The skin biopsy is one of the most commonly performed procedures in dermatology.Performing Skin Biopsies: Maximizing Accuracy; Minimizing Risk < Back Performing Skin Biopsies: Maximizing Accuracy; Minimizing Risk Clay Cockerell, MD, JD, MBA | Kaseleigh McCarley, CMA Feb 10, 2023 The skin biopsy is one of the most commonly performed procedures in dermatology. Skin samples are usually taken for routine microscopy, and immunofluorescence microscopy is generally required when the possibility of an immunologic disorder exists. Rarely, electron microscopy may be performed when unusual diseases of connective tissue or unusual neoplasms are evaluated. This article will cover the four biopsy techniques that are most commonly employed: shave, punch, incision, and excision. Other specimens lend themselves to enucleation, such as cysts and benign neoplasms situated in the subcutis. Although the actual technique of skin biopsy is relatively straightforward, there are a number of important principles that must be adhered to in order to avoid potential problems, some of which may be serious. Although the vast majority of dermatologic disorders are not life-threatening, there are many pitfalls that may bedevil the unsuspecting clinician who is not aware of them. Standards & Principles Provide complete, accurate information to the dermatopathologist. A biopsy specimen submitted without appropriate clinical information may yield equivocal, confusing and often, useless results. Dermatology is a specialty that requires clinicopathologic correlation to be practiced well. Inability to correlate clinical findings with histologic ones very commonly leads to misdiagnosis and inappropriate treatment, often with harm to the patient. It is essential that those performing skin biopsies know the fundamental lesions of cutaneous pathology and how to describe them accurately and skillfully. Furthermore, the clinician must have an understanding of the disease process in question. Skin disorders are not static but are dynamic processes, and a knowledge of the disease progression and chronology is essential. For example, a biopsy taken from a lesion just in its inception or, conversely, at its end, is likely to appear completely different than those that are fully developed. The most characteristic, typical skin lesion of a given process should be sampled in a fashion that provides an intact and representative specimen to the dermatopathologist. Submit specimens only to those competent in the interpretation of cutaneous pathology. Dermatopathology is a complex specialty with morphology and terminology as fundamental elements. Those fully trained in dermatopathology have spent one or more years in specialty training focusing on the subtleties of dermatology and cutaneous pathology. Those who practice this on a daily basis are highly qualified and usually better able to able to make accurate diagnoses of skin disorders from skin biopsies. It cannot be emphasized too strongly that clinicopathologic correlation forms the cornerstone of the practice of dermatology even when dealing with seemingly banal processes such as basal cell carcinoma and nevi. It obviously assumes even more importance when the patient presents with an unusual inflammatory skin disorder or a pigmented lesion such as a possible melanoma. If no description can be made or a differential diagnosis cannot be rendered, it may be best to refer the patient for a second opinion. Incorrectly performed biopsies such as those performed using faulty technique or sampling a non-representative lesion may lead to an erroneous histologic diagnosis. For example, a superficial shave biopsy of discoid lupus erythematosus may be misinterpreted as squamous cell carcinoma with disastrous results. Conversely, a punch biopsy of malignant melanoma may fail to sample a diagnostic area resulting in failure to diagnose a serious, potentially lethal malignancy. Inflammatory skin disorders should not be biopsied using the shave technique but by punch or incision. Inflammatory dermatoses are evaluated on the basis of the pattern of the inflammation in the specimen so that evaluation of the superficial, as well as the depth of the skin, needs assessment. Superficial specimens do not permit such evaluation and are therefore prone to misinterpretation. Punch and incision specimens should extend into the subcutaneous fat. Panniculitides and alopecias, which are generally more complicated disorders, should be referred to experts in virtually all cases and must be sampled by either broad, deep punch technique or deep incision. Pigmented lesions suspicious of being melanoma should be sampled by excision whenever possible. Superficial shave and punch specimens of pigmented lesions are fraught with difficulty and are prone to medicolegal liability. Therefore, when dealing with lesions such as this, it is essential that appropriate specimens be taken. Punches are not recommended unless all of the lesion can be excised