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Lack of skin biopsy equipment could lead to delayed diagnosis, treatment

JAMA Dermatology
Reuters Health - 01/03/2021 - Low-income countries that lack the necessary equipment for skin biopsies may not be able to diagnose and treat skin infections and cancers as soon as they should, according to a new report.

Patients often forgo biopsies or receive larger surgical biopsies later, which can lead to late-stage diagnosis, late-stage care and higher mortality, the authors write in JAMA Dermatology.

"Skin diseases are an important cause of disease worldwide and include potentially fatal conditions such as certain skin cancers," said lead author Dr. Esther Freeman of Harvard Medical School in Boston.

"Our ability to treat these skin conditions, and save lives, depends on our ability to make a diagnosis," she told Reuters Health by email. "In resource-limited settings, we often lack equipment or skilled personnel that are needed to make these diagnoses."

Dr. Freeman and colleagues in the U.S. and Uganda analyzed data from the Demographic and Health Survey program, focusing on biopsy equipment availability in 6,000 health facilities across Malawi, Tanzania, Nepal, Senegal, Haiti, Afghanistan and the Democratic Republic of the Congo between 2013 and 2019. They looked at the types of facilities, as well as the minimal equipment necessary for safe biopsies, such as handwashing facilities, skin disinfectant, lidocaine, disposable needles and syringes, scalpels, surgical scissors and sutures.

Overall, surgical skin biopsy equipment was available at 1,437 sites, or 24% of the health facilities. About 47% of the facilities with equipment were hospitals, followed by health centers and clinics or dispensaries. Surgical biopsies were most available in the Democratic Republic of the Congo, followed by Tanzania and Nepal.

Minor surgical procedures were available for free at 227 public or governmental sites, 31 private sites and 16 nongovernmental sites. Nongovernmental and private facilities were more likely to have the necessary skin biopsy equipment.

Nepal had the highest rate of facilities with biopsies available for free, at 15%, followed by Malawi at 7.5% and Tanzania at 2%.

The lack of equipment and access to free biopsies could further limit availability for patients, the authors write. Future research should also look at staff availability, histopathology services, the consistency of biopsy equipment and the cost of biopsy and histopathology services.

"It's important to understand that skin biopsy equipment is just one piece of the puzzle, or the 'cascade of care' as we call it," Dr. Freeman said.

"If equipment isn't available, then it's hard to do a biopsy," she said. "But even if equipment is available, that is not all that's needed - you will need pathology services to prepare the specimen and trained pathologists to read and interpret the slide."

Global-health dermatologists have proposed several solutions, such as building the capacity at the local level to perform, process and read skin biopsies, Dr. Freeman said. Rapid, point-of-care testing is also growing in countries such as Kenya and Uganda. In some cases, health facilities are also incorporating more teledermatology and telepathology services.

"Some patients have to travel distances to present to a healthcare facility with biopsy equipment, and many patients have to pay out of pocket for the equipment and services," said Dr. Carrie Kovarik of the University of Pennsylvania Perelman School of Medicine in Philadelphia. Dr. Kovarik, who wasn't involved in the study, has written about global access to dermatopathology services.

Few countries in sub-Saharan Africa have a trained dermatopathologists or specialized dermatologists, she said, yet many have expressed interest in virtual options. Local doctors could send digital slides to specialists across the world, and results could be communicated by phone or email, which would bypass challenges with cost, local infrastructure and ground transportation.

"For some patients, especially those with tumors or potentially dangerous rashes, a skin biopsy with interpretation by a skilled pathologist could lead to a diagnosis, which would drive treatment decisions," she told Reuters Health by email.

SOURCE: https://bit.ly/3dOTLwz JAMA Dermatology, online February 17, 2021.

By Carolyn Crist

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