Business 201 Faculty < Back Chase Murphy, CPA Tax Partner Passionate about innovation and propelling the ecosystem forward across the US. Helping entrepreneurs and venture markets enhance and protect value through expansive network of advisors and investors. Finding unique ways to collaborate as strategic partner through creative thinking, motivated introductions, proactive planning, and connections to funding opportunities. Specializes in income tax consulting for entrepreneurs, venture backed businesses, and investors. Particular focus on entity structuring, capital raising, and transaction planning. Experienced leader focused on engaging employees by connecting them to a purposeful mission, creating a culture that inspires them to do their best work, and development to reach their full potential. Currently holds an active CPA license. Business201 Home

Dipti Anand, MD < Back Dipti Anand, MD Faculty Dr. Anand is a native of New Delhi, India. She received her medical degree at Ramaiah Medical College in Bangalore, India, graduating in the top 1st percentile of her class. She did a year of Preliminary Medicine at Albert Einstein Medical Center in Philadelphia, where she received the “Outstanding Intern” award. She subsequently went on to complete an Anatomic Pathology Residency at the Hospital of the University of Pennsylvania. Her residency was followed by a year of a coveted dermatopathology fellowship, under the mentorship of Dr. Clay Cockerell, at the University of Texas Southwestern in Dallas. Dr. Anand is board certified in pathology as well as dermatopathology. She has been successfully running a well-reputed annual Dermatopathology Board Review course for the dermatology residents since, 2012. In addition, she also runs a biannual CME accredited dermatopathology teaching course for ancillary physician providers. Dr. Anand is passionate about education and is continuously on the teaching roster for didactic sessions for the dermatology residents at the Medical College of Georgia and Emory University School of Medicine. She is the recipient of the 2019 Voluntary Faculty Teaching Award from Emory. Dr. Anand is actively involved in mentoring residents and students in the field of dermatology. She is the Clinical Associate Professor of Medicine at Philadelphia College of Osteopathic Medicine and serves as the Program Director of Dermatopathology at D.O Dermatology Residency in Atlanta. She is on the Board of Directors for the annual Zola Cooper Lee T. Nesbitt Seminar. She is an active member of the Atlanta Dermatology and Dermatologic Surgery Society, the Georgia Society of Dermatology and Dermatologic Surgery, the American Academy of Dermatology, and the American Society of Dermatopathology. Dr. Anand has numerous publications in the fields of dermatology and dermatopathology. She has been practicing dermatopathology for the last eight years and is currently the CEO and Medical Director of SkinPath Solutions. PS Home

Whitney High, MD, JD, MEng < Back Whitney High, MD, JD, MEng Faculty Professor of Dermatology Vice-Chairman, Dermatology Director of Dermatology Clinic Director of Dermatopathology Laboratory, University of Colorado Whitney A. High, MD, MEng, a native of Colorado, is the Vice Chairman of Dermatology, and the Director of both the Dermatology Clinic and the Dermatopathology Laboratory at the University of Colorado. He is board-certified in Dermatology and Dermatopathology. He also has certification in Tropical Medicine & Hygiene. After practicing as a chemical engineer in the industry, Dr. High returned to medical school to receive his medical degree from the Mayo Clinic School of Medicine. Dr. High completed his dermatology residency training at the University of Texas Southwestern Medical Center, serving as Chief Resident. He completed his dermatopathology fellowship at the University of Colorado. Dr. High is appointed to the Departments of Dermatology & Pathology at the University of Colorado. His research laboratory was the first in the world to discover gadolinium in the tissue of patients with nephrogenic systemic fibrosis. Dr. High also has a degree in law from the University of Denver. He has authored 4 textbooks, 40 chapters, and more than 80 medical papers. He has served as an editor/editorial board member in many top medical journals in his fields. Dr. High’s current research interests include: Pigmented lesions Medicolegal issues Infectious disease/sexually transmitted disease Pharmacological and toxicological dermatology/dermatopathology Advanced biochemical testing applied to dermatology/dermatopathology 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

