Dermatopathology is the study of skin diseases seen with a biopsy. It requires a dual knowledge of skin diseases and pathology to interpret skin biopsies.
What is dermatopathology compared to dermatology? Dermatopathology is a specialization of dermatology and pathology that focuses on skin diseases. It requires extra training and additional board certification specific to skin diseases. A dermatopathologist is trained both in a dermatology clinic as well as in a pathology lab. We know what it’s like to see patients in a clinic and observe their skin conditions visually, but we also have studied pathology to understand how different cancers show up on the skin on a microscopic level.
When Do You Need To See A Dermatopathologist?
A dermatopathologist isn’t typically the person you see in the room when you visit the dermatologist, but they are a part of your healthcare team. If a dermatologist suspects skin cancer or is unable to diagnose a rash visually, they will perform a biopsy. The dermatopathologist is the person who examines the biopsy to make a diagnosis.
At Epiphany, our dermatopathologists, dermatologists, and practitioners communicate regularly about patient cases. This team approach helps us reach our primary goal — to get accurate diagnoses and provide great patient care. We all have the patient’s best interest in mind, even if we don’t see the patient in the office.
How is a Dermatopathologist Involved in Your Treatment?
Patients often visit the dermatologist because they have a new growth or rash. Maybe they notice tumor growth, flaky nodules, or pigmented lesions that are growing or changing. Or maybe they’re experiencing a rash that itches, burns, oozes, appeared suddenly, or just doesn’t look right.
The dermatologist will determine if it’s appropriate to treat the issue upfront, without a biopsy (which means we’re confident we know what the issue is, and it’s not cancerous). If we need further information, suspect cancer, or think it may require a treatment like Mohs surgery, we’ll conduct a biopsy.
Once we’ve taken the biopsy, we’ll send the sample to our dermatopathology lab, where our staff will take the tissue and process it overnight. The sample is then sliced into strips of skin thinner than the width of a red blood cell and put on a slide.
A dermatopathologist examines the slide under a microscope in order to tell the dermatologist what disease process may be going on in the patient. Then, the dermatologist can tailor their treatment to what the patient has.
When dealing with skin cancer, the type of cancer dictates treatment. Basal cell carcinoma (a skin cancer treated with a minor in-office procedure) can be easy to identify, but it can also be pigmented and look like melanoma. Melanoma treatment is completely different from basal cell carcinoma. Sometimes, a biopsy will reveal that a lesion that looks like basal cell carcinoma is actually melanoma with no pigment.
If a patient has a concerning growth — whether it appears to be basal cell, squamous cell carcinoma, or melanoma — a biopsy will allow a dermatopathologist to identify what type of cancer it is and the next best step to treat it.
Dermatopathologists are also consulted to identify rashes. Many rashes look very similar when observed at a clinic. There are some treatments that dermatologists can try immediately without a biopsy. Often, they work; but other times, non-distinguishable rashes need a specific, less-common treatment.
A biopsy can help us identify what kind of rash it is so the dermatologist can tailor the treatment to that specific cause. While many rashes are due to conditions where the treatments are similar, other rashes are unusual. It’s even possible for an area to look like a rash but be malignant. For example, T-cell lymphoma looks like a rash but is actually a malignant cancer, and we need a biopsy to diagnose it.
When your dermatologist needs a biopsy, your dermatopathologist will evaluate it to give you the most accurate diagnosis possible so you can begin the best treatment for your condition.
How sure are you about the diagnosis?
This is an understandable question. If you suspect a serious diagnosis, you want your doctor to be completely sure.
At Epiphany, we take extra measures to ensure accuracy of our biopsy evaluations. We require that at least two dermatopathologists look at every single case of serious conditions, particularly the highly concerning cancers like melanoma. If we diagnose a spot as melanoma, a patient can know we had two experts in dermatopathology look at the biopsy and come to that diagnosis.
Do you alter your diagnoses to encourage medical procedures?
No, we never alter a diagnosis.
Unfortunately, this has been reported to happen in a small number of companies with in-house labs trying to make money from unnecessary medical procedures. At Epiphany, we have a host of clinical dermatologists and practitioners, and we also have our own pathology lab. Patients often want to know if we’re calling something cancer when it’s not, so we can get insurance to pay for an excision.
Our first priority is patient care. Our focus is not trying to help our clinicians and company make more money. We do not have quotas to meet. There is no driving force at any level of our company for increasing the number of procedures. The focus is patient care first and foremost.
In dermatopathology, that means we’re going to do whatever we need to do to get an accurate diagnosis for the patient. Often, that means we form an in-house diagnosis. But if we need extra in-house consultation, we seek it. In cases where a lesion is difficult to diagnose and we can’t reach a consensus, we consult outside experts to make sure the diagnosis we give the patient is accurate.
How long does it take to get results from a Dermatopathologist?
Biopsy results are typically ready within a week. More than 90% of our biopsies are diagnosed within 72 hours, but it may take a few additional days for the dermatologist to call you with the results due to the sheer logistics of time and the number of patients they see.
If we need to do extra work in processing the biopsy sample to reach a diagnosis or if additional pathologists need to examine the biopsy, it can take about a week for us to have results ready for the dermatologist.
On rare occasions when particularly challenging cases require outside consultation or extra testing (like molecular studies), it can take 2-3 weeks to get results back.
What type of pathology lab are you sending this to?
Skin biopsies can be conducted by different providers: dermatologists, nurse practitioners, physician’s assistants, family practice doctors, internal medicine doctors, or surgeons. No matter who takes the biopsy, make sure it’s being sent to a lab with a board-certified dermatopathologist. They have the training and board-certification that ensures they have an extra level of expertise in skin diseases.
While some pathology labs have a dermatopathologist on staff, not all do. Even if they have a dermatopathologist on staff, it doesn’t guarantee that person will examine every skin sample.
A general pathologist with no specialized experience in skin diseases may examine skin biopsies. However, they may not be equipped to distinguish skin conditions. There are many skin conditions that look like other skin conditions. Certain tumors mimic other tumors. Rashes mimic other rashes. But the treatments can be very different.
Make sure someone with the appropriate expertise looks at your biopsy. You want them to be confident the answer is right — for treatment and insurance purposes. There are obvious negative implications for treatment if a condition is misdiagnosed. But a misdiagnosis also negatively affects insurance, particularly for serious diagnoses like melanoma.
Melanoma is one of the most heavily litigated parts of dermatopathology. If we tell a patient they have melanoma and they don’t, it drastically affects their insurance coverage and pricing. Insurance will document that they have melanoma (even if they diagnosis is later reversed), creating complications when changing insurance providers and resulting in higher premiums.
If you have a skin biopsy, make sure it’s being sent to a lab where a dermatopathologist is examining it.
Will one skin biopsy be enough?
It usually only takes one biopsy to get the correct diagnosis. However, there are certain diseases that take more than one biopsy to figure out the right diagnosis.
There are also disease processes that require additional biopsies for extra study. Those extra biopsies are usually done up front, although occasionally a dermatopathologist will recommend an additional biopsy or excision after the initial biopsy.
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