The NP, PA, or dermatologist in the dermatology clinic relies heavily on their dermatopathologist, and the two should focus on communication, says Michelle Hure, MD, MS, FAAD, Founder and Director of OC SkinLab in San Juan Capistrano, CA. Speaking during a Dermalorian™ Webinar in June, Dr. Hure, who is double board certified in dermatology and dermatopatholgy, said that in addition to providing the best sample, clinicians should provide as much information as possible about the case presentation.
Dr. Hure also encouraged clinicians to reach out to the dermatopathologist for more information or clarification, if needed. Her lecture included numerous practical tips related to biopsy technique and sample selection, and she walked viewers step-by-step through the process that a sample goes through once received in the lab.
A recording of the webinar will be posted to DermNPPA.org soon.
Dr. Hure answered multiple audience questions in the course of the evening but could not address all during the live event. Here are additional questions received and Dr. Hure’s responses:
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Saucerizations leave such a disfiguring scar that people hate, so I tend not to perform them and remove them instead so they can be closed nicely. Dr. Hure: You don’t have to take as much tissue depth as you may think. As discussed in the presentation, you only need to take about 1mm of depth. This is not that deep. Also, if you’re worried about a melanoma or NMSC, the patient will likely get a re-excision anyway, and the issue of a scar from the biopsy will be moot. Remember that doing an excision of a possible melanoma is not advised as it may interfere with the lymphatic flow and mapping to the sentinel lymph node if one is needed. |
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How new should the lesion be for vasculitis, less than 72 hours? Dr. Hure: The lesion should be as new as possible. There is no definite timeframe, but ask the patient which lesion is the newest and go from there. You’ll have to do your best to take what they say is the newest lesion. They may not know the exact time frame of development. |
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If you are concerned about a pigmented lesion, how many mm of normal skin do you want to get around it? Dr. Hure: We really don’t need normal skin around the lesion. The purpose of the biopsy is to sample the lesion, not to excise with margins. So just take the size of the lesion only. |
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Since you don’t recommend excisional biopsy, what do you recommend if the lesion is too large for a deep shave? Do you do scouting biopsies? Dr. Hure: I definitely perform scouting shave biopsies of a very large lesion. Again, you really only need to get about 1mm of depth in your shave. Try to sample more than half of the lesion if it’s too big to sample it all. |
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For rashes when do you recommend shaving vs punching? Dr. Hure: That’s a tricky question. Rule of thumb is to punch inflammatory lesions, but I’ve definitely done my fair share of shaves for them. The key is to recognize where the lesion is. If it’s mostly flat or slightly raised with a lot of scale, it will probably be an epidermal or superficial dermal lesion. You’ll likely get away with a deep shave. But if the lesion is raised, indurated and without much scale, you’ll need to get a good bit of dermis and need a punch. |
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If worried about melanoma how big does it have to be to saucerize vs do scouting biopsies? Dr. Hure: There is no definite cutoff for this. You’ll have to analyze it on a case-by-case basis depending on patient age, clinical site, etc. I tend to take the entire lesion up to about 1.5cm and then scouting biopsies for lesions larger than that. But this is just my experience, which can change based on the patient presentation. |
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Can you speak more to punch biopsy for DIF (direct immunofluorescence)? When to do lesional vs normal skin? Dr. Hure: You should always punch perilesional skin (normal skin next to the lesion) for DIF. If you sample a lesion for DIF, you may get a false negative finding. |
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