Identifying a Proliferating Pilar Cyst 

Images shown are not intended to be used for the diagnosis or treatment of a disease or condition.

Consider this: An elderly female patient presents with a nodule on her scalp, which has recently grown in size. It currently measures 10 cm in diameter and is ulcerated. What features would you look for in order to diagnose it as a proliferating pilar cyst?

In this episode of Digital Dermatopathology Digest, Rajni Mandal, MD, dermatopathologist at PathologyWatch, explains the characteristics of proliferating pilar cysts. 

“Proliferating pilar cysts are most commonly seen in adult women in the scalp,” Mandal says. “Most cases arise from a pre-existing pilar cyst, due to unknown triggers.”

In the video, Mandal goes on to identify the defining features of two categories of proliferating pilar cysts: 

Benign Proliferating Pilar Cyst

Cyst epithelium proliferates within the center of the cyst, giving it a “rolls and scrolls” appearance. The proliferating cells are trichilemmal, with small nuclei having smooth nuclear contours and a uniform chromatin pattern. The cyst lining has no granular layer, with abrupt dense, compact, pink keratin formation.

Malignant Proliferating Pilar Cyst

Also known as trichilemmal carcinoma, malignant proliferating pilar cysts differ from the benign version in key ways. In addition to the above characteristics, malignant cysts show cell crowding and cellular atypia (i.e., nuclei of varying size and shape). These cysts display mitotic activity, infiltrative growth, and cytologic atypia.

Whether you’re in residency, studying for board exams, or a practicing dermatologist looking to stay sharp, the Digital Dermatopathology Digest video series is your informational and convenient source for dermatopathology review. Find the full series here.

What Do You Know about Pilomatricoma?

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Often mistaken clinically for a more common skin growth like an epidermoid cyst, pilomatricoma is the focus of this Digital Dermatopathology Digest episode with Rajni Mandal, MD.

Pilomatricoma is a benign skin growth that typically occurs in children and young adults. Studies show that around 40 percent of cases happen to patients under age 10, and 60 percent of cases appear before age 20. Interestingly, research also shows girls are about 50 percent more likely to develop a pilomatricoma than boys.

This growth is associated with the somatic mutation of CTNNB1 in the hair matrix cell, which leads to increased beta-catenin (decreased cell adhesion) and uncontrolled cell division through the Wnt signaling pathway.

Pilomatricomas have very distinguishing pathologic features. “The keratin within the center of pilomatricoma is quite characteristic,” explains Mandal. “You can see multiple holes, or ghosts, of the keratinocyte nuclei.”

Although pilomatricomas aren’t painful or malignant in nature, they don’t resolve on their own. Dermatologists may recommend a skin biopsy to rule out cancer—and because they continue to grow and often appear on the head and neck, most patients opt to have them removed.

To learn more about pilomatricoma and other skin conditions, click here for more episodes of PathologyWatch’s Digital Dermatopathology Digest.

Improving Communication and Clinicopathological Correlation with the Dermpath Lab

Clinicopathological correlation is the thought process that combines both gross and microscopic information to determine the most probable diagnosis. Being captivated by seeing the clinical image and pathology slide side by side is a common sensation for physicians feeling drawn to dermatology. This marriage of clinical and pathologic findings is also fundamental to resident and continuing medical education for dermatologists.

Clinicopathological correlation helps to confirm clinical suspicions and to provide more information in more obscure clinical cases. A nine-year study of nearly 4,000 skin biopsy specimens reported that 23.2 percent of the pathological diagnoses were inconsistent with the clinical diagnoses, suggesting room for diagnostic accuracy improvement. 

Studies suggest that improved clinical and pathologic correlation can help bridge that gap. By reviewing your own biopsy slides, providing accurate clinical information to your pathologist, and correlating together on challenging cases, your dermatology practice can continue to give patients the quality care they deserve.

Back to Your Roots: Reviewing Biopsy Slides

While only one out of five dermatologists reportedly read their own slides, most dermatologists prefer to review their slides. Dermatologists also receive significant training in dermatopathology during residency, more than twice that of their general pathology colleagues, and dermatology journals include more articles on dermatopathology. While avoiding the liability of reading their slides, many dermatologists enjoy keeping up their skills, confirming their clinical findings, or obtaining additional information needed to secure a diagnosis.

However, the traditional dermatopathology workflow may prevent dermatologists from reading or reviewing their own slides. Less than 25 percent of dermatologists have an in-house lab; if sending to an outside lab, it can take up to two weeks to turn around slides and even results. By using a lab that utilizes a digital pathology workflow, like PathologyWatch, dermatologists have quicker and easier access to review their own pathology slides or those of their colleagues, providing helpful information when planning surgical excisions or Mohs procedures, for example. 

Don’t Rule Out the Dermatopathology Requisition

Research studies emphasize the importance of clinical information in making accurate pathologic diagnoses, particularly in dermatopathology. In a recent Dialogues in Dermatology podcast, an important study was reviewed, indicating that dermatopathologic diagnostic accuracy is 53 percent when no clinical information is provided; accuracy improves to 78 percent when information is provided. Another study emphasized the importance of continued correlation in difficult cases, noting that repeat biopsy with additional CPC improved the concordance of clinical and pathologic diagnoses further. 