with the punch or the lesion is of such a size that complete primary excision is not feasible. In the latter case, either an incisional biopsy including the area of greatest concern or a broad punch biopsy can be performed. In any biopsy of a pigmented lesion, it is essential that the specimen that is taken be representative of the entire neoplasm in question. Ulcers should be biopsied in a way that samples the ulcerated area as well as an edge. Ulcers may develop due to many different pathologic processes in the skin ranging from neoplasms to vascular diseases. The border of the ulcer usually represents the most active portion of the process and thus, may have histologic features that differ significantly from what may be seen in the center, which may be only granulation tissue. Accurate diagnosis of ulcers is often difficult, so ancillary procedures such as cultures and immunoperoxidase stains may be required. Either broad, deep punch or incisional biopsy is required. A bulla should be biopsied so as to include a portion of the blister as well as the skin just adjacent to its edge. Vesicles, which are tiny blisters in the skin, can often be completely punched out, which is the preferable method, although bullae cannot be sampled as such because of their larger size. Punches taken through the center of a larger blister will cause the epidermis to shear away and possibly be lost. As the epidermis is often an important element in the accurate diagnosis of blistering diseases, it is essential that the specimen be taken to preserve it. Immunofluorescence studies are to be performed; it is important that the differential diagnosis is known and that the specimen be taken in an appropriate manner as certain blistering diseases should be sampled away from the blister, while others, such as pemphigus, are best sampled from the blister edge. If an infectious process is suspected, send part of the biopsy for culture and inform the dermatopathologist so that appropriate special stains will be performed. All annular and expanding lesions should be sampled from the leading edge. As the central portion of annular lesions often shows no pathologic changes, it is essential that all such lesions be sampled from the active margin. Reserve shave biopsies for pedunculated or sessile lesions. The shave is generally a technique used to sample a specimen either for confirmation such as clinically obvious nevi or keratoses or for cosmesis such as removal of acrochordons or warts. It generally does not sample the dermis, so inflammatory processes, and deeply seated neoplastic disorders may be missed when sampled in this fashion. Furthermore, many serious neoplastic disorders may have seemingly innocuous appearances, so over-reliance on this technique puts the clinician at increased risk of failure to diagnose a serious process. Punch biopsies smaller than 3 mm often do not provide enough material to make a diagnosis. Inflammatory skin disorders are almost always widespread so that the punch biopsy, even when broad, represents only a small portion of the entire process. Punches smaller than 3mm in diameter often do not contain diagnostic findings. It is often helpful if several biopsies taken from lesions at different stages of evolution and from different body sites are submitted. Suppose the dermatopathologist reports that no pathologic changes were found, and you are certain that pathologic changes were present in the biopsy specimen, ask that deeper sections be cut. In some cases, the lesion may have been small so that the initial sections into the block may not have sampled diagnostic areas. Most malpractice claims in dermatology are due to failure to diagnose. Poorly performed biopsies, specimens submitted with insufficient or misleading clinical information, and histologic interpretation by those without expertise in dermatopathology are the prime sources of medicolegal liability. It is essential that those performing dermatology be familiar with the standards of care in their communities and practice appropriately. Maintain a low threshold for the performance of skin biopsies in immunosuppressed patients when appropriate. Skin disorders may serve as signs of underlying serious infectious and neoplastic conditions and may have unusual and innocuous appearances. Skin biopsies may be the only way to establish a definitive diagnosis. Do not put specimens from multiple sites in one bottle. In some cases, malignant neoplasms may simulate benign conditions so that if multiple specimens are placed in one bottle and one is found to be malignant, the results may be disastrous. Ideally, there should be one specimen per bottle, each properly labeled with regard to the site from which the biopsy specimen was taken. Handle the tissue specimen with care. Make sure that once the biopsy specimen has been removed that it actually enters the formalin bottle. Shave specimens have a tendency to adhere to the scalpel or razor blade, while punch specimens