At the 2020 Winter Clinical Dermatology Conference, Robert T. Brodell, MD, shared some of his tips and tricks for procedures in dermatology. His presentation used several pre-filmed videos of quick, fail-safe procedures performed in his practice to demonstrate the importance of punch biopsies and excisions in diagnosis.
Dr Brodell first reviewed a simple technique for optimal diagnosis with a punch biopsy. In the case report, he described a patient with slowly expanding lesion on the left posterior ankle. He noted that many times, primary care doctors may call for a punch biopsy of the center of a lesion or that some dermatologists would only take a shave or punch from the border skin as well, which will not provide an accurate diagnosis every time.
Instead, Dr Brodell described his basic technique to improve diagnosis
- Drawing a line with a surgical marker perpendicular to the cornoid lamella
- Punch that section out, and bisect the biopsy along the line.
When the biopsy reaches the dermatopathologist, the cornoid lamella will be featured with this technique, offering a greater view of the underlying cause.
In his second example, Dr Brodell applied the same biopsy technique as part of his method to diagnosis of blistering lesions. He used the same surgical marker line technique and applied it to a larger blister of an affected area before taking a punch biopsy of that line. “Get about 80% perilesional skin and about 20% blister,” explained Dr Brodell, “and then bisect it at the bedside.” He also instructed to take a punch biopsy of a smaller blister. There are numerous advantages to this method, including two samples and no worry over how the samples are bisected in the lab.
“But most importantly,” said Dr Brodell, “this test now mimics a salt-split skin study.” The salt-split skin test may detect circulating antibodies absent on indirect immunofluorescence.
In his third tip, Dr Brodell talked about the best method for removing a large lipoma through a small hole in a simple few words. “You grab it like a tick at the mouth parts, lift it off, and that’s the end of that.” However, he noted that a small bit may remain in the patient without serious side effect; the goal is to remove the largest bit that causes the patient the most pain. Dermatologists should be careful to put some bolster and apply pressure to the excision area to reduce the likelihood of blood fill and subsequent infection.
Lastly, Dr Brodell described his favorite tip for punch excision of keratinous cysts. “Try this with a pilar cyst,” said Dr Brodell. “These are the easiest ones to do by this technique.”
The dermatologist starts with a small injection of lidocaine to the cyst area, noting of dimples that can demarcate a cyst. The dermatologist should then use their surgical instrument to cut around the cyst. Then, after the cyst has been “cut,” the dermatologist should grab and pull it out. This technique should not leave any cyst behind, as noted by a study by Dr Brodell that noted only 3.6% of cysts recurred in a mean time to patient-initiated follow-up of 79.3 weeks on chart review, and 8.3% of cysts recurred in patients who responded to a survey following the procedure.
Brodell RT. Tips and tricks in procedural dermatology. Presented at: 2020 Winter Clinical Dermatology Conference; Kohala Coast, HI; January 20, 2020.