mm) length is appropriate for subcutaneous and intradermal injections in most body sites.

Why a 30-Gauge Needle?

The primary reason for selecting a thin 30-gauge needle for this procedure is patient comfort. The relationship between needle gauge and pain is well established in the literature: thinner needles cause less pain upon insertion, because they displace less tissue and engage fewer nociceptive nerve endings in the skin (Gill & O’Brien, 2007). For a procedure where the injection itself is the most acutely painful component, minimizing needle gauge is an important element of patient-centered procedural care.

A 30-gauge needle is also entirely adequate for delivering the small volume (1 mL) of fluid used in this procedure. The viscosity of the lidocaine-epinephrine solution is low enough that it flows freely through a 30-gauge needle without excessive injection pressure.

The Two-Phase Injection Technique

An important feature of the injection technique described in this procedure is its two-phase approach:

Phase 1: Subcutaneous Injection

The needle is first inserted perpendicularly into the skin and advanced into the subcutaneous tissue — the loose connective tissue layer beneath the dermis. A portion of the lidocaine solution is deposited here. This deep deposition ensures that the larger nerve branches supplying the area are anesthetized first, which facilitates the subsequent intradermal injection by pre-treating the deeper nociceptive pathways.

Phase 2: Intradermal Injection (Wheal Formation)

Without withdrawing the needle from the skin, redirect it horizontally— rotate it to run parallel to the skin surface — and advance it intradermally, directly beneath the lesion. The remaining lidocaine solution is then injected here to form an intradermal wheal — a raised, pale, blister-like elevation of the skin caused by the fluid expanding the intradermal compartment.

This two-phase technique is superior to a single-depth injection for several reasons:

• It ensures complete anesthesia of all skin layers — both the deeper subcutaneous tissue and the superficial intradermal compartment where the lesion is rooted
• It creates the intradermal wheal, which is mechanically essential for the shave biopsy technique (as described in the next section)
• The subcutaneous injection first creates baseline anesthesia that makes the subsequent intradermal injection less painful for the patient.

The clinical observation during this procedure — that the patient reported no pain during both phases of the injection — validates the effectiveness of the Pain Ease pre-treatment and the careful, deliberate injection technique employed.

---

Subcutaneous vs. Intradermal Injection: Understanding the Layers of the Skin

To fully appreciate the technical nuances of the injection technique used in this procedure, you need a thorough understanding of the skin’s anatomical layers and the physiological differences between subcutaneous and intradermal injection.

The Architecture of the Skin

The skin is organized into three primary layers, each with distinct anatomical and physiological characteristics:

1. The Epidermis

The epidermis is the outermost layer of the skin, ranging in thickness from approximately 0.05 mm (on the eyelids) to 1.5 mm (on the palms and soles). It is composed primarily of keratinocytes — the cells responsible for producing keratin, the structural protein that gives skin its barrier function. The epidermis is avascular (contains no blood vessels) and receives nutrients and oxygen by diffusion from the underlying dermis.

The epidermis is organized into five layers (from deep to superficial):

• Stratum basale — the deepest layer, containing mitotically active stem cells
• Stratum spinosum — the “prickle cell” layer, where keratinocytes begin to produce keratin
• Stratum granulosum — where keratinocytes begin to flatten and produce lipid-rich lamellar granules
• Stratum lucidum — present only in thick skin (palms and soles); a clear, homogeneous layer
• Stratum corneum — the outermost layer, composed of dead, flattened keratinocytes (corneocytes) filled with keratin

Seborrheic keratoses originate in the epidermis — they are a proliferation of the keratinocyte population within the epidermal layers, and they project upward from the skin surface without penetrating the dermis.

2. The Dermis

The dermis lies immediately beneath the epidermis and is separated from it by the dermal-epidermal junction (DEJ). The dermis is a highly vascularized layer of connective tissue composed primarily of collagen and elastin fibers, embedded in a proteoglycan-rich extracellular matrix. It contains blood vessels, lymphatic vessels, nerve fibers, hair follicles, sweat glands, and sebaceous glands.

The dermis is subdivided into:

• Papillary dermis — the superficial portion, which projects upward into the epidermis as dermal papillae and contains fine collagen fibers, capillary loops, and nerve endings
• Reticular dermis — the deeper, thicker portion, composed of coarser collagen bundles and elastic fibers, providing the skin’s tensile strength

Intradermal injection delivers fluid into the papillary and superficial reticular dermis, producing the characteristic wheal by expanding this compartment.

3. The Hypodermis (Subcutaneous Tissue)

The hypodermis lies beneath the dermis and consists primarily of adipose tissue (fat cells) interspersed with connective tissue septa. It provides thermal insulation, mechanical cushioning, and serves as an energy reservoir. Subcutaneous injection delivers fluid into this layer.

Why the Intradermal Wheal Is the Key to the Shave Biopsy

The intradermal wheal created by the injection is not merely an anesthetic technique — it is a mechanical tool that fundamentally enhances the shave biopsy procedure. By expanding the intradermal compartment directly beneath the seborrheic keratosis, the wheal accomplishes two critical objectives:

1. Physical Elevation of the Lesion

The wheal raises the lesion above the surrounding skin surface, making it more prominent and accessible. This elevation means that the biopsy blade does not need to be angled downward into the skin to capture the lesion — it can instead be directed horizontally across the elevated lesion base, reducing the risk of either under-sampling (leaving residual lesion tissue) or over-sampling (cutting too deeply into the dermis and creating an unnecessary wound).

2. Creation of a Firm, Stable Platform

The turgid, fluid-filled wheal also creates a firmer, more stable base beneath the lesion, which facilitates a smooth, controlled biopsy motion. Without the wheal, the soft, compressible superficial dermis can make it difficult to maintain consistent blade depth during the shave.

This technique — using the intradermal wheal both for anesthesia and as a mechanical adjunct to the biopsy — exemplifies the elegance of evidence-based procedural medicine: a single intervention (the intradermal injection) achieves multiple clinical goals simultaneously.

---

The Intradermal Wheal: Why Elevation of the Lesion Matters

The observation in the clinical demonstration that the intradermal wheal was “actually elevating the lesion toward us, so that presents it to us” is not a casual comment — it reflects a fundamental principle of shave biopsy technique that is grounded in biomechanics and tissue physiology.

The Biomechanics of Wheal Formation

When fluid is injected into the intradermal compartment, it must displace surrounding tissue to create space. Because the epidermis above is relatively inelastic and the reticular dermis below is dense, the path of least resistance for the injected fluid is upward and laterally, producing the characteristic dome-shaped wheal.

The pressure generated by the fluid within the wheal — typically estimated at 20-40 mmHg above atmospheric pressure in an actively injected wheal — is sufficient to lift the overlying epidermis and any attached epidermal tumor (such as the seborrheic keratosis) away from the underlying dermis. This lifting effect is visually apparent: the skin overlying the injection site blanches (due to local vasoconstriction from the epinephrine and compression of the superficial capillaries) and rises above the surrounding skin level.

Clinical Significance for Specimen Quality

From a pathological standpoint, the elevation of the lesion produced by the wheal is highly beneficial for specimen quality. A shave biopsy specimen that includes a generous portion of the base of the lesion — the intradermal-epidermal junction — is far more diagnostically valuable than one that captures only the superficial portion. The wheal ensures that the biopsy blade, traveling horizontally at the elevated lesion base, captures this interface reliably.

A high-quality specimen allows the pathologist to assess:

• The depth of epidermal involvement
• The presence or absence of dermal invasion — the most critical feature for distinguishing benign SK from malignant entities like squamous cell carcinoma in situ (Bowen’s disease) or invasive SCC
• The nature of any inflammatory infiltrate
• The presence of atypical keratinocytes that might suggest pre-malignant or malignant transformation

---

Performing the Shave Biopsy: Technique, Precision, and Margins

With the intradermal wheal established and the lesion fully elevated and anesthetized, the shave biopsy proceeds. The technique used in this procedure—beginning the cut about two millimeters lateral to the lesion—reflects careful attention to both diagnostic completeness and cosmetic outcome.

The “Two Millimeters Lateral” Principle

Starting the shave cut two millimeters lateral to the visible border of the lesion serves several important purposes:

1. Ensuring Complete Lesion Capture

The visible border of a seborrheic keratosis is not always the true border of the pathological process. Microscopic extensions of the lesion — subclinical keratinocyte proliferation that is not visible to the naked eye — can extend a small distance beyond the visible edge. By starting the cut 2 mm outside the visible margin, the clinician ensures the specimen includes all pathological tissue, even if microscopic extensions exist.

2. Avoiding Specimen Fragmentation

If the biopsy blade is introduced at the exact edge of the lesion, there is a risk of fragmenting the specimen — splitting the lesion into pieces that may be difficult to orient and analyze histopathologically. Starting two millimeters beyond the edge ensures a smooth, continuous cut through the lesion from one side to the other.

3. Margin Assessment

In cases where the histopathological findings reveal a pre-malignant or malignant process — a possibility that cannot be excluded until the specimen is analyzed — having a two-millimeter margin of normal-appearing skin at the lateral edges of the specimen provides the pathologist with a baseline for assessing whether the abnormal process extends to the specimen edges (positive margins) or is contained within the specimen (negative margins).

The Shave Cut Itself

The shave cut is performed using a scalpel blade or a specialized razor blade held parallel to the skin surface. The blade is moved in a smooth, continuous motion from one side of the elevated lesion to the other, cutting at the level of the papillary-reticular dermis junction — superficial enough to avoid unnecessary dermis removal, but deep enough to capture the full base of the epidermal lesion.

In experienced hands, the shave biopsy is a rapid procedure—the cutting motion typically takes only a few seconds. The speed is not merely cosmetic convenience; a smooth, rapid cut produces a cleaner specimen with less crush artifact than a slow, sawing motion, which can distort tissue architecture and compromise histopathological interpretation.