Providing dermoscopic images and essential diagnostic criteria for melanoma—like size, partial or complete biopsy, and evolution of a lesion—can also influence the pathologic diagnosis, likely resulting in improved patient outcomes. Dermatologists are particularly well-trained in providing helpful information on their requisition forms.

Tips on communicating effectively with the lab include having clinicians (rather than medical assistants) complete (or dictate) findings on the requisition, providing a helpful list of differential diagnoses, and giving other relevant clinical information and photographs. 

The Power of a Simple Phone Call

Lastly, in challenging cases, or simply where vital information was left out, a quick text or phone call with an experienced dermatopathologist can be invaluable in clinching the diagnosis. 

Sometimes you may find that important clinical information, such as a genetic disease or patient age, is left off the requisition, potentially skewing a pathologic diagnosis. This critical information needs to be passed on to the consultant, just as key clinical information from a patient may help in assuring your clinical diagnosis. 

If a dermatologist reads their own slides, consulting with a network of expert dermatopathologists like PathologyWatch on difficult cases can improve diagnostic accuracy.

While physicians are often pressed for time in the clinic, taking time to review pathology slides, providing accurate information to your dermatopathology lab, and interacting with consultants directly to make important clinicopathological correlations will ultimately result in time savings and better patient outcomes by making an accurate diagnosis. 

Can You Identify an Epidermal Inclusion Cyst?

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An epidermal inclusion cyst is the most common cutaneous cyst, often called a sebaceous cyst, which is actually a misnomer. The center of epidermoid cysts almost always contains keratin and not sebum. This keratin often has a “cheesy” appearance. They also do not originate from sebaceous glands; therefore, epidermal inclusion cysts are not truly sebaceous cysts.

In this episode of Digital Dermatopathology Digest, Rajni Mandal, MD, dermatopathologist at PathologyWatch, explains the common characteristics of an epidermal inclusion cyst.

“An epidermal inclusion cyst has an epidermis-like lining with a granular layer,” explains Mandal—as opposed to a nongranular layer, seen in a pilar cyst or steatocystoma. “Sometimes there is a connection with the overlying epidermis known as a punctum.” 

Mandal goes on to mention features, the lack of which can help distinguish epidermal inclusion cysts from other common cysts, including dermoid, pilar, and vellus cysts.

Ruling Out a Dermoid Cyst

A dermoid cyst has cell walls that contain hair follicles, sweat glands, and other multiple adnexal skin structures. By contrast, an epidermal inclusion cyst lacks adnexal structures.

Ruling Out a Pilar Cyst

What makes a pilar cyst unique is that it arises from the epithelium between the sebaceous gland and the arrector pili muscle. They are lined by stratified squamous epithelium without a granular cell layer, similar to what is seen in the outer root sheath of the hair follicle, and filled with keratin.

Often presenting themselves as a round, dome-like bump, a pilar cyst is typically firm to the touch but not painful for the patient, while an epidermal inclusion cyst may become inflamed and painful to the touch. 

Ruling Out a Vellus Hair Cyst

If small hairs appear in the vellum, with small red or brown bumps and a smooth dome shape, and often occur over the sternum, it is likely a vellus hair cyst.

Whether you’re in residency, studying for board exams, or a practicing dermatologist looking to stay sharp, the Digital Dermatopathology Digest video series is your informational and convenient source for dermatopathology review. Find the full series here.

PathologyWatch Announces Key Hire to Bolster Digital Dermatopathology Practice

Darren Whittemore, DO, joins the PathologyWatch team to support the delivery of optimal patient outcomes.

SALT LAKE CITY—DECEMBER 8, 2020—PathologyWatch, a full-service digital dermatopathology solution, is pleased to welcome Dr. Darren Whittemore, DO, to the growing PathologyWatch family. A qualified and respected dermatopathologist, Whittemore will be instrumental in establishing processes to ensure dermatology clinics receive the highest level of digital pathology services.  

Board certified in anatomic and clinical pathology and dermatopathology, Whittemore was fellowship-trained at the University of Texas Health Science Center after completing his residency at the combined US Air Force Wilford Hall Medical Center/Brooke Army Medical Center program.

“Dermatopathologists play a critical role in a patient’s recommended treatment,” said Dan Lambert, CEO and cofounder of PathologyWatch. “With expertise and attention to detail, Dr. Whittemore utilizes innovative advances in digital pathology to deliver the highest quality of care and efficiency to patients.”

Whittemore brings extensive subspecialty experience and proven abilities in diagnosing alopecia cases to PathologyWatch. Also, he embraces new technologies and the growing role they play in understanding the pathogenesis of diseases. 