Melissa Mauskar, MD < Back Melissa Mauskar, MD Faculty Melissa Mauskar, M.D., is an Associate Professor in the Department of Dermatology and the Department of Obstetrics and Gynecology at UT Southwestern Medical Center. Her clinical practice is focused on complex medical dermatology and vulvar dermatoses. She is the founder and Director of the Gynecologic Dermatology Clinic at UT Southwestern, a tertiary referral center for gynecologists, dermatologists, and primary care physicians serving Texas and surrounding states. Dr. Mauskar earned her medical degree at the University of Texas Health Science Center at San Antonio. She completed her residency in dermatology at Georgetown University Hospital and MedStar Washington Hospital Center and is certified by the American Board of Dermatology. In addition to general dermatology, she specializes in treating vulvovaginal conditions such as lichen sclerosus, lichen planus, lichen simplex chronicus, and pelvic floor disorders. She has a passion for educational initiatives to improve the recognition, diagnosis, and treatment of vulvar dermatoses. Dr. Mauskar serves as part of the Parkland Health vulvology clinical faculty, working alongside her gynecology colleagues to provide multispecialty collaboration for patients with complex vulvovaginal conditions. She is also an active member of the Dermatology Inpatient Consultation team and staffs the department’s High Complexity Clinic, where she specializes in treating patients with severe cutaneous drug eruptions. Her research interests include lichen sclerosus as well as Stevens-Johnson syndrome and toxic epidermal necrolysis. Her research is supported by the Dermatology Foundation, and she has been involved in site-specific planning of a NIH UO1 phase III prospective multi-institutional study comparing medical treatment to supportive care for Stevens-Johnson syndrome and toxic epidermal necrolysis. Dr. Mauskar lectures worldwide on vulvar dermatoses. She is a fellow of the International Society for the Study of Vulvovaginal Disease (ISSVD) and serves on the Board of Directors for the North American Chapter of the ISSVD. As an advocate for women’s health initiatives, she aims to improve the quality of life for women and their interpersonal relationships and empower patients to speak more freely about their conditions. PS Home

The COVID-19 pandemic has transformed the business environment for good.Top PR Strategies < Back Top PR Strategies Angela Kambarian | Dermatology Authority Feb 1, 2022 The COVID-19 pandemic has transformed the business environment for good. Now that we are coming off one of the most disruptive years in history, we should probably come to terms with the fact that we might be operating in a business environment that has been transformed for good. Influenced by the prolonged pandemic and rapid technological advancements, we will be a wide variety of new strategies emerging in business to business (B2B) and business to consumer (B2C) marketing. Here are a few to keep in mind as we transition to 2022. Media Outlets Are Relying More on Contributed Articles Since 2008, newsroom employment in the U.S. has fallen 26%, and demand for online content has grown exponentially. It means that media outlets have fewer full-time writers, resulting in increased demand for contributed articles by outside authors – the kind of thought leadership that is highly effective with B2B buyers. By the way, if you have been struggling to convince your executive team to invest the time and effort required for strong thought leadership, 2022 should be your year to change this. PR Professionals Will Use a Variety of Channels to Identify Media Opportunities From Muck Rack and Help a Reporter (HARO) to Twitter and Slack channels, it is easier for PR pros to respond and pitch via a plethora of new emerging platforms and channels. And that’s what digital transformation is all about. Public Relations Campaign Needs a Purpose In 2020 many brands were being heavily scrutinized or criticized for outdated policies, a lack of diversity in the workplace, or reluctance to get involved in social issues and make a difference. In 2021, however, many organizations had finally upgraded their policies, revamped or re-introduced DEI programs, openly expressed outrage over social injustices, and promised to step up their game. In 2022 brands should highlight their mission-based efforts across different communication channels and demonstrate more accountability. Public relation (PR) efforts should be focused on philanthropic involvement and social awareness; it’s crucial that businesses start transitioning from “talking the talk” to “walking the walk” and following through on “do-better” initiatives. Podcast Appearances Should No Longer Be Swept Under the Rug While local and national radio is still best for breaking news, podcasts seem more appropriate for extended discussions of hot topics. These podcasts may not have a vast number of listeners; however, those who do tune in will be highly engaged. If you were putting your appearance on a podcast on the back burner, it is time to give it some serious consideration. Impactful PR Will Have to be Part of a Larger Marketing Ecosystem PR usually generates more traction when combined with other marketing strategies. Let me assure you that in 2022 this will be vital. PR is a piece of the marketing puzzle and needs to be combined with a strong content strategy, paid ads strategy, and social strategy for bigger, better, and more powerful results. Keep it Simple We are living in turbulent and unpredictable times. Sadly, attention spans are short, and anxiety levels are sky-high these days. But the most crucial and impactful form of communication is also the most overlooked. Therefore, in my professional opinion, simplifying a brand message will be one of the important trends in PR for 2022. Companies of all sizes should make sure they avoid fancy language, long-winded copy, and tedious or complicated explanations. Keep your story short. Make it concise, easy-to-understand, and void of “highfalutin” terms. Just explain briefly what it is you do, why it matters, and how your prospects will benefit. ABOUT AUTHOR Angela Kambarian Kambarian.com | 516-724-4372 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

