Dermatology in Primary Care: Evidence for the Total Body Skin Exam and Cautions on Cryotherapy

A common dermatologic question asked in primary care is, Should everyone receive a total body skin examination (TBSE) every year? According to current evidence, the data are currently insufficient to support universal annual full body screening for the general population. A 2023 evidence synthesis for the US Preventive Services Task Force found that population-wide screening has not demonstrated clear mortality benefits.¹

William F Lewis, MD

The topic was discussed during the dermatology segment of a Multiple Small feedings of the Mind Session presented by William F. Lewis, MD, an instructor in the department of dermatology at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, at the American College of Physicians Internal Medicine Meeting 2025, April 3-5, in New Orleans, LA.

While the evidence for universal screening is lacking, however, Lewis outlined specific high-risk populations for whom annual examinations likely provide greater benefit:

• Individuals with numerous nevi (more than 40) or multiple atypical nevi (more than 2)
• Individuals with solid organ transplants or significant immunosuppression
• Individuals with strong family history of melanoma or known genetic predisposition syndromes (CDKN2A, CDK4, BAP1, POT1)
• Individuals with prior history of skin cancer
• Individuals with history of numerous peeling sunburns, tanning bed use, or extensive sun exposure

For individuals without these risk factors, the recommendation is to follow-up with a dermatologist on an as-needed basis rather than attend routine annual screening, according to Lewis. The decision to provide TBSE services in primary care settings should be based on the individual physician's comfort level, experience, time constraints, and the availability of specialists in the area, ne noted.²

Appropriate Use of Liquid Nitrogen Cryotherapy

In the second portion of the presentation, Lewis focused on optimal use of liquid nitrogen cryotherapy in primary care. First and foremost, he stressed, effective implementation requires both diagnostic acumen ("Is this an appropriate lesion to treat?") and technical skill ("Am I performing cryotherapy correctly?"). Practice requirements include observance of safe handling protocols and knowledge of appropriate billing procedures.

Lewis underscored several important cautions for clinicians electing to provide office-based cryotherapy:

• Individuals with skin of color risk significant permanent hypopigmentation following cryotherapy, which could warrant considering alternative treatment approaches
• Observe significant caution in areas with poor circulation or in individuals with impaired sensitivity, for example, those with peripheral neuropathy associated with diabetes
• There is a risk of nerve damage to areas where nerves are superficial, particularly on digit sides
• Undiagnosed skin lesions should be approached with caution

Appropriate Indications for Cryotherapy

Actinic keratoses: These gritty, scaly, erythematous premalignant macules on sun-damaged skin respond well to cryotherapy, which helps prevent progression to squamous cell carcinoma in situ. Lewis emphasized that indurated or raised lesions should be biopsied rather than frozen to rule out invasive squamous cell carcinoma. These can be billed as destruction of a premalignant lesion with the following CPT codes: 17000 (first lesion), 17003 (2-14 lesions), 17004 (15 or more lesions).

Warts: These HPV-associated, firm papules with characteristic "cauliflower"-like scale and thrombosed capillaries on dermoscopy can be effectively treated with cryotherapy as first-line therapy. These can be billed as destruction of a benign lesion with the following CPT codes: 17110 (1-14 lesions) and 17111 (15+ lesions).

Skin tags (acrochordons): The fleshy pedunculated growths in intertriginous areas or on the neck are easily identifiable and often bothersome to patients. Presented noted that Medicare does not reimburse for destruction unless they are bleeding, painful, or inflamed.

Steer Clear of Cryotherapy

The following conditions Lewis described as inappropriate for liquid nitrogen treatment:

Molluscum contagiosum: This poxvirus infection resolves spontaneously without scarring. Cryotherapy is painful, may cause scarring, and alternative treatments exist.

Keloids: These respond better to intralesional steroid injections than cryotherapy.

Skin malignancies: Cryotherapy is known to be generally ineffective or inappropriate in such cases

Seborrheic keratoses: Cryotherapy for these waxy, "stuck-on" benign epidermal growths with characteristic milia-like "horn cysts" is not typically reimbursed by Medicare unless, like skin tags, they are irritated or inflamed. Lewis cautioned, however, that melanoma and other skin cancers can co-occur within a seborrheic keratosis or mimic a seborrheic keratosis. Lewis cited research by Izikson et al showing that melanoma was identified in 61 of 9204 biopsies submitted with a clinical differential diagnosis that included "seborrheic keratosis," underscoring the importance of careful evaluation.³

References

1. Henrikson NB, Ivlev I, Blasi PR, et al. Screening for Skin Cancer: An Evidence Update for the U.S. Preventive Services Task Force \[Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2023 Apr. (Evidence Synthesis, No. 225.) Available from: <https://www.ncbi.nlm.nih.gov/books/NBK591447/>

2. Johnson MM et al. Skin cancer screening: recommendations for data-driven screening guidelines and a review of the US Preventive Services Task Force controversy. Melanoma Manag. 2017 Mar;4(1):13-37. doi: 10.2217/mmt-2016-0022

3. Izikson L, Sober AJ, Mihm MC Jr, Zembowicz A. Prevalence of melanoma clinically resembling seborrheic keratosis: analysis of 9204 cases. Arch Dermatol. 2002;138(12):1562-6. doi: 10.1001/archderm.138.12.1562