Dermatology and Dermatopathology Etiquette

In a multi-topic evening session at Winter Clinical Hawaii, Clay J. Cockerell, MD, MBA, clinical professor of dermatology and pathology at the University of Texas Southwestern Medical Center in Dallas, Texas, and founder and medical director of Cockerell Dermatopathology, gave a 2-hour overview of challenges and solutions in dermatopathology at the 2023 Winter Clinical Hawaii Dermatology Conference.

One of Cockerell’s mini sessions, “Dermatology and Dermatopathology Etiquette,” explored the issue of etiquette and communication breakdown in the US and how these challenges relate to treating patients. As Cockerell notes, Americans are not immune to the decline of manners.

Cockerell points out that the breakdown of communication is a large issue in both everyday life and the medical setting. Work demands, lack of training, and inappropriate workplace practices can lead to unprofessional conduct.

In dermatology and dermatopathology, clinicopathologic correlation is essential to perform accurate diagnoses and lessen medicolegal liability. Cockerell mentions that some diagnoses are pathognomonic (viral, cytopathic effect, basal cell carcinoma), and if there are no “cues” or guidance, dermatopathologists don’t always know what they’re looking for.

Cockerell then reviewed many “do’s” and “don'ts,” including:

1. Don’t submit insufficient information
   1. Don’t submit inflammatory disorders as “rash unspecified” without other information
   2. Record the “right” type of biopsy
2. Don’t submit “mechanical” diagnoses
   1. Don't write “rule out melanoma” for every pigmented lesion
   2. Don’t regurgitate resident “Grand Rounds” differential diagnoses
3. Do be mindful when submitting DDx
   1. Do not put differential diagnoses for things that look identical histologically
   2. Do not send something for DIF that would never be positive
4. Do understand real-world differential DX that you didn’t learn in training
   1. Ruptured folliculitis simulating basal cell carcinoma
   2. Rosacea simulating basal cell carcinoma
5. Do send clinical pictures of “tough” cases
   1. Send pictures of the biopsy
   2. Don’t send tough cases without any information
6. Do send representative biopsies
   1. Don't send small superficial shave or curettage biopsies of large neoplasms
   2. Do not punch into the middle of a pigmented lesion

Cockerell ended his discussion by stressing that dermatologists and dermatopathologists need to work together to efficiently help patients. “We’re here to serve you. We are your colleagues. Let’s work together for the benefit of our patients,” said Cockerell.

Reference

Cockerell C. Dermatology and dermatopathology etiquette. Presented at the 2023 Winter Clinical Hawaii Dermatology Conference; January 13-18, 2023; Kohala Coast, Hawaii.