Dodging Scalpels

Presented by:
Dorinda Johnstone, M.D., Dermatologist
Scottsdale, Arizona

The patient is a vibrant, independent-living nonogenarian who saw a mid-level provider at a plastic surgery office for a skin screening. A lesion was noted on her right nasolabial fold and a shave biopsy was taken (expand image to see "x"). Also, a few actinic keratoses were also treated with liquid nitrogen.
The pathologist reported a superficial squamous cell carcinoma and the patient was scheduled for excision by the mid-level professional’s plastic surgeon employer.
The patient was anxious about the surgery and sought the opinion of a DJ, a dermatologist she had seen in the past.

"x" marks center of the lesion that was biopsied

DJ did not feel the lesion needed urgent treatment. She got a copy the path report and saw that it had been signed out by a general pathologist. She asked a dermatopathologist colleague of the general pathologist’s to take a look at the slide. The dermatopathologist felt the legion was an actinic keratosis.

The patient was called and the revised diagnosis who is related. She expressed great relief. She will make a follow up in three months to see the dermatologist and decide whether anything needs to be done.

Take a messages:
1. Some mid-level providers working for high-volume surgical and dermatology practices serve as feeders for big-ticket procedures to their employers.
2. These surgeons and dermatologists rarely question biopsy reports.
3. It can be important to have the pathology reviewed by a board certified dermatopathologist.
4. The dermatologist who saw this patient tries to apply a palliative approach to elderly patients to spare them unnecessary procedures.
5. As long as we have fee-for-service medical care this kind of comedy will continue to happen.

IT’S A JUNGLE OUT THERE.

A Thing of Beauty

 Dermatoscopy has profoundly changed the practice of dermatology.  We have learned a lot and there is much more to discover.  A 30 yo woman was seen recently for a changing lesion on her abdomen.  The dermatoscopic picture looked benign, but it was unusual.

Clinically, this looked like seborrheic keratosis, but the pattern was unusual.  A biopsy was done to reassure the patient and so that we could learn something.

Later, we learned that she was using a self-tanner.  The clods seen in the image above represent the chemical in the horn cysts.  A similar pattern has been reported from hair dye.  The reference is the only one we could locate on PubMed.

The biopsy confirmed that this was a seborrheic keratosis,  No artifacts were seen, but they were probably washed out in processing,

Reference:
Sidharth Sonthalia, Pankaj Tiwary. Colored dots on trichoscopy-beware of artifacts. J Am Acad Dermatol. 2019 Jun;80(6):e143-e144. PMID: 30529542