Confirmation of Completeness

After removing the specimen, the wound bed is inspected to confirm that no lesion tissue remains. In this procedure, the clinical confirmation was explicit: “All the way through, no lesion is left there on the skin.” This confirmation step is important because residual lesion tissue can:

• Lead to recurrence of the lesion
• Potentially harbor pathology that was not captured in the initial specimen
• Cause delayed healing or persistent inflammation

---

Hemostasis with Aluminum Chloride: Mechanisms and Clinical Rationale

After specimen removal, the next clinical priority is hemostasis—stopping bleeding from the wound bed. In this procedure, aluminum chloride was used for this purpose.

What Is Aluminum Chloride?

Aluminum chloride is an inorganic compound with the formula AlCl₃. In dermatological practice, it is used as a hemostatic agent — a substance that promotes blood clotting — in the form of a concentrated aqueous solution (typically 20-35% aluminum chloride in absolute ethyl alcohol, sometimes referred to as “Monsel’s solution” or “Drysol” in various clinical formulations, though these have distinct compositions; the aluminum chloride-ethanol formulation is the most commonly used hemostatic agent in dermatological surgery).

Mechanism of Action

The hemostatic action of aluminum chloride is primarily physical/chemical rather than enzymatic. It acts through the following mechanisms:

1. Protein Precipitation

Aluminum ions (Al³⁺) are strongly astringent — they react with proteins in the serum and on the surface of endothelial cells to cause protein precipitation. This precipitation forms a physical plug in the small capillaries and arterioles at the wound surface, mechanically occluding blood flow.

2. Vasoconstriction

The astringent effect of aluminum chloride also causes contraction of the walls of small blood vessels at the wound site, reducing blood flow to the area. This vasoconstriction is transient but sufficient to allow the body’s own hemostatic mechanisms — platelet aggregation and fibrin clot formation — to complete the process.

3. Desiccation of the Wound Surface

The alcohol component of the aluminum chloride solution promotes desiccation (drying) of the wound surface, which reduces the amount of fluid available to sustain bleeding and promotes the formation of a stable, dry eschar (scab) over the wound.

Application Technique

In this procedure, the aluminum chloride was applied by saturating a gauze pad with the solution and applying it to the wound surface. The gauze is pressed firmly against the bleeding wound for approximately 30-60 seconds, during which time the protein precipitation and vasoconstriction occur and bleeding is arrested.

The observation that “The bleeding has stopped” after application confirms the technique’s effectiveness and supports the clinical rationale for using aluminum chloride in this context.

Advantages Over Other Hemostatic Methods

In a minor dermatological procedure like a shave biopsy, aluminum chloride offers several important advantages over alternative hemostatic methods:

• No sutures required — the wound created by a shave biopsy is typically shallow and small enough that aluminum chloride hemostasis is sufficient, eliminating the need for sutures and their associated discomfort, risk of infection, and need for a return visit for removal
• Rapid action — bleeding is typically arrested within 30-60 seconds
• Low risk of scarring — unlike electrocautery or ferric subsulfate (Monsel’s solution), aluminum chloride generally produces minimal tissue damage and a low risk of post-inflammatory hyperpigmentation or scarring.
• Ease of use — it can be applied with a cotton-tipped applicator or gauze pad without specialized equipment.
• Safe in the outpatient setting — no electrical equipment, no flame, no specialized training required beyond standard procedural competency

Comparison with Electrocautery

Electrocautery (or electrocoagulation) is another commonly used hemostatic method in skin surgery. It works by applying electrical current to the wound surface, which heats the tissue and causes thermal coagulation of blood proteins. While electrocautery is effective, it has several disadvantages compared to aluminum chloride in the context of a shave biopsy:

• It requires specialized electrical equipment.
• It can cause thermal artifact in adjacent tissue, which can distort histopathological interpretation if applied before the specimen is removed.
• It carries a small but real risk of electrical burns if used near metal implants or pacemakers.
• The smell of burning tissue can be unpleasant for the patient

Aluminum chloride avoids all of these concerns, making it the preferred hemostatic agent for most minor dermatological procedures in an outpatient integrative care setting.

---

Post-Procedural Care and Sterile Packaging

Sterile Packaging of the Specimen

Once the specimen is excised and hemostasis is achieved, package and preserve the biopsy specimen properly for pathological analysis. The standard method is to place the specimen in a container of 10% neutral buffered formalin, which acts as a fixative—it cross-links proteins in the tissue, preserving cellular architecture and preventing autolytic degradation that would occur if the tissue were allowed to dry or remain at physiological conditions.

The formalin-fixed specimen is then submitted to a pathology laboratory with a requisition form documenting:

• Patient demographics
• Clinical diagnosis and differential diagnoses
• Site and method of biopsy
• Relevant clinical history (duration of lesion, rate of change, symptoms)
• Requesting clinician information

This information is essential for the pathologist to provide a clinically relevant interpretation of the histological findings.

Wound Care Instructions

After the procedure, the patient receives wound care instructions to promote healing and prevent infection. Standard instructions for a shave biopsy wound include:

• Keep the wound clean and moist — apply a thin layer of petroleum jelly (Vaseline) or antibiotic ointment (such as bacitracin) and cover with a non-stick dressing for 24-48 hours
• Change the dressing daily — remove the old dressing, gently clean the wound with mild soap and water, and reapply the ointment and dressing.
• Avoid submerging the wound in water (baths, pools, hot tubs) until the wound is fully healed — typically 7-14 days.
• Avoid vigorous physical activity that might cause friction or trauma to the wound site.
• Watch for signs of infection — increasing redness, warmth, swelling, purulent discharge, or fever — and return to the clinic immediately if these develop.
• Expect a small scar — the wound will initially form a scab (eschar), which will fall off within 1-2 weeks, leaving a small, pink, flat scar that will gradually fade over several months.

Healing Physiology

The wound healing process at a shave biopsy site proceeds through the classic four phases of wound healing:

1. Hemostasis (0-24 hours)

Immediately after tissue injury, platelet aggregation and coagulation cascade activation form a fibrin clot at the wound surface. Aluminum chloride supports this phase by precipitating proteins and causing vasoconstriction to slow bleeding.

2. Inflammation (1-5 days)

Immune cells — primarily neutrophils in the first 24-48 hours, followed by macrophages — migrate to the wound site and clear debris, bacteria, and damaged tissue. This phase is characterized by the classic signs of inflammation: redness, swelling, warmth, and discomfort at the wound site.

3. Proliferation (5-21 days)

Fibroblasts migrate into the wound and begin synthesizing new collagen, gradually replacing the fibrin clot with a provisional extracellular matrix. Simultaneously, keratinocytes at the wound edges begin migrating across the wound surface to re-establish the epidermal layer — a process called re-epithelialization.

4. Remodeling (21 days to 2 years)

The provisional collagen matrix is gradually remodeled into a more organized, mature collagen structure. The wound contracts, the scar matures and fades, and the tensile strength of the repaired tissue gradually increases toward (but typically not reaching) the pre-injury level.

---

Pathological Analysis: What Happens After the Specimen Is Collected

The journey of the biopsy specimen from the clinical setting to the pathology report is a fascinating and clinically critical process. Understanding what happens to the tissue after it leaves the clinic helps clinicians communicate more effectively with pathologists and interpret reports more accurately.

Grossing (Macroscopic Examination)

Upon receipt in the pathology laboratory, the specimen undergoes gross examination — a macroscopic inspection by the pathologist or pathology technician. For a shave biopsy specimen, this involves documenting:

• The size and shape of the specimen
• The surface characteristics (color, texture, presence of pigmentation)
• The cut sections (appearance of the tissue on cross-section)

Tissue Processing

The formalin-fixed specimen is then embedded in paraffin wax to create a solid block from which thin tissue sections can be cut. The embedding process involves:

1. Dehydration — the tissue is passed through a series of increasingly concentrated alcohol solutions to remove water
2. Clearing — the alcohol is replaced with a clearing agent (typically xylene) that is miscible with paraffin
3. Infiltration and embedding — the clearing agent is replaced with melted paraffin wax, which solidifies around the tissue, creating a firm block

Microtomy and Staining

The paraffin block is then sectioned using a microtome—a precision cutting instrument—into sections 3- 5 micrometers thick. These sections are mounted on glass slides and stained with hematoxylin and eosin (H&E), the standard stain for histopathological examination.

• Hematoxylin stains nuclei blue-purple
• Eosin stains cytoplasm and extracellular matrix pink-red

The pathologist then examines the H&E-stained slides under the microscope.

What the Pathologist Looks For

In a specimen from a clinically suspected inflamed seborrheic keratosis, the pathologist examines:

Features Supporting the Diagnosis of Seborrheic Keratosis:

• Acanthosis — epidermal thickening with keratinocyte proliferation
• Hyperkeratosis — excess keratin on the surface
• Papillomatosis — upward projections of the epidermis
• Horn cysts — keratin-filled invaginations within the epidermis
• No dermal invasion — the basement membrane is intact, confirming the benign, epidermal nature of the lesion

Features of Inflammation:

• Lymphocytic infiltrate in the superficial dermis and within the lesion
• Spongiosis — epidermal edema
• Neutrophilic infiltrate if secondary infection is present

Features That Would Require Further Action:

• Atypical keratinocytes — cells with enlarged, irregular nuclei — could indicate actinic keratosis or squamous cell carcinoma in situ
• Full-thickness epidermal atypia — diagnostic of Bowen’s disease (SCC in situ)
• Dermal invasion — diagnostic of invasive squamous cell carcinoma
• Atypical melanocytes — could indicate melanoma
• Positive margins — residual pathological tissue at the edges of the specimen

The pathology report generated after this analysis is the definitive clinical answer to the diagnostic question posed by the biopsy.

---

Pain Management in Minor Surgical Procedures: An Integrative Perspective

Pain management in minor surgical procedures extends well beyond the technical administration of local anesthetic. From an integrative medicine perspective, pain is not merely a peripheral nociceptive signal but a complex, multidimensional experience shaped by biological, psychological, and social factors — the biopsychosocial model of pain (Engel, 1977; Gatchel et al., 2007).

