Quantcast

Question about friends patient encounter

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Status
Not open for further replies.

KeratinPearls

Full Member
10+ Year Member
Joined
Apr 3, 2007
Messages
1,305
Reaction score
340
Pathologist here....So long story short. My friend went to see a derm for what she thought was a pimple near her eye. The derm did what I think was a punch biopsy on it because he thought she had lupus. My friend had no other symptoms, no other skin lesions. No labs were ordered before biopsy. Now she has a small wound from the biopsy. The ANA was ordered after the biopsy which was negative.

when I heard this I was furious.

Was the biopsy clinically indicated? I was thinking several things. 1. the doc is an idiot 2. The doc is trying to make money off the biopsy or 3. The biopsy was clinically indicated based on appearance of the lesion and he did the right thing.

cam someone help me?
 

asmallchild

Full Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
15+ Year Member
Joined
Oct 22, 2006
Messages
2,246
Reaction score
704
This thread will be closely watched as it veers very closely towards asking for medical advice.

The simple answer is that no one here can tell because no one here saw the lesion.

I'm curious as to why you are furious? It seems like a fairly routine procedure that is performed every day in the office. Patient comes to doctor noting a lesion of unknown behavior. Some lesions we can look at and diagnose. Some lesions we need to perform a biopsy to diagnose.
 

KeratinPearls

Full Member
10+ Year Member
Joined
Apr 3, 2007
Messages
1,305
Reaction score
340
This thread will be closely watched as it veers very closely towards asking for medical advice.

The simple answer is that no one here can tell because no one here saw the lesion.

I'm curious as to why you are furious? It seems like a fairly routine procedure that is performed every day in the office. Patient comes to doctor noting a lesion of unknown behavior. Some lesions we can look at and diagnose. Some lesions we need to perform a biopsy to diagnose.

No other symptoms for lupus. No other symptoms period. i mean if someone comes to a dermatologist with what looks like a pimple would you biopsy it with no lab work done (ANA) beforehand or at least have some symptoms of lupus to support doing the biopsy? I mean anyone can come in to the office with something that looks like a pimple and you’d just biopsy it?

Lab workup like I said has been negative.

not looking for medical advice. Just a yes or a no a derm would be required to do a biopsy in a case like this would suffice.
 
Last edited:

sore eye asses

Full Member
10+ Year Member
Joined
Aug 14, 2009
Messages
608
Reaction score
217
Agree with asmallchild, impossible to know the intent of the physician without seeing the lesion. If the intent was to differentiate a potential cutaneous malignancy from cutaneous lupus or sarcoid or any number of other possibilities in the differential, then a biopsy would be wholly appropriate. One could take the pessimistic view that this biopsy was performed to make “extra money” but I think it’s unlikely and really only harms you (or your friend). That’s all to say that the physician wasn’t cackling while doing the biopsy and pontificating on how he/she was going to spend his/her $40 windfall.
 
  • Like
Reactions: 1 users

asmallchild

Full Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
15+ Year Member
Joined
Oct 22, 2006
Messages
2,246
Reaction score
704
No other symptoms for lupus. No other symptoms period. i mean if someone comes to a dermatologist with what looks like a pimple would you biopsy it with no lab work done (ANA) beforehand or at least have some symptoms of lupus to support doing the biopsy? I mean anyone can come in to the office with something that looks like a pimple and you’d just biopsy it?

Lab workup like I said has been negative.

not looking for medical advice. Just a yes or a no a derm would be required to do a biopsy in a case like this would suffice.

Again, impossible to say without seeing the lesion.

Perhaps my mind wouldn't have jumped to lupus with no other symptoms beyond a solitary cutaneous lesion. But there must have been something there for the physician to think lupus as the biopsy technique and initial workup has been appropriate if one truly suspected cutaneous lupus.

How long has it been there? <3 weeks? I would wait a few weeks and bring the patient back in for followup (which an outsider could also criticize as trying to be greedy and extract a second visit)

Perhaps it was suspicious for malignancy? I would probably do a shave biopsy in that case but an appropriately sized punch should be able to pick up an inflammatory or neoplastic process. Again, you cannot base your satisfaction on the results of the biopsy. If I find something, you are happy? If I don't find something, you assume I'm just trying to drum up business by unnecessarily biopsying?

