5 Derm Dilemmas You’ll Encounter (and How to Handle Them)

Learning Opportunities:  Common Problems, Smart Protocols

Problem 1: Brisk or Pulsatile Bleeding Post-Punch Biopsy

Sometimes a routine punch biopsy takes an unexpected turn when you encounter pulsatile bleeding. Even if you're not over a major artery, vessel-level bleeding demands immediate action.

Quick, confident measures like figure-of-8 sutures and direct pressure can control most cases. But if bleeding persists or returns, don’t hesitate to refer, better safe than sorry.

Problem 2: Cosmetic Lesion, Insurance Request

Patients occasionally request removal of benign lesions for cosmetic reasons and ask you to bill insurance. This puts you in an ethically and legally risky situation.

Be transparent, stand firm on policy, and never falsify diagnoses to satisfy billing demands. Patient trust is important, but so is professional integrity.

Problem 3: Anxious Patient with Prior Skin Cancer

A history of skin cancer can make even benign lesions feel threatening to a patient. When anxiety drives requests for multiple removals, a balanced approach is key.

Reassurance goes a long way. One representative biopsy may be all it takes to ease fear while avoiding unnecessary procedures.

Problem 4: Patient Refuses Pathology

Cost concerns sometimes lead patients to request lesion removal without pathology. It may seem harmless, especially if the lesion looks benign, but it’s not.

Always require pathology. It’s your legal and ethical safeguard, and it ensures the best outcome for both you and your patient.

Problem 5: Biopsy Over a Critical Structure

Biopsying over a nerve, vessel, or tendon raises the risk of unintended damage. But with the right technique, that risk is easily reduced.

Hydrodissection is a simple, effective way to protect critical structures. It’s a small extra step that can prevent major complications.