Rashes & bumps... What to do when you're just not quite sure.

As an APRN that specializes in foot and ankle conditions, I face a very similar clinical reality as my colleagues in primary care... Disorders of the skin.  The skin problems that I most often see are related to fungal infection and warts.   But every once in a while I am presented with a much more interesting and unique dermatological challenge.  In fact, I will present to you a patient case that just happened last week.

A 10 year old caucasion female is referred to my by her pediatrician for "wart removal" of a solitary plantar wart on her plantar medial heel that has been evident for the past 3 months.  The lesion grew over a section of skin that her mother said previously had a birth mark.  The lesion measured 6mm in diameter and was raised.  It had a pink-brown pigmentation and the borders of the lesion were smooth.  It did not have a rough "warty" appearance.  After taking a medical history and evaluating the lesion, I recommended that we biopsy the lesion.  I choose to do a simple 2mm punch biopsy (after numbing under the lesion with a marcaine with epinepherine mixture).  I sent the specimen to my Dermatopathologist, BAKO Pathology and 2 days later had a diagnosis... Spitz Nevus.  I referred this patient to my partner, Dr Paul Krestik, for a complete excision of the lesion. 

Spitz Nevus (Click for video information) 

Additional Information on Spitz Nevus

I believe that there are at least two major take home messages from the case above.  First, as APRN's we need to biopsy more lesions.  Why send our patients out to dermatology for biopsy when it can be simply and effeciently done in our own office?  Second, an excellent Dermatopathologist is a very important member of your clinical team.  After trying several different pathology companies in my practice, I have concluded that BAKO Pathology is the premiere. 

If you are not comfortable doing simple punch and shave biopsies in your office, I would challenge you to find a continuing education course on the topic and gain some confidence and skill in this area.  I will do a brief educational primer on these techniques in the near future.