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Live Blog: Better Biopsies – Pitfalls in Dermatopathology – Part Two. Faculty: Michael Conroy, MD.

In this live blog from the Annual Fall SDPA Conference in Orlando, Michael Conroy, MD, presented a lecture on Better Biopsies: Pitfalls in Dermatopathology. Here are some of the highlights of part two of his lecture: Tips and Tricks for an Effective Biopsy.

Tips and Tricks for An Effective Biopsy
In part one we shared the highlights of what it takes to process, examine, and report a biopsy sample. There are many steps, which means many opportunities for errors. Here are Dr. Conroy’s tips to PAs and other healthcare providers for executing an effective biopsy.

FIRST-THINGS-FIRST
Conroy stressed certain expectations and practices for creating the most positive and effective dermatologist/dermatopathologists collaboration:

– Dermopathologists must be the dermatology providers ally.

– PAs, Dermatologists and Dermatopathologists must have a “phone call” relationship. Clear and personal communication is key. Also, Dr. Conroy underlined that most dermatopathologists prefer photo documentation over a written description of a condition.

– Send clinical photos whenever possible…it’s all about CPC.

TIP 1 – DON’T BE A “NIPPER!”
Commit to your biopsy; dig deeply and effectively. If you’re a PA and you’re receiving notes from your dermatopathologist like “Superficial portions of biopsies cannot determine a diagnosis” then you might be a nipper! Conroy offers this helpful rhyme: “No blood…No bueno!” Beware of the shave biopsy on acral sites. If you don’t do a deep shave, the biopsy will not be successful.

TIP 2 – PUNCH
Everywhere on the body, with the exception of the face, do a 4mm punch when taking a biopsy of a rash. For facial biopsies, likely you are concerned about scarring, and in that case a 3mm punch is preferred. If you’re doing a DIF, get good tissue (do two 4mm punches). DIFs are expensive; get your patient’s money’s worth. As a side note, Dr. Conroy mentioned that with hair biopsies, the vertical punch is more significantly helpful than a horizontal punch. CPC is essential for hair biopsies.

TIP 3 – DO NOT SUTURE PUNCH
Here’s a few good reasons why suture punches are ineffective in the biopsy process…

  1. Suturing punches is time consuming
  2. It is more expensive
  3. They need an assistant
  4. Risk of needle-stick
  5. Increased risk of infection
  6. Appointments for suture removal take up staff time
  7. There is typically a poor scar outcome.

Instead, Dr. Conroy strongly recommended using gel foam to close punch biopsies.

TIP 4 – DO NOT COMBINE SAMPLES
Skin samples should not go in the same biopsy container. Combining those samples can put a patient at risk. Similarly, samples should never be discarded in the trashcan. If you are treating an unfamiliar rash, having multiple samples is extremely helpful for the dermatopathologist to identify the rash.

TIP 5 – WHERE TO AVOID BIOPSIES
Avoid biopsies of legs, particularly below the knee (they heal terribly). If at all possible, please stay away from biopsies of photo-damaged skin (especially in older patients). For example, avoid biopsying a forearm that has no epidermis left because of sun exposure.

Finally, Dr. Conroy stressed that all healthcare providers should reach out to their dermatopathologist and begin a relationship in order to collaborate on best practices between your office and theirs.

Image: Pathology Outlines




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