Pearls from the Scope— What Your Dermatopathologist Wants You to Know

J Clin Aesthet Dermatol. 2023;16(9 Suppl 2):S42–S44

by Maria R. Robinson, MD, MBA, FAAD

Dr. Robinson is a board-certified dermatologist and dermatopathologist with over 15 years of experience across the academic, private practice, and telehealth sectors. She has a passion for education, and is the founder of www.dermpathforapc.com, an innovative online dermatopathology CME course for advanced practice clinicians.  

FUNDING: No funding was provided for this article.

DISCLOSURES: Dr. Robinson reports no conflicts of interest relevant to the content of this article. 

ABSTRACT: The skin biopsy and histologic examination are an important part of providing dermatologic care. Effective communication with your dermatopathologist on the biopsy requisition form helps provide clinicopathological correlation and facilitates accurate and timely histopathologic diagnosis of the biopsy.

Welcome to Pearls from the Scope, where clinical pearls are shared from the perspective of your dermatopathologist to help enhance the provision of effective dermatologic care.  

Communication with your dermatopathologist is an important part of providing comprehensive dermatologic care. Effective communication primarily happens through the information provided on the biopsy requisition form (RF), which is a crucial link between the submitting clinician and the dermatopathologist. When the clinical information on the RF is comprehensive and accurate, it provides clinicopathological correlation and facilitates accurate and timely histopathologic diagnosis in dermatopathology.¹ In many situations, however, the RF contains clinical information that is incomplete, inaccurate, or sometimes missing altogether.^2,3 Additionally, when descriptions are present, they may consist of vague and nonspecific terms, such as “lesion,” “NUB,” (i.e., neoplasm of uncertain behavior), “rash,” or “recent changes.” These terms do not convey helpful clinical information to the dermatopathologist, nor do they contribute to clinicopathological correlation.⁴

Clinicians may also write rule out on the RF, a term which prevents the dermatopathologist from understanding the true clinical suspicion of a lesion. For example, “rule out basal cell carcinoma (BCC)” may mean the clinician thinks it’s a BCC. Or it may mean the opposite—the clinical suspicion for a BCC is low.⁴ A survey of the membership of the American Society of Dermatopathology (ASPD) highlighted some of these concerns, including discontent associated with the quality of RF clinical information and the added time spent gathering accurate information.²

The lack of accurate and comprehensive information on the RF can have significant consequences in the quality and safety of patient care.^1–5 Providing less information on the RF for inflammatory disorders has been shown to lead to additional stains, additional tissue sections, and a prolonged turnaround time for histopathologic diagnosis.¹ In many situations, relevant clinical information is captured in the Electronic Medical Record (EMR) Encounter Note, but it is not transferred to the RF provided to the dermatopathologist.¹ 

Clinical Case Review

Reviewing the following clinical cases will highlight the importance of clinical information on the RF. 

Patients 1 and 2 both had erythematous, annular plaques with similar underlying etiologies. The dermatitis in Patient 1 was located in a nonhair-bearing area (Figure 1). In Patient 2, however, the dermatitis extended into a hair-bearing area on the scalp (Figure 2). 

Punch biopsies from Patients 1 and 2 showed similar findings—mild inflammation and subtle epidermal changes suggestive of a dermatophyte; a Periodic acid-Schiff stain (PAS) stain confirmed the diagnosis of tinea in both cases (Figures 3 and 4 show biopsies from Patient 2; Patient 1 biopsies not shown). At this point, a diagnosis of tinea corporis could have been made for both Patients, but this would have only been a partial diagnosis for Patient 2.

The clinician for Patient 2 provided thorough clinical information and a photograph, which showed the possibility of follicular involvement by the rash. Because of this, deeper sections were performed, which showed dermatophyte involvement of a hair follicle (Figure 5), which potentially changed the management of the patient.⁶ 

When indicated by the clinical situation, deeper sections of a biopsy specimen can be done, which may show additional findings (Figure 6). In the absence of accurate and thorough clinical information, the clinicopathological correlation is limited, and this may hinder the histopathologic evaluation.

Optimizing communication with your dermatopathologist

Improving the communication with your dermatopathologist can result in a faster and more accurate histopathologic diagnosis. There are significant time-demands in a busy dermatology clinic. Fortunately, optimizing the clinician-pathologist communication doesn’t have to require a significant time commitment, and it can save time in the long run while improving patient care. 

Clinicians should include accurate and thorough clinical information on the RF when submitting a biopsy specimen. Vague terminology (such as “lesion” and “rash”) should be avoided, and clinical suspicion should be accurately reflected (e.g., “favor sebaceous hyperplasia, doubt BCC” or “confirm BCC”). 

When completing the RF, the 5 D’s, as listed below, can be used as a guide for providing accurate and complete clinical information: 

1. Demographics: Ensure age, sex, and race are included (these are often automatically included on the RF).
2. Description: Descriptors, such as appearance, location, distribution, prior treatment, and a clinical photo if possible should be used/included.⁸ The default EMR description is often not an accurate reflection of the clinical findings.
3. Duration: Describe how long the process has been present and if it’s changing. 
4. Diameter: For lesions, include an accurate size and whether it’s a partial biopsy.
5. Differential diagnosis: The clinician’s thoughts on the diagnosis, which also helps the dermatopathologist understand the clinical findings, should be clearly described.   

Pearl 1. Including accurate and thorough clinical information on the biopsy requisition provides clinicopathological correlation and enables accurate and timely histopathologic diagnosis. 

Pearl 2. When tinea occurs on hair-bearing skin, consider follicular involvement (such as tinea capitis or Majocchi granuloma).

The RF is an essential connection between the submitting clinician and the dermatopathologist, and it contains information vital for clinicopathological correlation and effective patient care. If questions ever arise about a clinical case or histopathologic diagnosis, the submitting clinician should not hesitate to call the dermatopathologist for discussion and further clarification.  

References

1. Romano RC, Novotny PJ, Sloan JA, et al. Measure of completeness and accuracy of clinical information in skin requisition forms: an analysis of 249 cases. Am J Clin Pathol. 2016;146(6):727–735.
2. Comfere NI, Peters MS, Jenkins S, et al. Dermatopathologists’ concerns and challenges with clinical information in the skin biopsy requisition form: a mixed-methods study review. J Cutan Pathol. 2015;42(5):333-345.
3. Comfere, NI, Sokumbi O, Montori VM, et al. Provider-to-provider communication in dermatology and implications of missing clinical information in skin biopsy requisition forms: a systematic review. Int J Dermatol. 2014;53:549–547. 
4. Sellheyer K, Berfeld WF. “Lesion,” “rule out…,” and other vagaries of filling out pathology requisition forms. J Am Acad Dermatol. 2005;52:914–915. 
5. Waller JM, Zedek DC. How informative are dermatopathology requisition forms completed by dermatologists? a review of the clinical information provided for 100 consecutive melanocytic lesions. J Am Acad Dermatol. 2010;62:257–261. 
6. Elewski BE. Treatment of tinea capitis: beyond griseofulvin. J Am Acad Dermatology. 1999;40:S27–S30.  
7. Boyd AS, Neldner KH. How to submit a specimen for cutaneous pathology analysis. Using the ‘5 D’s’ to get the most from biopsies. Arch Fam Med. 1997;6:64–66. 
8. Mohr MR, Sathish Indika SH, Hood AF. The utility of clinical photographs in dermatopathological diagnosis. a survey study. JAMA Dermatology. Arch Dermatol. 2010;146:1307–1308.  
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