We have set up a website at www.globalskinpathatlas.com/ads which allows a clinician to have an online area where he or she can submit clinical images and a structured history to which the pathologist can add their report and some histology images. This service is open to Australian Doctors only. The case can then be submitted to the website library if thought appropriate. See www.globalskinpathatlas.com
I think another good idea would be to have a structured path form where certain details can be added by the referring clinician simply by ticking a box. e.g.
Rash Morphology- Red scaly , Red non scaly, Pustular, Vesicular or Bullous
Tumour - Solitary, Multiple
Rash Site - generalised, face, trunk, acral, arms and legs, flexural, photodistribution
Other Features-
Your Probable diagnoses-
I will illustrate below how we can combine Mnemonics for these Types of rashes with the overview of the slide ie whether the process is Epidermal, Dermal or a mixture of both. By looking at the slide and applying the mnemonics you can consider the most relevant clinical conditions that would apply to that case and specifically look for features pointing to that diagnosis. The 4 Mnemonics are
Red Scaly PMs PET A little cat called PETAL
Red Non Scaly CUL DVA EVIE (See you later at the Department of Veterans Affairs Evie)
Pustular II (Aye Aye) Infective Inflammatory
Vesicular /Bullous ICI Infective Contact Inflammatory Immunological
Analysing a Path Slide
Look at the glass slide and the cuts
Choose the cut most likely to show pathology, but look at all the others later. Decide if the pathology is epidermal, dermal or both. If epidermal use the red scaly mnemonic. If dermal use the red non scaly mnemonic If both then use both but see which pattern predominates. If pustules use pustule mnemonic. If vesicles or blisters use blister mnemonic. Conventionally you look to establish a histological reaction pattern. I would contend you should not do this until you have decided on the diseases mnemonic.
Epidermal - PMsPETAL - look for para keratosis or layered orthokeratosis, acanthosis, acantholysis, pseudoepitheliomatous hyperplasia, any dysplastic changes, other cells in the epidermis, rete ridge extensions, basal layer hyperpigmentation , cellular pallor, subcorneal split, spongiosis, intraepidermal vesicles or pustules.
(In the video we explain what each of these features may mean.)
Dermal - CUL DVA EVIE Look for recognised histology inflammatory patterns Or is this a tumour. What cells are there especially infiltrating inflammatory cells. Collagen normal or thickened. Vessels ok. Adnexal structures present and ok Fat ok
The reason for bringing in the mnemonics very early is to bring diseases to the forefront and then discount them rather than to use the path features to arrive at a list of potential diseases.
Going with the wrong path feature will likely send you down the wrong diagnostic pathway. The mnemonics also list the more common and hence most likely clinical diagnoses. If both epidermal and dermal features then decide which one looks the major site of inflammatory change and go with it but run the other mnemonic over the slide as well before signing it out.
Tumours
If you decide something is a tumour then try to determine the cell of origin. Double check there is only one tumour. Determining cell of origin may require immunoperoxidase special stains. This is particularly so for spindled cell tumours and some Adnexal tumours.Epidermal tumours can be keratinocytic, melanocytic, histiocytic or appendigeal. They may also be due to cells infiltrating from the dermis including T cells, mast cells , Merkel cells etc. Metastases from internal organs also occur to the skin but they are usually dermal.
Exercises - Consider the following slides then look at the video analysis. Clinical history and age are both important in the final diagnosis as is the type of biopsy you are having to report on. I would provide a structured request form and a facility to upload clinical and dermatoscopic images. See www.globalskinpathatlas.com/ads for access.
Now for some cases.(To be added)
See the video below of a simplified version of this approach given at the Australian Institute of Dermatology Membership Weekend Skin Workshop.
.