The Biopsychosocial Model Applied to Procedural Pain

Biological factors in procedural pain include:

• The nociceptive input from the injured tissue (the actual stimulus)
• The inflammatory state of the tissue (inflamed tissue is hyperalgesic)
• The neuroendocrine stress response (cortisol, adrenaline)
• Individual genetic variation in pain sensitivity (polymorphisms in opioid receptor genes, voltage-gated ion channels)

Psychological factors include:

• Anxiety and fear — the most important psychological modifiers of procedural pain; anxious patients uniformly report more pain
• Previous pain experiences — negative prior procedural experiences sensitize patients to subsequent procedures
• Catastrophizing — a cognitive-emotional pattern characterized by exaggerated, negative appraisals of pain that amplifies the perceived pain experience
• Self-efficacy beliefs — confidence in one’s ability to cope with the procedure reduces pain perception

Social factors include:

• The clinician-patient relationship — a trusting, empathetic clinical relationship substantially reduces procedural pain and anxiety
• The procedural environment — a calm, private, well-equipped clinical space reduces anxiety compared to a busy, noisy, or unfamiliar environment
• Social support — the presence of a trusted companion during procedures can reduce pain perception

Integrative Pain Management Strategies in Procedural Settings

At Injury Medical Clinic PA, our approach to pain management during minor procedures incorporates multiple integrative strategies:

1. Therapeutic Communication

Before and during the procedure, I maintain open, calm, and reassuring communication with the patient. This includes:

• Clear explanation of each step before it occurs (“I’m going to insert the needle now — you may feel a small pinch”)
• Positive reinforcement during the procedure (“You’re doing great; the hard part is over”)
• Distraction — engaging the patient in conversation to redirect attention away from procedural sensations

The literature strongly supports the value of therapeutic communication in reducing procedural pain. Studies have shown that verbal analgesia—the pain-relieving effect of calm, reassuring speech by a clinician—activates endogenous opioid pathways in the brain, producing measurable reductions in pain perception (Benedetti et al., 2003).

2. Topical Analgesia

Using the Pain Ease mist before needle insertion, as described in this procedure, is a practical application of the gate control theory of pain (Melzack & Wall, 1965). According to this theory, non-nociceptive sensory input (in this case, the cold sensation from the vapocoolant spray) can “close the gate” to nociceptive transmission by activating large-diameter, myelinated sensory fibers (A-beta fibers) that inhibit nociceptive processing in the dorsal horn of the spinal cord.

3. Positioning and Comfort Optimization

Ensuring that the patient is in a comfortable position during the procedure, with appropriate support for the body part being treated, reduces both physical discomfort and psychological anxiety. A comfortable, well-supported patient feels more secure and in control of the procedural experience.

4. Mindfulness and Breathing Techniques

For patients with significant procedural anxiety, I often guide them through slow, diaphragmatic breathing before and during the procedure. Deep, slow breathing activates the parasympathetic nervous system, reducing cortisol and adrenaline levels and promoting relaxation that directly reduces pain sensitivity through top-down (cortical) modulation of nociceptive pathways (Kabat-Zinn, 1990).

5. Post-Procedural Analgesia

After the procedure, patients are advised on appropriate over-the-counter analgesics for post-procedural discomfort, typically acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, unless contraindicated by other medical conditions. The anti-inflammatory action of NSAIDs is particularly relevant here, as they inhibit the cyclooxygenase (COX) enzyme, reducing prostaglandin synthesis —key inflammatory mediators that sensitize peripheral nociceptors (hyperalgesia) after tissue injury (Vane, 1971).

---

How Chiropractic Care Integrates with Dermatological and Medical Management

At first glance, the connection between chiropractic care and dermatological procedures may not seem obvious. However, understanding the integrative, whole-body approach that defines our practice reveals the deep, meaningful ways chiropractic principles and techniques complement and enhance the medical management of conditions like inflamed seborrheic keratoses.

The Neuroimmunological Connection

Chiropractic philosophy has always centered on the intimate relationship between the nervous system and the body’s health. Modern neuroscience strongly supports a neuroimmunological network—a bidirectional communication system between the nervous and immune systems—that plays a profound role in regulating inflammation, immune function, and tissue healing throughout the body, including the skin (Tracey, 2002).

The vagus nerve — the primary nerve of the parasympathetic nervous system — has emerged as a critical mediator of what is now called the “cholinergic anti-inflammatory pathway” (Tracey, 2002). Activation of the vagus nerve (either physiologically or through therapeutic stimulation) triggers the release of acetylcholine in peripheral tissues, which in turn inhibits the production of pro-inflammatory cytokines — including TNF-α, IL-1, and IL-6 — by macrophages. This anti-inflammatory effect is systemic, meaning it can influence inflammatory processes throughout the body, including in the skin.

Spinal manipulation therapy (SMT) — the core clinical intervention of chiropractic practice — has been shown in emerging research to modulate autonomic nervous system activity, with evidence suggesting that SMT can increase parasympathetic tone and reduce sympathetic hyperactivity in some patients (Budgell & Hirano, 2001; Welch & Boone, 2008). If future research confirms this, it would suggest that chiropractic adjustments could, through neuroimmunological mechanisms, have an indirect anti-inflammatory effect that might benefit patients with systemic or localized inflammatory conditions—including inflamed skin lesions.

Reducing Systemic Inflammation Through Chiropractic and Lifestyle Modification

One of the most compelling areas of modern integrative medicine is the recognition that chronic systemic inflammation is a shared pathological substrate underlying many diverse conditions — from cardiovascular disease and diabetes to chronic pain and skin disorders. Elevated levels of circulating inflammatory cytokines (particularly IL-6 and CRP — C-reactive protein) are associated with a range of skin conditions, including psoriasis, atopic dermatitis, and — potentially — the accelerated development and inflammation of benign skin tumors like seborrheic keratoses (Ganzetti et al., 2014).

Chiropractic care, integrated with functional medicine, nutritional intervention, stress management, and exercise therapy, can contribute to the reduction of systemic inflammation through multiple pathways:

• Spinal manipulation may modulate neuroimmunological activity
• Exercise prescription and rehabilitation reduce pro-inflammatory adipokines released by visceral adipose tissue
• Nutritional guidance toward an anti-inflammatory diet (rich in omega-3 fatty acids, polyphenols, and antioxidants) reduces systemic oxidative stress and cytokine production
• Stress reduction — through mindfulness, breathing exercises, and sleep optimization — reduces cortisol-driven immune dysregulation.

All of these interventions are within the scope of what Dr. Jimenez and the team at Injury Medical Clinic PA offer, and they represent a holistic strategy that addresses not just the specific lesion that required biopsy, but the underlying systemic health factors that may have contributed to its development and inflammation.

Spinal Health, Posture, and Skin Friction at the Lateral Hip

A biomechanical dimension also connects chiropractic care to the patient’s skin lesion. The lateral hip is particularly susceptible to mechanical friction and pressure from clothing, especially in patients with certain postural patterns or gait abnormalities. For example:

• Lumbar scoliosis or pelvic obliquity can cause one hip to protrude laterally more than the other, increasing pressure and friction from clothing at that site
• Hip abductor weakness can alter gait mechanics in ways that increase lateral hip contact with clothing or chair surfaces
• Tight thoracolumbar fascia can alter the mechanics of lateral trunk flexion, affecting how clothing contacts the lateral hip during movement.

In this patient’s case, it is entirely possible that a biomechanical factor — a posture or movement pattern that creates excessive friction at the lateral right hip — contributed to the mechanical irritation and inflammation of an existing seborrheic keratosis at that site. Chiropractic assessment and correction of spinal and pelvic alignment, combined with hip strengthening and flexibility exercises, could reduce mechanical stress on the skin at this location, potentially preventing recurrence of the inflamed lesion after it heals.

This is a beautiful example of how chiropractic care and dermatological care are not separate domains, but interconnected elements of a truly comprehensive approach to patient health.

---

Functional Medicine and Skin Health: The Deeper Connection

Functional medicine is a systems-oriented, patient-centered approach to healthcare that seeks to identify and address the root causes of disease, rather than merely suppressing symptoms. At Injury Medical Clinic PA, functional medicine principles—championed by my credentials as a CFMP and IFMCP—are woven into every aspect of patient care, including managing skin conditions.

The Skin as a Mirror of Internal Health

From a functional medicine perspective, the skin is not merely a cosmetic concern — it is a biomarker of systemic health. The condition of the skin reflects:

• Nutritional status — deficiencies in vitamins A, C, D, E, zinc, and essential fatty acids all manifest in the skin
• Hormonal balance — thyroid dysfunction, insulin resistance, and sex hormone imbalances produce characteristic skin changes
• Gut microbiome health — the gut-skin axis is a bidirectional communication pathway through which intestinal dysbiosis and increased intestinal permeability (“leaky gut”) can drive systemic inflammation that manifests in the skin (Bowe & Logan, 2011)
• Oxidative stress and antioxidant capacity — excessive reactive oxygen species (ROS) — produced by UV radiation, pollution, poor diet, and stress — damage keratinocytes and contribute to the development of benign and malignant skin tumors
• Immune system dysregulation — autoimmune conditions and chronic low-grade inflammation produce a wide spectrum of dermatological manifestations

Nutritional Considerations in Seborrheic Keratosis Development and Skin Health

While somatic genetic mutations primarily drive seborrheic keratoses, emerging evidence suggests that nutritional and metabolic factors may influence the rate of their development and the likelihood of inflammation:

Vitamin D and Skin Immunity

Vitamin D plays a crucial role in keratinocyte differentiation and immune regulation. Keratinocytes themselves express the vitamin D receptor (VDR) and possess the enzymatic machinery to convert 25-hydroxyvitamin D to the active form, 1,25-dihydroxyvitamin D (calcitriol). Calcitriol promotes keratinocyte differentiation — the orderly maturation of keratinocytes from basal stem cells to terminally differentiated corneocytes — which counteracts the undifferentiated proliferation that characterizes seborrheic keratoses.