“With advantages that include enhanced clinicopathologic correlation, improved turnaround time and paperless, electronic workflows, digital dermatopathology represents the future of the dermatology industry,” Whittemore said. “Joining PathologyWatch places me in the heart of this burgeoning technology with individuals who are committed to helping dermatology clinics deliver industry-leading care to their patients.”

For more information on PathologyWatch, please visit pathologywatch.com.

About PathologyWatch

PathologyWatch is the groundbreaking leader of digital dermatopathology services. Through these services, dermatology clinics, hospitals and laboratories can improve operational efficiency by speeding up workflow and enhancing patient outcomes by utilizing the PathologyWatch expert professional team and partner laboratory services. This can facilitate best-in-class reads and, in some cases, enable additional revenue to the practice by in-housing pathology. With an intuitive and easy-to-implement digital pathology solution that includes access to top-tier dermatopathologists and a streamlined clinical workflow that interfaces directly into the EMR, PathologyWatch brilliantly combines state-of-the-art technology and clinical decision-making to deliver unprecedented patient care.

View the original release.

Managing a motivated and efficient dermatology staff

Across America, healthcare industry professionals play pivotal and often pressure-filled roles in keeping individuals and communities safe. However, this commitment to service comes with a toll in the form of heavy turnover rates. One two-year study found that family practices experienced an average turnover rate of 53 percent. Now is the time to ensure you’re running a motivated and efficient dermatology clinic staff.

While tending to patients is every dermatologist’s most critical concern, maintaining a productive and satisfied staff isn’t too far behind. By increasing your team’s high-level patient contact, sharpening your staff-retention efforts, and making sure you hire qualified individuals, your practice can continue to administer the level of care your patients have come to expect.

High-Level Patient Contact

Expanding individual responsibilities can improve staff morale while helping to reduce your workload. Since medical assistants represent the biggest group of individuals providing clinical support to dermatologists, increasing their contact with patients can result in more time for you to address other priorities. 

A well-trained MA may be capable of sharing diagnoses with patients on a case-by-case basis. To ensure seamless quality care, do the following:

  1. Provide staff members with a dermatology atlas to familiarize themselves with more common cases.
  2. Make sure every patient experience is consistent and professional by developing formal staff training programs.
  3. Promote knowledge and curiosity by teaching your team about frequent medications and treatments.

It would also help to train your staff to be conduits between your clinic and the dermatopathology lab. While full-service digital dermatopathology labs like PathologyWatch return diagnoses directly to your patients’ EMR, having a staff member that follows up on orders and results is a positive way to keep the lines of communication open. 

Staff Retention

Spending more time now to retain reliable dermatology staff members means spending less time in the future filling positions and training new employees. Since preventable employee factors are responsible for 80 percent of healthcare industry turnover, here are some suggestions to ensure your team members feel job satisfaction:

Create a comfortable office culture.

Is anyone happy working in a frantic environment that treats every task like an emergency? While there will be times when urgency is in order, do your best to set the example of composure and positivity by setting reasonable expectations for tasks and time management. This includes keeping a level head and being respectful in your actions and speech.

See team members as individuals.

You’re all in this together, so avoid focusing on individual mistakes. Likewise, nobody wants to be singled out or embarrassed in front of others. Be encouraging, promote camaraderie, listen to employee feedback, and find teachable moments to increase efficiency and skills.

Share accolades and rewards. 

Small gestures can go a long way. In addition to praising accomplishments with kind words, keep your staff motivated with performance pay or other incentivized bonuses

Provide employee discounts.

Offer discounts on procedures and products to turn your staff into brand ambassadors. As a result, you can build loyalty from your employees while increasing public awareness. 

Creating an environment where people look forward to coming to work benefits your staff retention while leaving a good impression on your patients.

Hire Qualified People

Tending to patients while meeting the demands of running a thriving dermatology practice would be a daunting challenge without reliable staff support. Start on the right foot by hiring individuals with the characteristics and skill sets you require to deliver quality care to your patients.

According to the Bureau of Labor Statistics, the healthcare industry will add nearly 2.5 million jobs by 2029. With a labor pool that size to choose from, make sure you aren’t settling for employees that aren’t going to make long-term contributions to your clinic. Trust your instincts if you don’t feel someone is a good fit for the job’s values, pace, or expectations. If you’re on the fence, suggest a trial period to ensure both parties are satisfied with the duties and performance. 

Here are some personality traits to keep in mind as you identify features that translate to a valuable dermatology staff member:

  • Ambitious: Your workload can get lighter with the support of enthusiastic individuals who don’t mind shouldering additional responsibilities.
  • Personable: Single out people who are comfortable communicating and showing compassion with patients of all ages.
  • Teachable: Surround yourself with staff members who are eager to learn and share new knowledge and skills.
  • Team Player: Dermatology clinics require staff members to wear many hats to keep the front office and exam rooms working efficiently. 

Managing a motivated and efficient dermatology clinic staff requires consistent attention and leadership. By expanding your team’s patient contact level, focusing on staff-retaining actions, and hiring qualified team members, you can surround yourself with the right people to serve your patients.