In this video blog, Whitney High, MD, discusses highlights from his lecture, Pathology Pearls and Pitfalls For The Experienced APP , on November 7, 2024, 5th Annual Elevate-Derm West Conference at the Westin Kierland Resort in Scottsdale, AZ.

In this video

Interviewed by nurse practitioner Veronica Richardson, Dr. High explains why a requisition should say more than "rule out non-melanoma skin cancer." His "three Ds" — description, diameter, and diagnosis (or disease) — help flag misidentified or crossed-over tissue when it doesn't match the clinical suspicion, sharpen the dermatopathologist's read, and demonstrate that the clinician executed their responsibilities should a medical-legal misadventure arise. He notes clinical photos can be "very, very helpful," and that "savvy clinicians" send one even when their EMR isn't accessible to the outside lab.

Because bullous pemphigoid is rising with an aging population, Dr. High calls it the one autoimmune bullous disease worth knowing. He prefers to shave off an entire appropriately sized blister to preserve architecture, or take a punch from the edge overlapping onto normal skin — and warns against driving a punch through the center, which disjoints the epidermis and dermis. DIF should sample perilesional skin 5–10 mm away, never the blister itself, since separating epidermis binds immune reactants and gives false information. He also points to H&E clues in urticarial BP — a shallow split, a pristine dermis, eosinophilic spongiosis — that should prompt a recommendation for DIF.

  • Include the "three Ds" — description, diameter, and diagnosis (disease) — on every pathology requisition to catch mismatched tissue, refine the read, and document your diligence.
  • Clinical photos help the dermatopathologist; send one even when the lab can't access your EMR.
  • Know bullous pemphigoid — it's the most common autoimmune bullous disease and rising with the aging population.
  • To biopsy a BP blister, shave off the whole blister or punch the edge overlapping normal skin; never drive a punch through the blister center.
  • For DIF, sample perilesional skin 5–10 mm away — biopsying the blister gives false results because separating epidermis binds immune reactants.
  • In urticarial BP, watch for H&E clues (shallow split, clean dermis, eosinophilic spongiosis) that warrant recommending a DIF.