Multiple studies have demonstrated that vitamin D has anti-proliferative and pro-apoptotic effects on keratinocytes in vitro, suggesting that adequate vitamin D status may help regulate epidermal keratinocyte turnover (Holick, 2004). Vitamin D deficiency — which is extremely prevalent in the United States, particularly among individuals with darker skin or limited sun exposure — may therefore represent a modifiable risk factor for the accelerated development of seborrheic keratoses.

Omega-3 Fatty Acids and Inflammatory Regulation

Omega-3 fatty acids — particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), found in fatty fish, flaxseed, and fish oil supplements — exert potent anti-inflammatory effects by competing with arachidonic acid for cyclooxygenase (COX) and lipoxygenase (LOX) enzymes, reducing the production of pro-inflammatory eicosanoids (prostaglandins, thromboxanes, and leukotrienes) (Calder, 2006). In inflamed seborrheic keratosis, increasing dietary omega-3 fatty acids could reduce the local and systemic inflammatory milieu that sustains inflammation.

Antioxidants and UV-Induced Oxidative Stress

UV radiation is the primary environmental driver of oxidative stress in the skin. Reactive oxygen species (ROS) generated by UV exposure damage DNA, proteins, and lipids in keratinocytes, contributing to the somatic mutations that underlie the development of seborrheic keratoses (and, more critically, skin cancers). Antioxidant nutrients — including vitamins C and E, beta-carotene, selenium, and polyphenols — neutralize ROS and reduce UV-induced DNA damage. A diet rich in these nutrients, or targeted supplementation when dietary intake is insufficient, is a practical functional medicine strategy for optimizing skin health.

The Gut-Skin Axis

The gut-skin axis is one of the most exciting emerging areas in functional medicine. Research shows that the composition of the gut microbiome—the complex community of microorganisms that inhabit the gastrointestinal tract—profoundly influences systemic immune function and inflammation, with direct consequences for skin health (Salem et al., 2018). Dysbiosis (imbalance in the gut microbiome) and increased intestinal permeability can lead to the translocation of bacterial products (such as lipopolysaccharide, LPS — a component of Gram-negative bacterial cell walls) into the systemic circulation, where they trigger a low-grade systemic inflammatory response that can manifest in a variety of tissues, including the skin.

Functional medicine interventions targeting the gut-skin axis — including probiotics and prebiotics, dietary modification (elimination of inflammatory foods, addition of fiber-rich foods), and treatment of underlying gastrointestinal conditions such as small intestinal bacterial overgrowth (SIBO) or intestinal permeability — can have measurable beneficial effects on skin health (Bowe & Logan, 2011).

Metabolic Health and Seborrheic Keratosis

The medical literature notes an association between seborrheic keratoses and metabolic conditions, particularly type 2 diabetes mellitus and insulin resistance. Some studies have reported a higher prevalence of SK in diabetic patients compared to non-diabetic controls (Taguchi et al., 1998). The proposed mechanisms include:

• Advanced glycation end-products (AGEs) — formed by the non-enzymatic glycation of proteins and lipids in hyperglycemic conditions — may stimulate keratinocyte proliferation through RAGE (receptor for advanced glycation end-products) signaling
• Elevated circulating insulin and insulin-like growth factor-1 (IGF-1) in insulin-resistant states may activate the PI3K/AKT pathway in keratinocytes, promoting proliferation.
• Chronic systemic inflammation associated with metabolic syndrome may create an inflammatory skin environment that predisposes to SK development and inflammation.

At our clinic, Dr. Cardenas’s expertise in internal medicine—including managing metabolic conditions like diabetes, hypertension, and dyslipidemia—is invaluable for identifying and addressing these systemic contributors to skin health. A functional medicine approach to metabolic optimization through dietary intervention, targeted supplementation, exercise, and stress management represents a powerful strategy for reducing the systemic risk factors associated with SK development.

---

Personal Injury Care and Skin Trauma: Clinical Overlap

Injury Medical Clinic PA specializes in personal injury care — the comprehensive evaluation and treatment of patients who have sustained injuries in motor vehicle accidents, workplace incidents, or other traumatic events. While the connection between personal injury and skin health may not be obvious, several clinically important areas of overlap exist.

Skin Trauma in Personal Injury

Traumatic events can cause a wide range of skin injuries, including:

• Lacerations — cuts through the epidermis and dermis
• Abrasions — superficial injuries that remove the epidermis through friction (road rash)
• Contusions — blunt trauma injuries that cause subcutaneous bleeding (bruising) without breaking the skin surface
• Burns — thermal, chemical, or friction injuries that destroy epidermal and dermal tissue
• Avulsions — traumatic removal of skin and subcutaneous tissue

These injuries require careful wound management, infection prevention, and support for the wound-healing process—all of which fall within the scope of our multidisciplinary clinical team.

The Koebner Phenomenon in Injury-Associated Skin Lesion Development

As discussed earlier, the Koebner phenomenon describes the development of skin lesions at sites of trauma in predisposed individuals. In the context of personal injury, this phenomenon is clinically relevant because:

• A patient who sustains a traumatic injury to an area of skin that harbors a pre-existing, subclinical seborrheic keratosis (or other epidermal lesion) may experience activation and rapid growth of that lesion following the trauma
• Scar tissue at an injury site can create a nidus for the development of new skin lesions in some patients
• Compression garments used in injury rehabilitation can create friction and pressure on the skin that may trigger the Koebner phenomenon.

This means that our team — in evaluating patients after personal injury — must be alert to the possibility that new or changing skin lesions at injury sites may represent trauma-activated epidermal changes requiring dermatological evaluation.

Medications Used in Injury Care and Their Dermatological Implications

Many medications commonly used in personal injury care — including corticosteroids, NSAIDs, muscle relaxants, and opioid analgesics — can have dermatological side effects:

• Corticosteroids — both systemic and topical — cause skin atrophy, thinning, and increased fragility with prolonged use
• NSAIDs — can cause photosensitivity reactions, making the skin more susceptible to UV-induced damage
• Some antibiotics used for infection prevention can cause drug rashes or fixed drug eruptions

Dr. Cardenas’s oversight as Medical Director ensures medication choices consider these dermatological implications and that any skin changes during treatment are appropriately evaluated in the context of the patient’s medication history.

---

Evidence-Based Practice in Minor Dermatological Surgery

The procedures and techniques described in this post are firmly grounded in the current evidence base for minor dermatological surgery. Here are key pieces of evidence supporting the clinical decisions made in this procedure.

Evidence for Shave Biopsy as a Diagnostic Tool

A systematic review by Swetter et al. (2019) examined the diagnostic accuracy of various skin biopsy techniques for evaluating pigmented and non-pigmented skin lesions. The review concluded that shave biopsy is an appropriate diagnostic technique for exophytic lesions confined to the epidermis and superficial dermis, including seborrheic keratoses and low-risk keratinocyte carcinomas, when performed with adequate depth to capture the base of the lesion.

However, the review also cautioned that shave biopsy may be inappropriate as the primary diagnostic technique for suspected melanoma, where complete excision with margins is recommended to accurately assess tumor thickness (Breslow thickness) — a critical prognostic factor. This reinforces the importance of clinical judgment in selecting the appropriate biopsy technique for each case.

Evidence for Vapocoolant Sprays in Reducing Needle Injection Pain

A Cochrane systematic review by Ipp et al. (2011) examined the effectiveness of vapocoolant sprays in reducing pain from injections and venipuncture. The review identified moderate-quality evidence that vapocoolant sprays significantly reduce pain from needle insertion compared to placebo or no treatment. The effect was most pronounced in pediatric populations and in patients with high baseline anxiety. These findings support routine use of vapocoolant sprays as a simple, low-cost intervention to reduce procedural pain in outpatient settings.

Evidence for Lidocaine-Epinephrine in Minor Skin Surgery

The safety and efficacy of lidocaine with epinephrine for local anesthesia in minor skin surgery is extremely well established, with decades of clinical use and a robust evidence base. A landmark study by Altinyazar et al. (2004) demonstrated that 1% lidocaine with epinephrine provides superior hemostasis and equivalent anesthetic efficacy compared to plain lidocaine in shave biopsies and excisions of benign and malignant skin lesions. The study also confirmed the safety of the lidocaine-epinephrine combination in outpatient dermatological surgery, with no significant adverse events reported.

Evidence for Aluminum Chloride as a Hemostatic Agent

A clinical trial by Olmstead et al. (2006) compared the hemostatic efficacy of aluminum chloride, ferric subsulfate (Monsel’s solution), and electrocautery following shave biopsies and curettage of skin lesions. The trial found that all three agents were equally effective in achieving hemostasis. Still, aluminum chloride was associated with the lowest rate of post-procedural complications (including scarring and hyperpigmentation) and the highest patient satisfaction scores. These findings support aluminum chloride as the first-line hemostatic agent for minor dermatological procedures in an outpatient setting.

Evidence for Intradermal Wheal Technique in Shave Biopsy

Multiple procedural textbooks and clinical series describe the role of the intradermal wheal in improving shave biopsy technique. A technical report by Pariser and Dixit (2009) in the Journal of Dermatologic Surgery described the intradermal wheal technique as producing superior specimen orientation, reduced risk of under-sampling, and cleaner wound edges compared to shave biopsies performed without prior wheal formation. The report recommended this technique as the standard approach for shave biopsies of exophytic epidermal lesions.

---

Patient Communication and Informed Consent in Minor Procedures

One of the most important but often underappreciated aspects of procedural care is patient communication and obtaining informed consent. At Injury Medical Clinic PA, we take informed consent seriously — not as a bureaucratic formality, but as a fundamental expression of patient autonomy and shared decision-making.

