Business 201 Faculty < Back Jeff Libby Partner Jeff Libby is more than an outstanding attorney and counselor; he is a trusted advisor. Jeff's practice focuses on commercial real estate and commercial loan transactions in which he assists clients on a local and national basis in a wide array of development, leasing, lending and construction matters. Mr. Libby works alongside developers of medical office buildings, retail shopping centers, multifamily complexes and single-family lots assisting with site acquisition, due diligence, subdivision and platting, zoning, entitlements and financing, as well as the construction of improvements, leasing, management and asset disposition. Jeff helps landlords and tenants successfully negotiate their commercial lease agreements, and counsels owners and contractors throughout the construction process. Mr. Libby also assists local community banks and national institutional lenders in processing and closing commercial loan transactions. Specialties Include: Commercial Real Estate Transactions Commercial Loan Transactions Commercial Lending Site Acquisition and Disposition Sale-Leaseback Transactions Medical Office Building Development Retail Development Mixed Use Development, Shopping Center Development Office Building Development Multifamily Development Single-Family Development Leasing (Landlord / Tenant) Medical Office Leasing Retail Leasing Shopping Center Leasing Commercial Office Leasing Industrial Leasing Warehouse Leasing Construction (Owner, Contractor, Subcontractor) Entitlements and Zoning Business Loan Transactions (Lender / Borrower) Commercial Mortgage Loans (Lender / Borrower) Title and Survey Easements Covenants, Conditions and Restictions (CCRs) Deed Restrictions Owner Associations Business Transactions Corporate Transactions https://www.libbysparks.com/ Business201 Home

Practical Symposium | Winter Learn, Shred, Learn! January 29 - February 1, 2026 The Hythe | Vail, CO Registration Fees LEARN | SHRED | LEARN PS Winter Home Early Bird Physician PA | NP Resident | Fellow | Student Office Staff Guest of Attendee $500 $500 $200 $300 $250 After 10/31 $700 $650 $250 $350 $300 Register Today! The Practical Symposium | Winter registration fee includes access to all conference components, including educational sessions, the exhibit hall, and meals/social events listed on the agenda. Registration fees do not include lift tickets or ski rentals. Cancellations received on or before November 30, 2025, are subject to a $100 administrative fee. Cancellations received after November 30, 2025, are non-refundable. Attendee Brochure

Skin cancer epidemic.Cockerell Dermatopathology: Committed to Excellence < Back Cockerell Dermatopathology: Committed to Excellence Brand McCarley Feb 18, 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

Practical Symposium | Winter Learn, Shred, Learn! January 29 - February 1, 2026 The Hythe | Vail, CO CME & Document Center CME Certificate: The CME evaluation must be completed to receive your CME certificate. Only registered attendees will be eligible to earn CME credit. CME Evaluation & Certificate - Click Here >> (link will be provided before the symposium starts) Practical Symposium | Winter Accreditation Practical Symposium | Winter January 29 - February 1, 2026 | Vail, CO | https://www.dermatology.academy/practical-symposium-winter This activity is jointly provided by Med ical Education Resources and Cockerell Educational Foundation. Target Audience This activity has been designed to meet the educational needs of physicians, physician associates/assistants, and nurse practitioners involved in caring for patients with dermatologic disorders. Program Overview This symposium aims to strengthen the clinical skills of physicians, physician associates/assistants, and nurse practitioners focused on treating dermatologic disorders. Educational Objectives After completing this activity, the participant should be better able to: Discuss & translate the current trends and future innovations associated with clinical dermatology and dermatopathology Demonstrate an improved knowledge base of the various treatment options and the use of multiple modalities in treating specific dermatologic disorders. Recall the basic principles for treating dermatologic disorders, including biologics, combination therapy, and futu re treatments. Discuss & implement learned skills about the clinical and histopathologic features, management, and treatment of common skin cancers and non-cancerous skin disorders. Appraise & evaluate new diagnostic and treatment algorithms for pigmented neoplasms (including melanoma), carcinomas, and inflammatory conditions. Assess the use of physical therapies, including cryotherapy, radiation therapy, photodynamic therapy, and light therapy, in treating skin lesions. Faculty Click here to view the 2026 Practical Symposium | Winter faculty. Program Agenda Click here to view the 2026 Practical Symposium | Winter agenda. Accreditation Statement In support of improving patient care, this activity has been planned and implemented by Medical Education Resources (MER) and Cockerell Educational Foundation. MER is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Physician Credit Medical Education Resources designates this live activity for a maximum of 12.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nursing Credit Medical Education Resources designates this live activity for a maximum of 12.25 nursing contact hours. Nurses will be awarded contact hours upon successful completion of the activity. Physician Associates/Assistant Credit Medical Education Resources has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 12.25 AAPA Category 1 CME Credits. Physician Associates/Assistants should only claim credit commensurate with the extent of their participation. Disclosure of Relevant Financial Relationships Medical Education Resources ensures balance, independence, objectivity, and scientific rigor in all our educational activities. In accordance with this policy, MER identifies relevant financial relationships with its instructors, content managers, and other individuals who are in a position to control the content of an activity. Reported relevant financial relationships are mitigated by MER to ensure that all scientific research referred to, reported, or used in a CE activity conforms to the generally accepted standards of experimental design, data collection, and analysis. MER is committed to providing learners with high-quality CE activities that promote improvements or quality in health care and not the business interest of an ineligible company. PS Winter Home