Courtney Schadt, MD Courtney Schadt, MD Faculty Board Certifications: Dermatology Medical Degree: Vanderbilt University School of Medicine Residency: Vanderbilt University Division of Dermatology Internship: Internal Medicine, Vanderbilt University Medical Center Special Areas of Expertise: General Dermatology, Medical Dermatology, Skin Cancer Affiliations: Associate Professor of Medicine, University of Louisville Division of Dermatology PS Winter Home

Theodore Rosen, MD < Back Theodore Rosen, MD Faculty Dr. Rosen, a native of Chicago. attended Michigan State University as a National Merit Scholar, and graduated from the University of Michigan Medical School cum laude. He trained in internal medicine at the University of Alabama and in dermatology at Baylor College of Medicine, where he currently serves as Professor and Vice-Chair of Dermatology. Dr. Rosen previously served on the Board of Directors and is a past Vice-President of the American Academy of Dermatology. He is also a past-President and Secretary-Treasurer of the Houston Dermatological Society and prior Chairman and Secretary-Treasurer of the Dermatology Section, Southern Medical Association. Dr. Rosen was the 2017 recipient of the AAD Thomas G. Pearson Memorial Award for lifelong achievement in education, and the 2021 recipient of the Robert J Freeman Memorial Mentoring and Leadership Award from the Texas Dermatology Society. Dr. Rosen has written over 300 peer-reviewed journal articles, 28 textbook chapters and 4 textbooks. Dr. Rosen is an avid numismatist, diehard Chicago Cub fan and devotee of horror films. PS Home

Karen Nern, MD, MBA Karen Nern, MD, MBA Faculty Dr. Karen Nern is a board-certified dermatologist and dermatologic surgeon with expertise in general, cosmetic, and surgical dermatology. She performs Mohs micrographic surgery and has extensive experience treating both benign and malignant skin growths. She also performs many cosmetic procedures, including JUVÉDERM®, VOLUMA®, KYBELLA®, chemical peels, and CO2 laser. Her formal education and training include: Arizona State University (Tempe, AZ) – BS, Finance San Diego State University (San Diego, CA) – MBA, International Business University of California, Davis (Davis, CA) – Doctor of Medicine Scripps Mercy Hospital San Diego (San Diego, CA) – Transitional Medicine Internship University of California, San Diego (San Diego, CA) – Dermatology Residency A diplomate of the American Board of Dermatology (ABD), a fellow of the American Academy of Dermatology (AAD), and the American Society for Mohs Surgery (ASMS), Dr. Nern is a preceptor for medical students and is passionate about teaching. She is dedicated to taking exceptional care of her patients to help them achieve skin health and skin cancer prevention. In her spare time, Dr. Nern enjoys skiing, horseback riding, boating, and hiking. Dr. Nern is also on the Board of The Colorado Melanoma Foundation and initiated a philanthropic project called The Sun Bus. The Sun Bus attends major events and is a free sun safety education and skin cancer screening vehicle serving the underserved populations of Colorado. PS Winter Home

Business 201 Faculty < Back Chris LeLash Sales Associate Christian LeLash teams with wife, Jennifer, to provide professional luxury real estate services to busy professionals. Together, the LeLash Group has sold millions in luxury properties with sales as high as $12 million. Chris and Jennifer have extensive knowledge of Dallas' real estate market, its private and public schools, and its neighborhoods. They specialize in handling discreet, private real estate transactions for high-net-worth families. Clients attest to Chris’ and Jennifer's professional, discreet, and seamless client service from beginning to end. In addition to real estate, Chris has twenty years of experience in consulting, financial analysis, business development, investments, and high-net-worth client service. He is also a private foundation trustee with experience in investment management, grantmaking, and board governance. Chris attended the University of Pennsylvania and The Wharton School as an undergrad and earned an MBA from New York University's Stern School of Business. Chris enjoys traveling with his family and coaching youth soccer and basketball. Chris and Jennifer are active members within the Shelton and Parish Episcopal school communities and volunteer their time to many charitable efforts close to their hearts. • D Magazine Top Producer 2016-2019 • Multi-Million Dollar Producer • Current or former Board Member, Lymphoma Leukemia Society, Turtle Creek Conservancy, and Wipe Out Kids’ Cancer. https://www.sothebysrealty.com/eng Business201 Home

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

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