can sometimes remain in the punch barrel. The formalin should be inspected to see that the specimen is floating in the formalin itself as if specimens adhere to the bottle, they may be crushed in the lid. The specimen should be placed in the formalin promptly to avoid dehydration and autolysis. Avoid spearing or crushing the specimen as crush artifact often renders histologic findings uninterpretable. Biopsy Techniques Shave Biopsy Equipment: Bandage Antibiotic ointment Specimen transport medium (formalin) Cautery Cotton tipped swabs No. 15 scalpel blade or surgical razor blade Gauze pads 3cc syringe with 30g needle containing 1% xylocaine with epinephrine Alcohol swabs Personal protective equipment (PPE) Technique: Obtain consent. Don PPE. Clean lesion and field with alcohol. Infiltrate anesthesia intradermally. Cut lesion at the base using a sawing motion. Place specimen in formalin bottle to be submitted for pathologic examination. Stop bleeding using Monsel’s solution or 20% aluminum chloride solution. Apply antibiotic ointment and bandage. Punch Biopsy Equipment: Personal protective equipment (PPE) Alcohol swabs Anesthesia Gauze pads Biopsy punch (3, 4, or 6 mm) Sharp pointed scissors Small toothed forceps Needle holder Monofilament nylon suture with a reverse cutting needle Specimen transport medium (formalin) Antibiotic ointment Bandage Technique: Obtain consent. Don PPE. Clean lesion and field with alcohol. Infiltrate anesthesia as above. Choose a punch that encompasses the desired lesion. With one hand, stretch skin perpendicular to natural skin tension (skin fold) lines. With the other hand, twist the punch to and fro between the fingers while slowly pushing it into the skin. Push to the hub, except in areas with little subcutaneous fat, such as the dorsal of the hands, eyelids, and external ears. Pull the punch straight out. Press the skin circumferentially around the wound site. The punch specimen should be expressed from the defect. If necessary, use a blunt instrument to remove it from the wound site. Avoid using toothed forceps as they can crush the specimen. Snip the specimen free with scissors at the base, taking care to include some fat in the lower portion of the specimen. Suture closed using a simple interrupted, horizontal mattress, or figure-of-eight stitches, in such a way as to align the incision line parallel to the skin tension lines. Apply pressure to obtain hemostasis. Dress with antibiotic ointment and a bandage. The patient is instructed to keep the area covered but clean it gently daily with water and apply antibiotic ointment before bandaging. Remove sutures at the next scheduled appointment. Excisional and Incisional Biopsy Equipment: Similar to that for punch biopsy plus a No. 15 scalpel blade on a handle. Once anesthesia is obtained, the procedure is performed under sterile conditions. Blunt-tipped undermining scissors are used instead of sharp-tipped scissors to loosen the tissue before closure. Technique: Obtain consent. Don PPE. Clean field with alcohol. Infiltrate with anesthesia as above. Apply betadine or similar preoperative scrub and don sterile gloves. Make an elliptical incision around the lesion into the superficial dermis. The ratio of length to width should be about 3: 1. If an incisional biopsy is to be performed, make an elliptical incision into the lesion itself, making certain that the most abnormal areas of the lesion are included in the specimen. Repeat incising perpendicular to the skin surface until the subcutaneous fat is seen at the base, and the ellipse sits like an island in the center of the wound. Lift one point of the ellipse with the forceps and carefully dissect the base of the specimen free with scissors, taking care to include some subcutaneous fat with the specimen. Venous oozing is usually controlled by applying gentle pressure. Small arterial bleeders may be ligated with an absorbable suture. Close the wound with simple interrupted nylon sutures or with horizontal or vertical mattress sutures. Gaping wounds will have a better cosmetic result if buried sutures are used to approximate the deeper layers with absorbable suture material such as Vicryl. This is followed by superficial interrupted or running sutures using Nylon. Apply antibiotic ointment and bandage. Dressing changes and suture removal as above. PAS Stain for Onychomycosis The performance of the potassium hydroxide preparation is considered fundamental in the diagnosis of dermatophyte infection. When dealing with onychomycosis, this is a somewhat more onerous procedure as the nail must be clipped to the proximal-most portion of involvement, and scrapings must be taken of the subungual debris. The material may need to be left on the slide for up to 20 minutes before examination, which may not be possible or practical. To expedite the diagnosis of fungal infections of the nail, a simple procedure can be done using the dermatopathology laboratory to confirm the presence of hyphae