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Dermpath On Demand is an online educational website for all things dermatopathology. Join Dr. Clay Cockerell in the library 24/7/365 to view eSlides and case review videos. 4th Wednesday Case Review hosted by Clay Cockerell, MD, MBA, JD DOD Home Join Clay Cockerell at the virtual microscope to review interesting dermatopathology cases. eSlide Example | Actual slides can be viewed fullscreen. Lecture Example When: 4th Wednesday of Each Month Time: 7:00 AM CT Duration: Each lecture lasts approximately 45-60 minutes. Sign Up: Gain access to eSlides and Zoom 4th Wednesday Sign Up

Your Academy is a series of in-person symposiums and online educational events that are focused on core and emerging dermatology and dermatopathology topics. The goal is to improve each physician and clinician's clinicopathologic correlation which leads to better management of the patient. Iron Sharpens Iron In-Person & Online Events Focused on Dermatology, Dermatopathology & Business About | Your Academy It is now more important than ever to understand the importance of the close cross-fertilization that occurs among dermatology, dermatopathology, and industry. In order to plan optimal treatment and provide the best patient care, correlation between dermatologists and pathologists is crucial. In this ever-changing field, clinicopathologic correlation also helps to guide research, new drugs, and device product development within dermatology. We hope you will join us at one of our upcoming in-person symposiums or online educational events! Clay J. Cockerell, MD Event Portfolio PRACTICAL SYMPOSIUM AUGUST 20-23, 2026 | VAIL, CO LEARN MORE SKI SYMPOSIUM JAN 29 - FEB 1, 2026 | VAIL, CO LEARN MORE HONE PA+NP SYMPOSIUM SEPTEMBER 12, 2026 | DALLAS, TX LEARN MORE DERMPATH ON DEMAND ONLINE 24/7/365 LEARN MORE BUSINESS 201 ONLINE LECTURES LEARN MORE

Dermpath On Demand is an online educational website for all things dermatopathology. Join Dr. Clay Cockerell in the library 24/7/365 to view eSlides and case review videos. About & Testimonials DOD Home With the advances in teaching technologies and the American Board of Dermatology embracing digital reading for the dermatopathology component of the board exam, the timing is perfect to launch Dermpath On Demand. Why waste your valuable time and money traveling to a board review or other training when we can offer a high-quality training experience from the safety and comfort of your own home? In addition to the annual Digital Board Review (DBR), Dermpath On Demand offers numerous interactive educational events hosted by many of the nation's leading dermatopathologists. Subscribe to the calendar and opt-in to our scholarly communications to stay up to date on all upcoming events. The weekly educational Zoom meetings have improved my confidence in dermpath and preparing for the board exam. Excellent comprehensive course provided by a distinguished lineup of dermatopathologists! High volume of cases that will leave you feeling much more comfortable and prepared for upcoming board examinations. Fantastic comprehensive high yield review course! Highly recommend for all residents taking the CORE and boards! This was a great and comprehensive dermpath review that went way beyond just making the diagnosis from the slide. The differentials covered and pearls given about exam-taking techniques were extremely helpful. Excellent course filled with outstanding and incredibly knowledgeable dermatopathologists and teachers. With many in-person courses canceling, this is now the best dermpath prep course out there! The flexibility of the recorded sessions on YouTube has allowed me to watch lectures on my schedule. This board review has been a game-changer. Thank you!

Dermpath On Demand is an online educational website for all things dermatopathology. Join Dr. Clay Cockerell in the library 24/7/365 to view eSlides and case review videos. Board Reviews DOD Home Who could benefit by participating? Residents | Dermatology & Pathology Fellows | Dermatopathology & MOHS Practicing physicians preparing for their recertification exam Medical students with interest in dermatology or pathology Cost: Thanks to the generous support of our industry partners, there is no cost to attend an in-person or virtual board review. Thank you, industry partners! Be sure to check out their services (websites.) Without their support, these board reviews would not be a reality. Included: Access to all board review e-slides. Access to the exams with a comprehensive answer key. Access to Dr. Cockerell's in-person or virtual case reviews. Cockerell 100 | Dermpath Board Review eSlides, Exam, Answer Key & Case Review Visit our Educational Library to view the 2025 Cockerell 100 content. Date: Saturday, June TBA, 2026 Virtual Times: 365/24/7: eSliding Reading. e-Slides will be provided one week before the event. To mimic the Applied exam, allow no more than 2 minutes per slide. 12:00 PM CDT: Business Lecture by Clay Cockerell, MD, MBA, JD 1:00 PM CDT: Case Review by Clay Cockerell, MD, MBA, JD via Zoom. Host: Clay J Cockerell, MD, MBA, JD Digital Board Review eSlides, Exam, Answer Key & Video Case Review Self-Paced Cases