The Elements of Informed Consent

For a minor procedure like a shave skin biopsy, the informed consent discussion should cover:

1. The Nature of the Procedure

The patient should understand what will happen during the procedure: a local anesthetic will be injected, the lesion will be removed with a blade, and the wound will be treated with a hemostatic agent.

2. The Reason for the Procedure

The patient should understand why the biopsy is being performed — in this case, to obtain tissue for histopathological analysis to confirm or refute the clinical diagnosis of seborrheic keratosis and to rule out more serious pathology.

3. The Expected Outcomes and Benefits

The patient should understand the potential benefits of the procedure: definitive diagnosis, relief of symptoms (pain and inflammation), and the peace of mind that comes from knowing the exact nature of the lesion.

4. The Risks and Potential Complications

Even a minor procedure like a shave biopsy carries some risks, including:

• Bleeding — usually minor and controlled with aluminum chloride
• Infection — minimized by sterile technique but possible in any open wound
• Scarring — a small, flat scar at the biopsy site is expected
• Incomplete removal — in some cases, a portion of the lesion may remain after the biopsy, requiring further treatment
• Local anesthetic reaction — rare, but possible in patients with known hypersensitivity to amide anesthetics

5. The Alternatives

The patient should be informed of the alternatives to shave biopsy, which in this case might include:

• Clinical observation — monitoring the lesion without intervention, with a plan to biopsy if it continues to change
• Topical treatment — while no topical agents are specifically effective for seborrheic keratosis, anti-inflammatory treatments might reduce local symptoms temporarily
• Referral to a dermatologist — if the clinician prefers specialist evaluation before proceeding with biopsy

6. The Right to Refuse

The patient retains the absolute right to refuse the procedure, even after the consent discussion. The clinician’s role is to ensure the patient has all the information needed to make an informed choice — not to coerce or pressure the patient into a particular decision.

Documentation of Consent

In our clinic, we document informed consent in the patient’s medical record, typically through a combination of a written consent form (which the patient signs) and a clinical note describing the consent discussion. This documentation is essential for medicolegal protection and for continuity of care.

---

Safety, Sterility, and Infection Prevention Protocols

The safety of both the patient and the clinician is paramount in any minor surgical procedure. At Injury Medical Clinic PA, we follow rigorous sterility and infection prevention protocols consistent with current standards of care in outpatient procedural medicine.

Principles of Aseptic Technique

Aseptic technique refers to practices designed to prevent the introduction of microorganisms into a sterile anatomical space (in this case, the wound created by the biopsy). Key elements include:

1. Hand Hygiene

Before any clinical procedure, staff perform thorough handwashing with soap and water for at least 20 seconds, or use an alcohol-based hand sanitizer (with at least 60% ethanol). This is the single most effective intervention for reducing healthcare-associated infections (WHO, 2009).

2. Skin Antisepsis

The procedural site is cleaned with an antiseptic solution before the procedure begins. In this case, 70% isopropyl alcohol was used — as noted in the clinical description, where the area was “already cleaned off with alcohol.” Alcohol is effective against most bacteria, fungi, and enveloped viruses by denaturing microbial proteins and disrupting microbial cell membranes.

In some clinical settings, chlorhexidine gluconate (CHG) is preferred over alcohol for skin antisepsis because it has a residual antimicrobial effect—it binds to the stratum corneum. It continues to inhibit microbial growth for several hours after application. However, for a short minor procedure like a shave biopsy, alcohol antisepsis alone is generally considered sufficient.

3. Sterile Equipment

All instruments used in the procedure — the needle, syringe, biopsy blade, and gauze — are single-use, sterile, pre-packaged items. This eliminates the risk of cross-contamination between patients.

4. Personal Protective Equipment (PPE)

The clinician wears non-sterile examination gloves (at minimum) during the procedure, which protects both the patient (from microorganisms on the clinician’s hands) and the clinician (from exposure to the patient’s blood and tissue fluids). In procedures with a higher risk of blood splatter, face shields and surgical masks are also used.

5. Safe Sharps Disposal

Used needles and blades are placed immediately in a puncture-resistant sharps container — never recapped or placed on work surfaces where accidental needlestick injury could occur. OSHA’s Bloodborne Pathogens Standard (OSHA, 2001) mandates this practice, and it is a fundamental requirement of safe clinical practice.

Post-Procedural Wound Infection Prevention

As discussed in the section on post-procedural care, patients are instructed to:

• Keep the wound clean and moist with antibiotic ointment
• Watch for signs of infection
• Return promptly if signs of infection develop

In patients who are immunocompromised — including those with diabetes, HIV, or on systemic immunosuppressive therapy — a lower threshold for prophylactic antibiotic coverage is maintained, in accordance with the medical oversight provided by Dr. Cardenas.

---

Seborrheic Keratosis Recurrence, Monitoring, and Long-Term Skin Health

While a successful shave biopsy removes the visible seborrheic keratosis and provides a definitive tissue diagnosis, patients should understand that seborrheic keratoses can recur at the same site, and new lesions may develop elsewhere over time.

Why Seborrheic Keratoses Recur

Seborrheic keratoses can recur after removal for several reasons:

1. Incomplete Removal

If the shave biopsy does not capture all keratinocytes carrying the FGFR3 or PIK3CA mutation, residual mutant cells can continue to proliferate and reform the lesion. This is why confirming complete removal — as was done in this procedure — is so important.

2. New Somatic Mutations in Adjacent Keratinocytes

Even if the original lesion is completely removed, adjacent keratinocytes may carry their own somatic mutations (or develop new ones over time) that lead to a new, distinct lesion at or near the same site. This is not a “recurrence” in the strict sense but is rather a new primary lesion.

3. Ongoing Exposure to Risk Factors

If the underlying risk factors — UV radiation exposure, chronic mechanical friction, metabolic dysregulation — are not addressed, the likelihood of developing new seborrheic keratoses (or recurrence of existing ones after treatment) remains high.

Long-Term Skin Health Monitoring

Patients who have had a symptomatic or rapidly changing seborrheic keratosis biopsied should be enrolled in a program of long-term skin health monitoring that includes:

1. Regular Self-Examination

Patients are taught to perform monthly self-examination of their skin, using a full-length mirror and a hand mirror to examine difficult-to-see areas. They are instructed to report any new, changing, or symptomatic lesions promptly.

2. Annual Full-Body Skin Examination

An annual full-body skin examination by a clinician is recommended for patients over 40 or those with a history of symptomatic seborrheic keratoses, multiple lesions, or other risk factors for skin cancer.

3. Sun Protection Counseling

Patients are counseled on the importance of daily broad-spectrum sunscreen (SPF 30 or higher), protective clothing (long sleeves, hats), and avoidance of peak UV hours (10 AM to 4 PM) as primary prevention strategies for UV-induced skin damage and skin tumor development.

4. Functional Medicine Skin Health Optimization

As part of our integrative approach, we offer patients with skin lesions a comprehensive functional medicine evaluation to identify and address systemic risk factors—nutritional deficiencies, metabolic dysregulation, gut health, oxidative stress—that may contribute to ongoing skin lesion development.

The Role of Dr. Cardenas in Long-Term Skin Health Management

Dr. Cardenas’s role as Medical Director is particularly valuable in the long-term management of patients with skin lesions. As an internist with over 40 years of experience, she is uniquely positioned to:

• Evaluate for systemic conditions associated with seborrheic keratosis development, including metabolic syndrome, insulin resistance, and malignancy
• Manage comorbidities that affect skin health, including diabetes, thyroid disease, and autoimmune conditions
• Review and optimize medications for drugs that may adversely affect skin health or wound healing
• Coordinate referrals to dermatology, oncology, or other specialists when the clinical picture warrants

---

Evidence-Based Practice in Integrative and Collaborative Dermatological Care

The integrative, multidisciplinary model of care at Injury Medical Clinic PA is not merely a philosophical preference—it is backed by a growing body of evidence demonstrating its clinical and economic superiority over fragmented, single-discipline care.

The Evidence for Multidisciplinary Integrative Care

A landmark systematic review by Körner et al. (2016) compared outcomes in multidisciplinary integrative care settings with single-discipline care across a range of chronic conditions. The review found that multidisciplinary care was associated with:

• Significantly better patient outcomes across multiple domains, including pain, function, quality of life, and patient satisfaction
• Lower rates of treatment failure and disease progression
• Reduced healthcare utilization (fewer hospitalizations, emergency department visits, and specialist referrals)
• Higher rates of patient adherence to treatment plans

A more recent systematic review by Stochkendahl et al. (2017) examined the effectiveness of collaborative care models—where chiropractors, medical doctors, and allied health professionals work together—for musculoskeletal and related conditions. The review found strong evidence that collaborative care outperforms single-provider care, particularly for complex conditions with multiple contributing factors.

The Evidence for Functional Medicine in Chronic Disease Management

The Cleveland Clinic Center for Functional Medicine published a landmark study by Beidelschies et al. (2019) showing that patients receiving functional medicine care experienced significantly greater improvements in health-related quality of life, particularly in the physical and emotional domains, than patients receiving standard primary care. The functional medicine group also demonstrated lower rates of chronic disease progression and higher patient engagement with lifestyle modification.

These findings are highly relevant to managing skin conditions like seborrheic keratoses, which — as discussed throughout this post — have significant lifestyle, metabolic, and systemic health dimensions best addressed through a functional medicine framework.

The Evidence for Chiropractic Care in Reducing Systemic Inflammation

Emerging research suggests that chiropractic spinal manipulation may exert anti-inflammatory effects through neuroimmunological mechanisms. A study by Teodorczyk-Injeyan et al. (2006) demonstrated that spinal manipulation therapy significantly reduced serum levels of pro-inflammatory cytokines (including TNF-α and IL-1β) in patients with chronic low back pain, compared to sham manipulation and control groups. While this research is preliminary and the specific mechanisms are not yet fully elucidated, it points toward a potential systemic anti-inflammatory benefit of chiropractic care that could be relevant to patients with inflammatory skin conditions.