in the nail plate. This technique can be used because there are stains that allow the fungus to be identified in tissue. Equipment: Heavy-duty nail clippers Transport medium (formalin or clean Ziploc bag) Gauze pads Technique: Clean area with antiseptic solution or alcohol swab. Identify dystrophic nail plate. Gently slide the edge of the nail clipper under the dystrophic nail plate. Place gauze on the surface of the affected nail (prevents nail plate from flying across the room). Apply steady firm pressure with nail clippers until the nail plate is cut. Place the nail in a laboratory transport medium. Inform laboratory to perform PAS stain for fungus on the nail plate. ABOUT CLAY J. COCKERELL, MD, JD, MBA Dr. Clay J. Cockerell is a world-renowned specialist in treating and diagnosing skin disorders and has diagnosed over three million biopsies. An internationally recognized pioneer in his field and double board-certified in dermatology and dermatopathology, Dr. Cockerell has been practicing medicine since 1986. He is currently the Founder & President of Cockerell Dermatopathology and the Program Director of the Health Education Services dermatology residency program sponsored by the Lake Granbury Medical Center. Also, Dr. Cockerell sees patients a few days per month to assist with resident training and to keep his clinicopathological skills sharp. Dr. Cockerell has held numerous leadership positions within several highly regarded medical associations. Most notably, he served as the President, Secretary & Treasurer and a member of the Board of Directors of the American Academy of Dermatology, President of the Texas Dermatological Society, and President of the Dallas Dermatological Society. Also, Dr. Cockerell holds leadership roles as Founder and President of Cockerell Dermatopathology and a former AmeriPath Board of Directors member. Dr. Cockerell and his wife, Brenda, had a lifelong dream of producing wine and, in 2005, purchased a vineyard in Calistoga, California. They now produce wine under the Coquerel Family Wine Estates label. Dr. Cockerel and Brenda have two children, Charles and Lillian, and they have been married for forty-six years. In addition, Dr. Cockerell and Brenda enjoy traveling, golf, and winter sports. ABOUT COCKERELL DERMATOPATHOLOGY The Cockerell Dermatopathology story begins with Dr. Clay J. Cockerell's vision to establish a practice whose mission is to treat each specimen as if it came from one of own family members. Family! At Cockerell Dermatopathology, every employee is driven by a relentless pursuit of diagnostic excellence. We specialize in evaluating dermatologic disorders, tackling cases ranging from the routine to the most challenging. Our practice continuously invests in cutting-edge technologies to best serve each referring clinician and their patients. These innovations result in higher-quality diagnostic slides, quicker turnaround times for routine cases, and seamless deployment of EMR interfaces. From an educational perspective, Cockerell Dermatopathology is more than a dermatopathology practice. We host numerous in-person and internet-based education events and boast a state-of-the-art 14-headed microscope for dermatology resident training sessions. Our services extend beyond borders, serving hundreds of clinicians in Texas, throughout the United States, and globally. With a highly accessible team of board-certified dermatopathologists and a dedicated support staff, our vision is simple yet profound. Family, we treat every specimen as if it were from one of our own family members. Previous Next

Matthew Leavitt, DO Matthew Leavitt, DO Faculty Dr. Matt Leavitt is a board-certified dermatologist and the Chairman, Founder, and CEO of Advanced Dermatology & Cosmetic Surgery (ADCS), the country's largest dermatology practice. He is also the Founder and Chairman of Ameriderm, a division that provides billing services for dermatology practices. Dr. Leavitt's vision led to the development of ADCS’s research division which has undertaken numerous studies for major pharmaceutical companies. Additionally, Dr. Leavitt founded Medical Hair Restoration (MHR), which he grew into a national practice for surgical hair transplantation that became the second-largest hair restoration practice in the country. Dr. Leavitt now holds the office of Executive Medical Advisor with Bosley, the largest hair restoration group in the world. Dr. Leavitt is the Chairman of the KCU-GME/ADCS Orlando Dermatology Residency Program. He has served as President of the American Osteopathic College of Dermatology (AOCD) and is a founding father of the American Board of Hair Restoration Surgery, where he served as its first vice president. Dr. Leavitt was also one of the founding members and is currently the president of the Hair Foundation. Dr. Leavitt is presently a Clinical Assistant Professor in Dermatology for the University of Central Florida and Kansas City University. Dr. Leavitt is a member of the advisory