My viewpoint is biased as I primarily practice surgical dermatology with a more elderly patient population. So yes, if you took the time to come into my office and ask me to look at a lesion, more often than not, you would probably leave my practice with a biopsy scar. (Again, if it truly looked like a pimple and had been present for < 3 weeks than I would not biopsy)
 
  • Like
Reactions: 1 user

reno911

Full Member
10+ Year Member
Joined
Jul 16, 2009
Messages
322
Reaction score
172
As everyone is saying, it's impossible to say without seeing a lesion.

Also your description of "looked like a pimple" is essentially worthless. I'm pretty sure I have heard non-dermatologists at some point describe lesions from a large variety of dermatologic conditions as looking like "pimples". Even lupus.

I will also say that a dermatologist who is unethical and is biopsying things unnecessarily to make money (sure there are some bad apples out there) will be very unlikely to biopsy something near the eye. There is all sorts of lower hanging fruit. That's just generally not what those people do. Especially if the patient is young and female.
 
Last edited:
  • Like
Reactions: 2 users

doctalaughs

Member
15+ Year Member
Joined
Jul 9, 2003
Messages
1,307
Reaction score
1,907
You do realize that you can have cutaneous lupus with a negative ANA, right?

This is like saying every immunostain that a pathologist does is because he’s “an idiot and just wants to make money”. Really no way for me to know - as I’m not a pathologist and if I looked at the slide (or even worse a layperson did) the opinion would be pretty worthless. See what I mean? I’m sure there are some pathologists that over-order stuff like that, but judging 2nd hand is not a good idea.
 
Last edited:
  • Like
Reactions: 1 user

Dral

Full Member
10+ Year Member
Joined
Jan 8, 2009
Messages
2,311
Reaction score
1,807
If she thought it was a pimple, why did she schedule an appointment with a physician? Normally, people don’t seek medical care for a single acne lesion.

If she thought it was a pimple but there were worrisome things about it to prompt a biopsy (the likely reason she scheduled an appt), a punch bx is the best way to investigate a follicular based process (more a 3mm punch biopsy imo, but possibly a 4 if done carefully).

Based on what we know I would probably have done a shave, but there was likely a reason they wanted to do a punch. If anything, we try to do shaves because punches take longer and don’t heal as well. If you want to talk cost I’m guessing it is more cost effective based on time to do a shave. We usually do a punch when we know it’s the right thing to do. The more common sentiment in our world is “why did they shave this instead of punching it?” opposed to the opposite.
 
Last edited:
  • Like
Reactions: 1 user

smartparts

Full Member
10+ Year Member
Joined
Sep 12, 2009
Messages
235
Reaction score
61
Pathologist here....So long story short. My friend went to see a derm for what she thought was a pimple near her eye. The derm did what I think was a punch biopsy on it because he thought she had lupus. My friend had no other symptoms, no other skin lesions. No labs were ordered before biopsy. Now she has a small wound from the biopsy. The ANA was ordered after the biopsy which was negative.

when I heard this I was furious.

Was the biopsy clinically indicated? I was thinking several things. 1. the doc is an idiot 2. The doc is trying to make money off the biopsy or 3. The biopsy was clinically indicated based on appearance of the lesion and he did the right thing.

cam someone help me?

Just because the point hasn't been made yet: biopsies on the face usually heal really well over time.
 

doctalaughs

Member
15+ Year Member
Joined
Jul 9, 2003
Messages
1,307
Reaction score
1,907
Also I’ve seen a good number of cases of cystic or hormonal “acne” treated with poor response for several years (even occasionally by other dermatologists) that are actually cutaneous lupus and needed work up + plaquenil. Acneiform presentations are not super-uncommon imo and morphology clues to raise suspicion takes a keen eye (kinda like those rare cases of cutaneous lymphoma that look very much acneiform- but more common in this situation).
 

asmallchild

Full Member
Staff member
Administrator
Volunteer Staff
Lifetime Donor
15+ Year Member
Joined
Oct 22, 2006
Messages
2,246
Reaction score
704
Sorry, locking, this was deemed to be medical advice after all

If the OP and/or the OP's friend is unhappy with care, I recommend following up with the original dermatologist for further information or seeking a 2nd opinion.
 
  • Like
Reactions: 1 user
Status
Not open for further replies.
Top