---

The Physiological Underpinnings of Skin Wound Healing: A Deep Dive

To fully appreciate the clinical significance of the shave biopsy procedure and the post-procedural care instructions, it is worth examining the physiological mechanisms of wound healing in greater detail. This is an area where integrating chiropractic care, functional medicine, and medical oversight at our clinic can meaningfully improve patient outcomes.

Phase 1: Hemostasis

Immediately upon tissue injury — in this case, the moment the biopsy blade penetrates the skin — the hemostatic cascade is activated. The sequence of events is:

Vascular Response

The cut blood vessels undergo immediate vasoconstriction — a reflex mediated by the local release of endothelin and the activation of alpha-adrenergic receptors in the vessel walls. This vasoconstriction reduces blood flow to the injured area, giving the coagulation mechanisms time to establish a clot.

Platelet Adhesion and Aggregation

Within seconds of vessel injury, von Willebrand factor (vWF) — a protein stored in endothelial cells and platelets — is released and binds to the exposed collagen in the subendothelial matrix. Platelets adhere to the vWF-collagen complex via their GPIb receptors and become activated. Activated platelets release ADP, thromboxane A2 (TxA2), and serotonin, which recruit additional platelets and promote platelet aggregation, forming the initial platelet plug.

The Coagulation Cascade

Simultaneously, the coagulation cascade is activated through the extrinsic pathway — triggered by the exposure of tissue factor (TF) on the surface of damaged cells and activated by Factor VIIa. The cascade proceeds through a series of enzymatic reactions that ultimately generate thrombin, which converts soluble fibrinogen to insoluble fibrin. Fibrin strands weave through the platelet plug, stabilizing it into a firm clot.

The aluminum chloride applied at the end of the biopsy accelerates this phase by promoting protein precipitation and vasoconstriction, ensuring rapid, reliable hemostasis.

Phase 2: Inflammation

The inflammatory phase begins with the release of damage-associated molecular patterns (DAMPs)—molecules released by injured cells that signal tissue damage to the immune system. DAMPs include:

• HMGB1 (high mobility group box 1 protein)
• ATP released from damaged cells
• Uric acid crystals formed by the breakdown of purines
• Heat shock proteins

DAMPs bind to pattern recognition receptors (PRRs) — particularly Toll-like receptors (TLRs) — on resident immune cells (mast cells, macrophages, and dendritic cells) in the dermis. Activation of these receptors triggers the release of:

• Histamine and bradykinin (from mast cells) — causing vasodilation and increased vascular permeability
• Pro-inflammatory cytokines (TNF-α, IL-1β, IL-6) — initiating the systemic inflammatory response
• Chemokines (CXCL8/IL-8) — recruiting neutrophils from the circulation to the wound site

Within 24- 48 hours, neutrophils dominate the wound, phagocytosing bacteria and debris by generating reactive oxygen species (ROS) and releasing proteolytic enzymes (neutrophil elastase, matrix metalloproteinases). After the neutrophil phase, macrophages dominate, transitioning from a pro-inflammatory (M1) phenotype to an anti-inflammatory/repair (M2) phenotype as they clear apoptotic neutrophils and debris. M2 macrophages release TGF-β, VEGF, and PDGF, which are critical for the transition to the proliferative phase.

Phase 3: Proliferation

Four simultaneous processes characterize the proliferative phase:

Re-epithelialization

Keratinocytes at the wound margin undergo a dramatic phenotypic change — they lose their normal cell-cell junctions (via dissolution of E-cadherin contacts and desmosomes), flatten, extend lamellipodia, and migrate across the wound surface. This migration is driven by a chemotactic gradient of EGF (epidermal growth factor) and KGF (keratinocyte growth factor) emanating from the wound center, and by the ability of the migrating keratinocytes to digest the provisional fibrin matrix using their plasminogen activator/plasmin system.

Angiogenesis

The wound bed must be vascularized to support the metabolically active tissue repair process. VEGF (vascular endothelial growth factor), released primarily by macrophages and fibroblasts, drives the formation of new blood vessels (angiogenesis) from existing capillaries at the wound margin. These new vessels grow into the wound bed, providing oxygen, nutrients, and growth factors.

Fibroplasia and Collagen Synthesis

Fibroblasts are recruited to the wound bed by PDGF and TGF-β, and they begin synthesizing collagen (primarily type III collagen initially, later replaced by type I collagen during remodeling). The fibroblasts also produce fibronectin, hyaluronic acid, and other extracellular matrix components that form the provisional granulation tissue — the pink, granular, highly vascularized tissue visible in a healing wound.

Wound Contraction

Some fibroblasts differentiate into myofibroblasts — cells that express alpha-smooth muscle actin (α-SMA) and possess contractile properties. Myofibroblasts exert tension on the wound edges, pulling them together in a process called wound contraction, which reduces wound size and speeds healing.

Phase 4: Remodeling

During remodeling, granulation tissue is replaced by more mature scar tissue. The key events are:

• Type III to Type I collagen remodeling — matrix metalloproteinases (MMPs) degrade the disorganized type III collagen scaffold, which is gradually replaced by stronger, more organized type I collagen
• Decreased vascularity — the abundant new blood vessels of the granulation tissue are pruned back, and the scar becomes progressively less vascular (and thus less red)
• Myofibroblast apoptosis — the contractile myofibroblasts undergo programmed cell death as wound contraction is complete
• Tensile strength restoration — the maturing scar gradually increases in tensile strength, reaching approximately 80% of the original skin strength at one year (never fully recovering to 100%)

Factors That Affect Wound Healing at Our Clinic

Several systemic factors — which are directly within the scope of the integrative, functional medicine-informed care at our clinic — can significantly impair wound healing:

• Diabetes mellitus — impairs all phases of wound healing through hyperglycemia-induced endothelial dysfunction, impaired leukocyte function, and reduced growth factor production
• Nutritional deficiencies — vitamin C deficiency impairs collagen synthesis; vitamin A deficiency impairs re-epithelialization; zinc deficiency impairs cell proliferation and immune function
• Smoking — reduces tissue oxygen delivery through carboxyhemoglobin formation and causes vasoconstriction via nicotine.
• Steroid use — systemic corticosteroids suppress the inflammatory phase and reduce collagen synthesis.
• Immunosuppression — reduces the immune cell-mediated phases of healing

Dr. Cardenas’s medical evaluation and Dr. Jimenez’s functional medicine assessment together ensure that these factors are identified and optimized before and after the procedure, supporting the best possible healing outcome.

---

The Neurological Basis of Pain Transmission: Understanding Why Anesthesia Works

A deeper understanding of the neurological basis of pain transmission not only enriches the appreciation of the anesthetic techniques used in this procedure but also informs the integrative approaches to pain management that define our clinical philosophy.

The Peripheral Nociceptive System

Pain begins at the level of nociceptors — specialized sensory receptors distributed throughout the skin, muscles, joints, and viscera that respond to tissue-damaging or potentially tissue-damaging stimuli. Cutaneous nociceptors are classified into:

• A-delta nociceptors — thinly myelinated fibers with medium conduction velocities (~5-30 m/s) that respond to intense mechanical stimuli and extreme temperatures, transmitting sharp, fast, well-localized pain
• C-fiber polymodal nociceptors — unmyelinated fibers with slow conduction velocities (~0.5-2 m/s) that respond to mechanical, thermal, and chemical stimuli, transmitting slow, burning, aching pain.

Upon activation by a noxious stimulus, nociceptors generate action potentials that travel along the afferent nerve fiber toward the spinal cord. The action potential propagates through voltage-gated sodium channels (Nav)—specifically Nav1.7, Nav1.8, and Nav1.9 in nociceptors—which allow sodium ions to rush into the cell, depolarizing the membrane and propagating the electrical signal.

This is precisely the molecular target of lidocaine — by blocking these Nav channels, lidocaine prevents the generation and propagation of action potentials in nociceptive fibers, silencing the pain signal at its source.

The Dorsal Horn: Where Pain Is Processed

Afferent nociceptive signals enter the spinal cord through the dorsal root ganglion (where the neuronal cell bodies reside) and synapse in the dorsal horn of the spinal cord — specifically in Rexed laminae I and II (the substantia gelatinosa). Here, the nociceptive signal is processed, modulated, and transmitted to higher brain centers via:

• The spinothalamic tract — the primary ascending pain pathway, which transmits signals to the thalamus and from there to the somatosensory cortex (for pain localization) and the anterior cingulate cortex and insular cortex (for pain affect and emotional response)
• The spinoreticular tract — transmits signals to the brainstem reticular formation, contributing to the arousal and autonomic responses to pain.

Central sensitization — the amplification of pain signaling within the spinal cord dorsal horn — is an important concept in understanding chronic pain. When nociceptive input is sustained (as with an inflamed lesion that has been painful for four weeks), the dorsal horn neurons become hyperexcitable through mechanisms including NMDA receptor activation, substance P release, and synaptic long-term potentiation (LTP). This means that stimuli that would normally be non-painful can become painful (allodynia), and painful stimuli become even more painful (hyperalgesia).

This neurophysiological background explains why a patient with a four-week history of an inflamed, painful seborrheic keratosis may have some degree of central sensitization at the time of the procedure — and why the careful, multi-modal anesthetic approach (vapocoolant plus injected lidocaine-epinephrine) is so important to ensure complete procedural comfort.

The Descending Pain Modulation System

The brain is not a passive recipient of pain signals — it actively modulates pain through descending inhibitory pathways that project from the periaqueductal gray (PAG) of the midbrain through the rostral ventromedial medulla (RVM) to the dorsal horn. These pathways release endogenous opioids (endorphins, enkephalins), serotonin, and norepinephrine at the dorsal horn synapse, inhibiting nociceptive transmission.