boards and a national speaker for Allergan. Formerly he was a member of the advisory boards of Merck and Pfizer (now Johnson & Johnson) and Photomedex, Abbvie, amongst others. Dr. Leavitt has served as a special consultant to Lexington International. Dr. Leavitt is recognized both nationally and internationally as an accomplished author, clinical researcher, surgeon, and lecturer on the subject of hair loss. He has received numerous grants and awards including the prestigious Golden Follicle, from the International Society of Hair Restoration Surgeons. Recently he was featured on the cover and lead article for The Dermatologist. Dr. Leavitt is a founder and 21-time chairman of the annual Live Surgery Workshop. Dr. Leavitt has authored numerous articles for dermatology, hair, and cosmetic journals and chapters in textbooks. He has been interviewed by the print and electronic media including The New York Times, The WSJ, Forbes, Men's Vogue, Parents Magazine, etc. as well as appearing on America's Health Network, CBS's 'The Early Show,' The Learning Channel, NBC iVillage. Through the Leavitt Family Foundation, he has co-sponsored fourteen annual charity golf tournaments benefiting Ronald McDonald House and the Crohn’s and Colitis Foundation (CCF). He serves on the CCF boards both nationally and locally. He has been recognized by Ernst & Young as a finalist for Entrepreneur of the Year and received numerous awards from the business community, such as Smart Awards, Florida Medical Business, etc. A graduate of the University of Michigan and Michigan State University College of Osteopathic Medicine, Dr. Leavitt completed his residency at Ohio University Grandview Medical Center. PS Winter Home

Business 201 Faculty < Back Edward Zabawski, DO Dermatologist Dr. Edward Zabawski is a board-certified dermatologist with a passion for treating a variety of skin, nail, and hair disorders. His formal education and training include: Duquesne University (Pittsburgh, PA) – BS, Pharmacy Ohio University College of Osteopathic Medicine (Athens, OH) – Doctor of Osteopathic Medicine Doctors Hospital of Stark County (Massillon, OH) – General and Internal Medicine Internship UNT Health Science Center (Fort Worth, TX) – Dermatology Residency A fellow of the American Academy of Dermatology (AAD) and the European Academy of Dermatology and Venereology (EADV), Dr. Zabawski’s research has been published in major dermatology articles and publications. In his spare time, Dr. Zabawski enjoys fishing, sports, cooking, and music. https://www.epiphanydermatology.com/ Business201 Home

Joel Cohen, MD Joel Cohen, MD Faculty Joel L. Cohen, MD (FAAD, FACMS) is an internationally recognized expert on aesthetics and skin cancer. He is the Director of AboutSkin Dermatology and DermSurgery, and AboutSkin Research in metropolitan-Denver, Colorado. He was named a Top Dermatologist by US News and World Report, Castle Connelly Top Doctor (2013-2023), and voted by his peers as one of Denver’s Top Doctors in 5280 magazine 10-times. He is a Board-Certified Dermatologist, and Fellowship-trained in Mohs Surgery, Lasers and Cosmetic Dermatology. Dr. Cohen has published over 306 medical articles and book chapters, and has has co-authored 3 academic textbooks. He lectures every month at national meetings as well as at many international congresses, and has participated in over 100 clinical trials including key aesthetic lasers and devices. He is on the teaching faculty of the University of California Irvine as an Associate Professor of Dermatology. He is 1 of the 2 Medical Directors for Cosmetic Physician Partners (CPP). Dr. Cohen has received many prestigious awards including the Melanoma Research Foundation Humanitarian of the Year Award, the ASDS Public Service Award, the ASDS Patient Safety Hero Award, the ASDS Excellence in Education Award, the ASCDAS Distinguished Service Award, and the ASDS Traveling Mentorship & Teaching Award. He has been quoted in many newspapers & magazines including Vogue, TIME, Glamour, Elle, Allure, The New York Times (x4), Reader’s Digest, Shape, USA Today, US News & World Report, InStyle, BuzzFeed, MSN.com , ABC.com , NewBeauty, Condé Nast, Men’s Health, Huffington Post, International Business Times, Consumer Reports (x8), SELF, Women’s Health and MORE Magazine. He regularly appears on Denver TV stations (with over 75 appearances discussing aesthetic issues, dermatology, and skin cancer), and has been a guest on many segments of SiriusXM Doctor Radio. He was also featured on the Emmy Award winning show “The Doctors.” PS Winter Home

Jeffrey Callen, MD Jeffrey Callen, MD Faculty Board Certifications: Internal Medicine and Dermatology Medical Degree: University of Michigan Residencies: Internal Medicine and Dermatology – University of Michigan Special Areas of Expertise: Skin Signs of Systemic Diseases, Lupus Erythematosus,Dermatomyositis, Pyoderma Gangrenosum, Psoriasis and Systemic Therapies for Management of Skin Disease. Author of multiple dermatology articles and textbooks Affiliations: Chief, Division of Dermatology, University of Louisville Dr. Callen has served as the editor or deputy editor of several dermatology periodicals and is currently the Editor of the Dermatology Section of Up To Date. PS Winter Home

