Identifying Trichoepithelioma

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At first glance, these individual lesions may look like basal cell carcinoma, but don’t be confused: Trichoepithelioma appears as firm, rounded, and shiny tumors that originate in the hair follicle. 

In this episode of Digital Dermpath Digest, Rajni Mandal, MD, a dermatopathologist at PathologyWatch, discusses distinct features of trichoepithelioma and how to identify them.

What Is Trichoepithelioma?

The distinct rounded and shiny appearance of this rare benign skin lesion occurs primarily on the cheeks, on the eyelids, and around the nose, yet it can spread to arms and stomach. They typically increase in number as the patient ages and presents as papillary-mesenchymal bodies, granulomas, and signs of calcification. 

“There are three clinical types of trichoepithelioma,” says Mandal, “Solitary, multiple, and desmoplastic.”

  • Solitary trichoepithelioma: This variant is characterized by a single firm dermal papule or nodule that often appears on the face.
  • Multiple trichoepitheliomas: Often called Brooke-Spiegler Syndrome, it’s composed of familial cylindromatosis and multiple familial trichoepitheliomas variants. 
  • Desmoplastic trichoepithelioma: Characterized by a prominent, sclerotic stroma, the most common features of this variant include asymptomatic, solitary, ring-shaped, centrally depressed papules. When viewed as a digital slide, this variant has tadpole-shaped islands, fibrous stroma, and calcifications. They can appear anywhere but are more commonly found on the upper cheek. 

What Are the Most Common Treatments?

Dermatologists can surgically remove individual lesions, particularly if there are risks of malignancy. Other treatment options include carbon dioxide laser and dermabrasion, which may improve the skin’s appearance, but there is a slight possibility of regrowth. 

To learn more about this skin condition and other common diseases, join us for each episode of Digital Dermpath Digest right here on

Using EMR Technology to Reduce Clinical Errors

A healthy practice relies on establishing meaningful relationships with your patients. You want them to feel special and valued. So it can be a little disconcerting when you’ve pulled the file for a pregnant patient you anticipate is getting checked for melasma only to meet a 16-year-old new patient, who arrived to discuss his acne. 

Sometimes file mix-ups have more serious consequences than mistaken identities. Studies show that from the initial biopsy to the acquisition of the pathology report, a specimen may pass through the hands of more than twenty people and several workplaces. 

To prevent specimen mix-ups and other errors with patient information, NIH recommends, first, standardization in work processes, and second, automating tasks wherever possible. To do this, consider digitizing your clinic and laboratory processes. 

Here are three ways transitioning to electronic medical records (EMR) have helped numerous dermatology practices minimize errors and create a streamlined and error-free clinic workflow. 

Patient Data Is Easy to Share

EMR technology was designed to house patient information in a location that is easy to organize and share with other healthcare providers, insurance, pharmacies, labs, other clinics, billing, etc. 

The Center for Medicare and Medicaid Services (CMS) says, “Documenting a patient’s record with all relevant and important facts, and having that information readily available, allows providers to furnish correct and appropriate services that can improve quality, safety, and efficiency.” 

At PathologyWatch, our clients appreciate easy access to digital images as well as pathology reports, patient’s HIPAA-compliant, digital medical history, etc., which are accessible on the patient’s EMR. 

EMR Provides a Complete Patient Record 

Did you know around one out of every 20 people who saw a doctor last year reported having to redo a test or procedure because their prior data was unavailable?

Maintaining a patient’s identity and complete medical history throughout the biopsy pathway is critical for the practice of dermatology and dermatopathology. Your patients need to trust that you can provide the best care based on a comprehensive understanding of their patient history. So while a recent study discovered 32 percent of people who visited a doctor within the past 12 months experienced a gap in information exchange, your patients shouldn’t have to worry about the quality of their care if you’ve transitioned their patient information to EMR. You can confidently address your patient’s case and concerns based on a complete and current patient record. 

Add Value To Other Parts of Workflow

Surveys show that 60 percent of clinics already have implemented EMRs in their practice, but most have not yet experienced the full capabilities that an interface provides. “The exchange of information through this interface can simplify your daily workflow considerably,” explains April Larson, a practicing dermatologist and director of clinical implementation and advisory board at PathologyWatch. “By way of an HL7 interface, the lab can send reports electronically directly to your patient chart and, in certain instances, populate the diagnosis and treatment, streamlining your review and signoff.”

The adoption of EMR technology minimizes menial, time-consuming tasks for your clinical staff and allows them to participate more in patient care, which increases both staff and patient satisfaction.

Your patients depend on you to provide the best care possible. When you use an EMR system to organize patient information that’s easy to access, update, and share with health services partners, you can focus on what really matters: your patient. 

Learn more about the pros and cons of an EMR interface here.

Identifying a Proliferating Pilar Cyst 

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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.