Practical Symposium | Winter Learn, Shred, Learn! January 29 - February 1, 2026 The Hythe | Vail, CO Who Should Attend? LEARN | SHRED | LEARN PS Winter Home The Practical Symposium | Winter is designed for: Dermatologists Mohs Surgeons Dermatopathologists Pathologists Dermatology Physician Associates/Assistants Dermatology Nurse Pra ctitioners Plastic Surgeons that Treat Skin Disorders Family Practitioners that Treat Skin Disorders Podiatrists that Treat Skin Disorders Dermatology and Mohs Fellows Dermatopathology Fellows Dermatology Residents Pathology Residents Register Today! Attendee Brochure Top Reasons to Learn | Shred | Learn Earn CME | Presented by World-Renowned Luminaries Virtually all of the major topics of dermatology and dermatopathology will be covered in this 3 day comprehensive seminar. Learn the essentials of clinicopathologic correlation, the cornerstone of dermatology and dermatopathology. Earn 12.25 CME credit hours. Sessions on Fillers, Superficial Radiation Therapy, Molecular Diagnosis, Pediatric Dermatology, Therapeutics, and more... Creative sessions and updates on these essential topics are included for a more intense didactic education. The Vail Valley Vail is the world's best winter playground. Practical Symposium Goals Achieve your educational goals with the ability to earn CME credits/hours. Comprehensive agenda topics covering a broad spectrum of dermatology and clinicopathologic correlation topics through engaging lectures. Advance your knowledge base by interacting in live demonstrations featuring emerging dermatologic technologies. Access to specialty and industry luminaries to strengthen your clinical and diagnostic skill sets. Expand your professional and social networks by mingling with colleagues, key opinion leaders, and industry executives. Prepare for the board or recertification exam through intense self-assessment and review sessions. Educational Objectives Translate the current trends and future innovations associated with clinical dermatology and dermatopathology. Demonstrate an improved knowledge base of the various treatment options and the use of multiple modalities in treating specific dermatologic disorders. Recall the basic principles for the treatment of dermatologic disorders, including biologics, combination therapy, and evolving treatment options. Implement learned skills about the clinical and histopathologic features, management, and treatment of common skin cancers and non-cancerous skin disorders. Evaluate new diagnostic and treatment algorithms for pigmented neoplasms (including melanoma), carcinomas, and inflammatory conditions. Assess the use of physical therapies in treating skin lesions, including cryotherapy, radiation therapy, photodynamic therapy, and light therapy. We would be honored to have you join us in Vail. We know that you will come away learning an incredible amount and have a great time in the process.

Dermpath On Demand is an online educational website for all things dermatopathology. Join Dr. Clay Cockerell in the library 24/7/365 to view eSlides and case review videos. FAQ DOD Home What is Dermpath On Demand? With the advances in teaching technologies and the American Board of Dermatology embracing digital reading for the dermatopathology component of the board exam, the timing is perfect to launch Dermapth101. "Why spend your valuable time and money traveling to a board review or other training when we can offer a high-quality training experience from the comfort of your own home", said Dr. Cockerell from Dallas, TX. What is the cost of the Digital Board Review (DBR)? Thanks to the generous support of our industry partners, there is no cost associated with the DBR. Thank you, industry partners! Be sure to check out their services (websites.) Do I need to register for the DBR? To make the process as simple as possible, you do not need to register for the DBR. Our only request is to check out our industry partners' services. Without their support, hosting a complimentary DBR would not be a reality. How many cases do you plan to present at the DBR? There will be ~60 high-quality e-slides to read, be quizzed on, and reviewed. All cases were hand-selected by Dr. Cockerell and are a good representation of the cases that could be presented on the board exam. We will also have an additional ~40 self-paced cases with a detailed answer key to test your knowledge base. Will the case review be recorded? Yes, Dr. Cockerell's in-depth case review will be recorded and will be made available for all participants. Note: The self-paced "S1 - S40" cases will not be discussed. Where can I find additional educational content? From the Dermpath101 homepage, click on the Dermpath On Demand Library. At the library, you can view all e-slides and associated training videos. If Mom calls, tell her you are at the library!

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