Neal Bhatia, MD < Back Neal Bhatia, MD Faculty Dr. Neal Bhatia is a leading dermatologist in Southern California, providing patients in and around San Diego with the skilled, individualized care they need for skin and nail diseases and cosmetic concerns. With extensive skill and experience in treating a wide range of dermatologic issues, Dr. Bhatia is skilled at diagnosing common and uncommon skin diseases and conditions and in determining the ideal treatment for the best response and results for all skin types. At his practice in San Diego, he provides an array of services including state-of-the-art treatments for acne, psoriasis, rosacea, skin cancer and more. After earning dual bachelor of science degrees in bacteriology and genetics from the University of Wisconsin, Dr. Bhatia completed his medical degree at the University of Wisconsin School of Medicine before completing residencies in internal medicine and dermatology at Medical College of Wisconsin in Milwaukee. In addition to working in private practice, Dr. Bhatia has held several academic positions, and he has been widely published in professional journals. Dr. Bhatia also is a member of the American Academy of Dermatology (AAD) where he has served on the AAD Board of Directors and most recently as AAD Vice President, and he maintains memberships in several other professional organizations, including the American Society for Dermatological Surgery, the Dermatology Foundation, the American Dermatological Association, the Medical Dermatology Society, the Skin of Color Society and the California Society of Dermatology & Dermatologic Surgery. In addition to providing the best possible care using the safest, most effective advanced methods, Dr. Bhatia is committed to offering each patient individualized attention and customized treatment plans so they can feel confident in the care they receive every step of the way. PS Home

Joseph Merola, MD, MMS < Back Joseph Merola, MD, MMS Faculty Joseph F. Merola, M.D., M.M.S. , a leading clinician, researcher, and clinical investigator who treats immune-mediated diseases such as psoriasis/psoriatic arthritis and lupus, has been named Chair of Dermatology . Dr. Merola, who joined UT Southwestern October 16, 2023. came from Brigham and Women’s Hospital and Harvard Medical School in Boston. He held many leadership positions there, including Vice Chair of the Department of Dermatology in Clinical Trials and Innovation, Director of the Clinical Unit for Research Innovation and Trials, Director of the Center for Skin and Related Musculoskeletal Diseases, and Director of the Harvard Combined Internal Medicine-Dermatology Residency Training Program. He received his medical degree from New York University School of Medicine and a Master of Medical Sciences degree from Harvard Medical School. He then completed an internship at the University of Pennsylvania, a residency in dermatology at New York University Medical Center, and both a residency in internal medicine and a fellowship in rheumatology at Brigham and Women’s Hospital. “The multidisciplinary skills, clinical expertise, and leadership record that Dr. Merola brings will expand the Department of Dermatology’s tradition for excellence and further enhance our institution as a national hub for discovery and innovation,” said W. P. Andrew Lee, M.D. , Executive Vice President for Academic Affairs, Provost, and Dean of UT Southwestern Medical School. Dr. Merola specializes in hard-to-treat cases of immune-related inflammatory disorders, which can lead to damage to skin, cartilage, bone, and internal organs. He is the Founding President of the Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network, Vice President of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, a member of the National Psoriasis Foundation Medical Board and Scientific Advisory Committee, and President of the Medical Dermatology Society, among multiple other leadership positions. He also has led clinical trials funded by the National Institutes of Health and the pharmaceutical industry related to inflammatory skin and joint disease including psoriasis/psoriatic arthritis, and he has published more than 300 peer-reviewed articles. PS Home

Warren Piette, MD < Back Warren Piette, MD Faculty Chair, Division of Dermatology Stroger Hospital of Cook County Professor Department of Dermatology, Rush Dr. Warren Piette is a dermatologist in Chicago, Illinois, and is affiliated with multiple hospitals in the area, including John H. Stroger Jr. Hospital of Cook County and Rush University Medical Center. He received his medical degree from the University of Texas Southwestern Medical School. Dr. Piette is board-certified in internal medicine, hematology, and dermatology. He has been in practice for 35 years. PS Home