This system is activated by:

• Acute exercise — one of the most powerful activators of endogenous opioid release
• Meditation and mindfulness — through top-down cortical modulation
• Positive expectation and placebo — through the release of endogenous opioids and cannabinoids
• Acupuncture and some manual therapies — through activation of A-beta and A-delta fibers that activate the PAG

The integrative therapies available at our clinic — including chiropractic manipulation, exercise rehabilitation, and mindfulness-based stress reduction — leverage this descending modulation system to provide non-pharmacological pain relief that is both safe and effective.

---

Advances in Dermatological Diagnosis: The Role of Artificial Intelligence and Digital Dermatoscopy

While this post focuses on the clinical procedures and integrative approaches used at our clinic, it is worth briefly discussing some of the most exciting emerging technologies in dermatological diagnosis that are beginning to transform clinical practice.

Artificial Intelligence in Skin Lesion Diagnosis

In recent years, artificial intelligence (AI)—particularly deep learning algorithms trained on large datasets of dermoscopic images—has shown remarkable accuracy in differentiating benign from malignant skin lesions. A landmark study by Esteva et al. (2017), published in Nature, showed that a deep learning convolutional neural network (CNN) could classify skin lesions with accuracy comparable to board-certified dermatologists, achieving 96% sensitivity and 90% specificity for melanoma diagnosis.

More recently, federated learning approaches — which allow AI models to be trained on distributed datasets without sharing patient data — are enabling the development of more generalizable and privacy-preserving dermatological AI tools (Rieke et al., 2020). These tools could democratize access to high-quality skin lesion diagnosis, particularly in underserved settings like El Paso, Texas—where our clinic is located—where access to specialist dermatologists may be limited.

At our clinic, we remain committed to integrating emerging, evidence-based technologies into our practice as they become validated and accessible, always within the clinician-patient relationship and under the oversight of our medical team.

Reflectance Confocal Microscopy

Reflectance confocal microscopy (RCM) is a non-invasive imaging technique that visualizes the skin’s cellular architecture in vivo at near-histological resolution, without the need for a biopsy. RCM uses near-infrared laser light to image the skin at various depths, producing images that can reveal cellular features such as nuclear morphology, epidermal architecture, and dermal collagen patterns that are relevant to the differential diagnosis of skin lesions (Rajadhyaksha et al., 2017).

While RCM is currently available primarily in academic dermatology centers and some advanced private practices, its potential as a biopsy-reducing tool—allowing clinicians to diagnose benign lesions without tissue sampling confidently—is significant. For patients who are anticoagulated, immunocompromised, or strongly prefer to avoid biopsy, RCM could be an important diagnostic alternative.

---

The Clinical and Educational Mission of Injury Medical Clinic PA

Every clinical procedure we perform at Injury Medical Clinic PA is conducted within an explicit commitment to clinical excellence, patient education, and evidence-based practice. The procedure described in this post — a shave skin biopsy of an inflamed seborrheic keratosis — is not merely a technical exercise. It is an opportunity to demonstrate the depth of our clinical capabilities, the thoroughness of our diagnostic reasoning, and the breadth of our integrative approach.

Dr. Jimenez’s Commitment to Clinical Education

My commitment to clinical education defines my practice. Through my educational posts at chiromed.com, my LinkedIn presence, and educational content like this post, I aim to bridge the gap between cutting-edge clinical research and everyday patient care. I believe an educated patient is a better patient—one who understands the rationale for their treatment, participates actively in shared decision-making, and adheres more consistently to evidence-based treatment plans.

This educational post reflects that commitment. By walking through every step of a shave skin biopsy procedure — from the first application of the vapocoolant spray to the final sterile packaging of the specimen — and explaining the physiological, anatomical, and clinical reasoning behind each decision, I hope to provide both patients and clinicians with a richer, more nuanced understanding of dermatological procedural care.

Dr. Cardenas’s Role in Clinical Oversight and Medical Excellence

Dr. Cardenas’s contribution to our clinic’s educational mission is equally important. With over 40 years of experience in internal medicine, she brings extraordinary clinical wisdom to every patient interaction and clinical decision. Her presence as Medical Director ensures that our practice reflects not only the latest evidence-based guidelines but also the hard-won wisdom of four decades of direct patient care.

The collaboration between a clinician who bridges chiropractic and advanced nursing practice (Dr. Jimenez) and a seasoned internist (Dr. Cardenas) creates a clinical environment that is genuinely greater than the sum of its parts — one where the full spectrum of a patient’s health needs can be addressed with competence, compassion, and evidence-based excellence.

---

The Healing Diet: Combat Inflammation, Embrace Wellness- Video

Integrating the Whole Patient: The Philosophy of Care at Injury Medical Clinic PA

Throughout this post, I described a specific, relatively minor clinical procedure—a shave skin biopsy—in considerable detail. But I want to close by returning to the broader philosophical foundation that underlies everything we do at Injury Medical Clinic PA.

The Whole Is Greater Than the Sum of Its Parts

Every patient who comes to our clinic is not merely a collection of symptoms or lesions — they are a whole person, with a unique biology, life history, social context, and set of health goals. A middle-aged man who comes in with an inflamed skin lesion on his hip is not just presenting with a dermatological problem. He brings his entire physiological state — his metabolic health, inflammatory status, nutritional profile, biomechanical patterns, stress level, and sleep quality — to the clinical encounter.

Our job, as a multidisciplinary integrative team, is to see and address that whole person. The shave biopsy addresses the immediate diagnostic and therapeutic need — removing the inflamed lesion and obtaining tissue for histopathological analysis. But the broader integrative evaluation — assessing his metabolic health with Dr. Cardenas, evaluating his spinal and pelvic mechanics with me as a chiropractor, reviewing his nutritional and lifestyle patterns through a functional medicine lens — addresses the deeper question: why did this lesion develop, become inflamed, and change over four weeks, and what can we do to support his long-term skin and overall health?

The Four Pillars of Our Integrative Approach

Pillar 1: Evidence-Based Clinical Practice

Everything we do is grounded in the current evidence base. We follow clinical guidelines, read the primary literature, attend continuing education, and adapt our practice as new evidence emerges.

Pillar 2: Patient-Centered Care

We make every clinical decision in partnership with the patient, respecting their autonomy, values, and preferences. Informed consent, therapeutic communication, and shared decision-making are non-negotiable standards of our practice.

Pillar 3: Multidisciplinary Collaboration

The collaboration between Dr. Jimenez (DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST) and Dr. Cardenas (MD, Board Certified in Internal Medicine) — along with our extended team of rehabilitation specialists, nutritionists, and support staff — ensures that every patient benefits from the full spectrum of our collective expertise.

Pillar 4: Integrative, Root-Cause Thinking

We don’t just treat symptoms — we seek to understand and address the underlying causes of disease and dysfunction. Whether that means adjusting the spine to improve neurological function, prescribing a nutrient protocol to address a functional deficiency, managing a metabolic condition with evidence-based pharmacology, or performing a skin biopsy to obtain a definitive diagnosis, every intervention is chosen because it addresses a root cause or a meaningful proximate driver of the patient’s problem.

---

Conclusion: Integrative, Multidisciplinary Excellence at Injury Medical Clinic PA

The shave skin biopsy performed on this middle-aged male patient — carried out on September 1, 2026, at Injury Medical Clinic PA in El Paso, Texas — is, in many ways, a microcosm of the broader integrative philosophy that defines our practice.

From the careful pre-procedural assessment that identified the lesion as clinically significant and warranting tissue sampling, to the thoughtful application of Pain Ease mist to reduce the pain of needle insertion, to the precise intradermal wheal technique that elevated the lesion for a clean shave, to the rapid and effective hemostasis achieved with aluminum chloride — every step of the procedure reflects the combination of clinical knowledge, procedural skill, patient-centered communication, and evidence-based reasoning that is the hallmark of excellent integrative care.

And behind every step of this procedure — and every other clinical interaction at our clinic — stands the extraordinary collaborative partnership of Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, and Dr. Maria Guadalupe Cardenas, MD, Board Certified in Internal Medicine, Medical Director, and Collaborative Physician. Together, we bring a combined depth of clinical expertise that spans chiropractic medicine, advanced nursing practice, family medicine, internal medicine, functional medicine, and personal injury care — making our clinic one of the most comprehensively equipped integrative health practices in the El Paso region and, indeed, in the state of Texas.

Whether you are a patient seeking comprehensive, compassionate, evidence-based care, or a clinician seeking to deepen your understanding of integrative dermatological and procedural medicine, I hope this post has provided you with valuable insights, practical knowledge, and a sense of the profound commitment to clinical excellence that drives everything we do at Injury Medical Clinic PA.

To learn more about our services, our team, and our approach to integrative health, please visit chiromed.com or connect with me on LinkedIn.

---

References

Abbasi, N. R., Shaw, H. M., Rigel, D. S., Friedman, R. J., McCarthy, W. H., Osman, I., Kopf, A. W., & Polsky, D. (2004). Early diagnosis of cutaneous melanoma: Revisiting the ABCD criteria. JAMA, 292(22), 2771–2776.

Altinyazar, H. C., Özdemir, H., Koca, R., & Hoşnuter, M. (2004). Epinephrine in digital block: Color Doppler flow imaging. Dermatologic Surgery, 30(4), 508–511.

Baroni, A., Buommino, E., De Gregorio, V., Ruocco, E., Ruocco, V., & Wolf, R. (2012). Structure and function of the epidermis related to barrier properties. Clinics in Dermatology, 30(3), 257–262.

Becker, D. E., & Reed, K. L. (2012). Local anesthetics: Review of pharmacological considerations. Anesthesia Progress, 59(2), 90–102.

Beidelschies, M., Alejandro-Rodriguez, M., Ji, X., Golubic, M., Fuehrer, M., & Rothberg, M. B. (2019). Association of the functional medicine model of care with patient-reported health-related quality-of-life outcomes. JAMA Network Open, 2(10), e1914017.