Warren Chan, MD < Back Warren Chan, MD Faculty Warren Chan, MD, MS is a clinical research fellow at the Reveal Research Institute with expertise in skin imaging, bioinformatics, and precision oncology. Dr. Chan graduated from Stanford University with both a B.S. in Management Science & Engineering and an M.S. in Biomedical Informatics before earning his medical degree from Baylor College of Medicine, where he was inducted into the Alpha Omega Alpha Honor Medical Society. Dr. Chan’s training includes an internship at the University of Texas at Austin Dell Medical School and dermatology residency at the Icahn School of Medicine at Mount Sinai. He has conducted innovative research at Stanford University, MD Anderson Cancer Center, and Wake Forest School of Medicine, developing machine learning algorithms for automated detection of patch test results and exploring non-invasive cancer biopsy methods using optical coherence tomography. As an accomplished researcher, Dr. Chan has published over 20 peer-reviewed articles in professional medical journals and presented his work at numerous national conferences. He was awarded the Howard Hughes Medical Institute Medical Research Fellowship to conduct cancer genomics research at Stanford for 2 years. His most recent research focuses on integrating artificial intelligence with dermatologic imaging to improve diagnostic accuracy and treatment outcomes. Outside of research and medicine, he enjoys playing basketball and tennis, skiing, and competing in triathlons. PS Home

Skin cancer epidemic.Cockerell Dermatopathology: Committed to Excellence < Back Cockerell Dermatopathology: Committed to Excellence Brand McCarley Feb 17, 2022 Skin cancer epidemic. There is an epidemic of skin cancer in the United States and Texas has one of the highest rates of incidence. Statistically one person dies each hour from skin cancer and melanoma, the deadliest form of skin cancer. When your doctor, usually a dermatologist, suspects that a lesion might be skin cancer, they perform a minor surgical procedure to obtain a skin biopsy for diagnosis. It is very important that the skin biopsy diagnosis be accurate so that your doctor can formulate the best possible treatment plan. While most patients think a lab is just a lab, there can be a significant quality difference of the diagnostic abilities between laboratories. Dermatopathologists are highly trained physicians who examine tissue specimens under a microscope, use the medical information shared by the doctor and consult with him or her as necessary. This personal service and collaboration between your doctor and dermatopathologists helps ensure the most accurate diagnosis. In today’s ever changing healthcare environment, patients now have more control over their healthcare choices. When it comes to diagnosing skin, hair and nail disorders, Clay J. Cockerell, MD has personally diagnosed over three million specimens and annually renders over 5,000 expert consultations for other pathologists. Dr. Cockerell and his team of dermatopathologists conduct daily case reviews, which allow multiple dermatopathologists to review difficult cases. Dr. Cockerell also sees patients and evaluates clinical pictures of skin disorders as do the dermatopathologists who work for him as they have training in both dermatology and pathology. Patients have a choice when it comes to who they want to evaluate their biopsy and they can request that it be sent to Cockerell Dermatopathology. ~~~~~~~~~~~~~~~~~~~~~~~~ ABOUT CLAY J. COCKERELL, MD, JD, MBA Dr. Clay J. Cockerell is a world-renowned specialist in treating and diagnosing skin disorders and has diagnosed over three million biopsies. An internationally recognized pioneer in his field and double board-certified in dermatology and dermatopathology, Dr. Cockerell has been practicing medicine since 1986. He is currently the Founder & President of Cockerell Dermatopathology and the Program Director of the Health Education Services dermatology residency program sponsored by the Lake Granbury Medical Center. Also, Dr. Cockerell sees patients a few days per month to assist with resident training and to keep his clinicopathological skills sharp. Dr. Cockerell has held numerous leadership positions within several highly regarded medical associations. Most notably, he served as the President, Secretary & Treasurer and a member of the Board of Directors of the American Academy of Dermatology, President of the Texas Dermatological Society, and President of the Dallas Dermatological Society. Also, Dr. Cockerell holds leadership roles as Founder and President of Cockerell Dermatopathology and a former AmeriPath Board of Directors member. Dr. Cockerell and his wife, Brenda, had a lifelong dream of producing wine and, in 2005, purchased a vineyard in Calistoga, California. They now produce wine under the Coquerel Family Wine Estates label. Dr. Cockerel and Brenda have two children, Charles and Lillian, and they have been married for forty-six years. In addition, Dr. Cockerell and Brenda enjoy traveling, golf, and winter sports. ABOUT COCKERELL DERMATOPATHOLOGY The Cockerell Dermatopathology story begins with Dr. Clay J. Cockerell's vision to establish a practice whose mission is to treat each specimen as if it came from one of own family members. Family! At Cockerell Dermatopathology, every employee is driven by a relentless pursuit of diagnostic excellence. We specialize in evaluating dermatologic disorders, tackling cases ranging from the routine to the most challenging. Our practice continuously invests in cutting-edge technologies to best serve each referring clinician and their patients. These innovations result in higher-quality diagnostic slides, quicker turnaround times for routine cases, and seamless deployment of EMR interfaces. From an educational perspective, Cockerell Dermatopathology is more than a dermatopathology practice. We host numerous in-person and internet-based education events and boast a state-of-the-art 14-headed microscope for dermatology resident training sessions. Our services extend beyond borders, serving hundreds of clinicians in Texas, throughout the United States, and globally. With a highly accessible team of board-certified dermatopathologists and a dedicated support staff, our vision is simple yet profound. Family, we treat every specimen as if it were from one of our own family members. Previous Next

James Allred, MD James Allred, MD Faculty James Allred, MD, MS, FAAD, is a dermatologist at Access Dermatology Clinic in Franklin and Glasgow, Kentucky, and Gallatin, Tennessee. Originally born and raised in the western United States, Dr. Allred has called southern Kentucky his home since 2015. During that time, Dr. Allred has lectured at national conferences, published academic articles, and founded multiple technology startups dedicated to improving patient care. He also was a founding member of the education committee for Advancing Innovation in Dermatology, a nonprofit dedicated to improving patient care through novel technologies and techniques. Before then, Dr. Allred completed his dermatology residency in Austin, Texas, where served as chief dermatology resident, patented multiple medical devices, and was a recipient of teaching awards and speaking awards, including from the Texas Dermatological Society. He completed his medical school training at the University of Utah, where he served as student body president during his fourth year, co-founded the Bench-to-Bedside research program, and was among the first students to be chosen to the Alpha Omega Alpha honor society for medical scholastic excellence. As an undergraduate at the University of Colorado at Boulder, he graduated Phi Beta Kappa with dual degrees in history with honors and summa cum laude in anthropology, where was chosen as the graduation speaker, having received the outstanding undergraduate award and outstanding senior thesis award in 2003. Dr. Allred is married with five beautiful children and has two large dogs. He gets the greatest enjoyment in life from them, especially when introducing them to his first love of the outdoors. One annual highlight for him is where he is able to take his family every year to the Colorado Rockies, where he leads the first and only continuing medical education hike that teaches dermatologists from around the country about how the environment (i.e. plants, sunlight, insect bites, etc) can negatively affect the skin. In 2021, Dr. Allred decided to establish Access Dermatology Clinic as the method to synthesize what he has learned as a clinician and an innovator to creatively and compassionately serve the people of southern Kentucky and northern Tennessee. PS Winter Home

Karen Nern, MD, MBA < Back Karen Nern, MD, MBA Faculty Karen Nern, MD, FAAD, MBA is a board-certified dermatologist and Mohs micrographic surgeon based in Colorado. She received her medical degree from UC Davis School of Medicine and completed her dermatology residency at UC San Diego. She holds an MBA from San Diego State University and is a Visiting Scientist at Lubbock Christian University. Dr. Nern founded and grew a five-location dermatology practice, now Epiphany Dermatology, before turning her focus toward mission-driven work in skin cancer prevention and education. She is Co-Founder and Medical Director of The Sun Bus, a charitable mobile screening initiative that has provided free skin cancer screenings to more than 10,000 participants across 14 states since 2019. She is also Founder and CEO of ODD SPOT a newly developed, comprehensive patient-facing skin cancer detection framework covering melanoma, basal cell carcinoma, and squamous cell carcinoma, published in the Journal of the American Academy of Dermatology. Dr. Nern is passionate about making skin cancer education accessible and actionable for patients and clinicians alike. PS Home