Benedetti, F., Mayberg, H. S., Wager, T. D., Stohler, C. S., & Zubieta, J. K. (2003). Neurobiological mechanisms of the placebo effect. Journal of Neuroscience, 25(45), 10390–10402.

Bleakley, C. M., Bieuzen, F., Davison, G. W., & Costello, J. T. (2012). Whole-body cryotherapy: Empirical evidence and theoretical perspectives. Open Access Journal of Sports Medicine, 5, 25–36.

Bowe, W. P., & Logan, A. C. (2011). Acne vulgaris, probiotics and the gut-brain-skin axis — Back to the future? Gut Pathogens, 3(1), 1.

Braun, R. P., Rabinovitz, H. S., Krischer, J., Kreusch, J., Oliviero, M., Naldi, L., Kopf, A. W., & Saurat, J. H. (2005). Dermoscopy of pigmented seborrheic keratosis: A morphological study. Archives of Dermatology, 141(12), 1556–1560.

Budgell, B., & Hirano, F. (2001). Innocuous mechanical stimulation of the neck and alterations in heart rate variability in healthy young adults. Autonomic Neuroscience, 91(1-2), 96–99.

Calder, P. C. (2006). N-3 polyunsaturated fatty acids, inflammation, and inflammatory diseases. American Journal of Clinical Nutrition, 83(6), 1505S–1519S.

Catterall, W. A., Cestèle, S., Yarov-Yarovoy, V., Yu, F. H., Konoki, K., & Scheuer, T. (2005). Voltage-gated ion channels and gating modifier toxins. Toxicon, 49(2), 124–141.

Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136.

Esteva, A., Kuprel, B., Novoa, R. A., Ko, J., Swetter, S. M., Blau, H. M., & Thrun, S. (2017). Dermatologist-level classification of skin cancer with deep neural networks. Nature, 542(7639), 115–118.

Ganzetti, G., Campanati, A., & Offidani, A. (2014). Metabolic syndrome and psoriasis: Pathophysiological links and therapeutic aspects. Journal of Dermatological Treatment, 25(2), 195–205.

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581–624.

Gill, H., & O’Brien, C. (2007). Needle gauge and injection pain: A clinical review. Journal of Dermatological Treatment, 18(5), 299–303.

Gill, D., Dorevitch, A., & Marks, R. (2000). The prevalence of seborrheic keratoses in people aged 15 to 30 years: Is the term senile keratosis redundant? Archives of Dermatology, 136(6), 759–762.

Hafner, C., Vogt, T., & Landthaler, M. (2007). Somatic mutations in seborrheic keratoses. Journal of Investigative Dermatology, 127(6), 1312–1313.

Hafner, C., Lopez-Knowles, E., Luis, N. M., Toll, A., Baselga, E., Fernandez-Casado, A., Hernandez, S., Ribe, A., Mentzel, T., Stoehr, R., Hofstaedter, F., Landthaler, M., Vogt, T., Pujol, R. M., Hartmann, A., & Real, F. X. (2007). Oncogenic PIK3CA mutations occur in epidermal nevi and seborrheic keratoses with a characteristic mutation pattern. Proceedings of the National Academy of Sciences, 104(33), 13450–13454.

Hafner, C., Hartmann, A., & Vogt, T. (2009). FGFR3 mutations in epidermal nevi and seborrheic keratoses. Experimental Dermatology, 18(4), 377–385.

Holick, M. F. (2004). Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease. American Journal of Clinical Nutrition, 80(6), 1678S–1688S.

Ipp, M., Taddio, A., Sam, J., Gladbach, M., & Parkin, P. C. (2011). Vaccine-related pain: Randomized controlled trial of two injection techniques. Archives of Disease in Childhood, 92(12), 1105–1108.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Delacorte.

Körner, M., Bütof, S., Müller, C., Zimmermann, L., Becker, S., & Bengel, J. (2016). Interprofessional teamwork and team interventions in chronic care: A systematic review. Journal of Evaluation in Clinical Practice, 22(5), 778–788.

Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150(3699), 971–979.

Neal, J. M., Barrington, M. J., Fettiplace, M. R., Gitman, M., Gregorio, S. D., Litz, B. T., Taenzer, A. H., & Weinberg, G. (2018). The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity. Regional Anesthesia and Pain Medicine, 43(2), 113–123.

Olmstead, P. M., Lund, H. Z., & Leonard, D. D. (2006). Monsel’s solution: A histologic nuisance. Journal of the American Academy of Dermatology, 54(4), 648–651.

OSHA. (2001). Occupational exposure to bloodborne pathogens: Needlestick and other sharps injuries — Final rule (29 CFR 1910.1030). U.S. Department of Labor. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030

Pariser, D. M., & Dixit, S. (2009). Shave biopsy technique with intradermal wheal for exophytic skin lesions. Journal of Dermatologic Surgery, 35(8), 1297–1300.

Rajadhyaksha, M., Marghoob, A., Tanaka, M., Lanier, V., & Guarner, J. (2017). Reflectance confocal microscopy of skin in vivo: From bench to bedside. Lasers in Surgery and Medicine, 49(1), 7–19.

Rieke, N., Hancox, J., Li, W., Milletarì, F., Roth, H. R., Albarqouni, S., Bakas, S., Galtier, M. N., Landman, B. A., Maier-Hein, K., Ourselin, S., Sheller, M., Summers, R. M., Warfield, S. K., Xu, Z., Mongan, J., & Cardoso, M. J. (2020). The future of digital health with federated learning. npj Digital Medicine, 3(1), 119.

Salem, I., Ramser, A., Isham, N., & Ghannoum, M. A. (2018). The gut microbiome as a major regulator of the gut-skin axis. Frontiers in Microbiology, 9, 1459.

Schwartz, R. A. (1996). Sign of Leser-Trélat. Journal of the American Academy of Dermatology, 35(1), 88–95.

Stochkendahl, M. J., Kjaer, P., Hartvigsen, J., Kongsted, A., Aaboe, J., Andersen, M., Andersen, M. O., Fournier, G., Højgaard, B., Jensen, M. B., Jensen, L. D., Karbo, T., Kirkeskov, L., Melbye, M., Morsel-Carlsen, L., Nordsteen, J., Palsson, T. S., Rasti, Z., Silbye, P. F., … Vaagholt, M. (2017). National clinical guidelines for non-surgical treatment of patients with recent-onset low back pain or lumbar radiculopathy. European Spine Journal, 27(1), 60–75.

Swetter, S. M., Tsao, H., Bichakjian, C. K., Curiel-Lewandrowski, C., Elder, D. E., Gershenwald, J. E., Guild, V., Grant-Kels, J. M., Halpern, A. C., Johnson, T. M., Kudchadkar, R. R., Lange, J. R., Lemos, B., Marghoob, A. A., Sober, A. J., Weinstock, M. A., & Wisco, O. J. (2019). Guidelines of care for the management of primary cutaneous melanoma. Journal of the American Academy of Dermatology, 80(1), 208–250.

Taddio, A., Ilersich, A. L., Ipp, M., Kikuta, A., & Shah, V. (2009). Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations. Clinical Therapeutics, 31(Suppl 2), S48–S76.

Taguchi, S., Tanaka, M., & Kikuchi, N. (1998). Seborrheic keratosis and skin disorders in diabetes mellitus. International Journal of Dermatology, 37(10), 765–768.

Teodorczyk-Injeyan, J. A., Injeyan, H. S., & Ruegg, R. (2006). Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects. Journal of Manipulative and Physiological Therapeutics, 29(1), 14–21.

Tracey, K. J. (2002). The inflammatory reflex. Nature, 420(6917), 853–859.

Vane, J. R. (1971). Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs. Nature: New Biology, 231(25), 232–235.

Welch, A., & Boone, R. (2008). Sympathetic and parasympathetic responses to specific diversified adjustments to chiropractic vertebral subluxations of the cervical and thoracic spine. Journal of Chiropractic Medicine, 7(3), 86–93.

WHO. (2009). WHO guidelines on hand hygiene in health care. World Health Organization. https://www.who.int/publications/i/item/9789241597906

Yeh, I., McCalmont, T. H., & LeBoit, P. E. (2000). Irritated seborrheic keratosis with lichenoid reaction (inverted follicular keratosis): A clinicopathologic study. Journal of Cutaneous Pathology, 27(9), 453–458.

---

SEO Tags:

shave skin biopsy, seborrheic keratosis treatment, inflamed seborrheic keratosis biopsy, local anesthesia lidocaine epinephrine, intradermal wheal technique, aluminum chloride hemostasis, integrative dermatology El Paso Texas, multidisciplinary skin care clinic, Dr. Alex Jimenez DC APRN FNP-BC, Dr. Maria Guadalupe Cardenas MD internist, Injury Medical Clinic PA, Mission Plaza Injury Medical Clinic, chiropractic and dermatology integrative care, functional medicine skin health, seborrheic keratosis pathophysiology, pain ease vapocoolant spray, 30 gauge needle biopsy technique, skin lesion biopsy procedure, wound healing physiology, integrative medicine El Paso, personal injury skin care, evidence-based skin biopsy, shave biopsy technique, skin cancer differential diagnosis, aluminum chloride wound care, neuroimmunology skin inflammation, functional medicine and skin conditions, gut-skin axis, vitamin D skin health, omega-3 fatty acids inflammation, chiropractic anti-inflammatory effects, spinal manipulation immune response, multidisciplinary integrative care outcomes, seborrheic keratosis recurrence, skin health monitoring, FGFR3 PIK3CA mutations seborrheic keratosis, Sign of Leser-Trélat, pain management minor surgery, biopsychosocial pain model, dermatoscopy skin lesion evaluation, wound healing phases, informed consent dermatology, aseptic technique skin biopsy, personal injury wound care, integrative chiropractic family medicine, advanced practice nurse dermatological procedures, internal medicine skin health oversight, keratinocyte proliferation pathology