Dermatology procedures and biopsies for the Portfolio Pathway: what assessors need to see

Why procedural evidence sits at the heart of Dermatology Portfolio Pathway

Dermatology sits within the JRCPTB portfolio of medical specialties and is assessed against a Specialty Specific Guidance (SSG) document that defines the Capabilities in Practice (CiPs) assessors use to evaluate Portfolio Pathway applications. Reading the current SSG in full before building your evidence plan is the single most important preparatory step. This article is a practical companion to the SSG for the procedural strand of evidence, not a replacement for it.

Within the Dermatology Portfolio Pathway, procedural competence sits alongside medical dermatology, skin cancer pathway working, dermatopathology correlation, and the general internal medicine knowledge base that Group 2 specialties require. But procedures occupy a distinctive position in the evidence hierarchy for one reason: they are directly observable and directly verifiable. When an assessor reads a DOPS entry for a punch biopsy or a wide local excision, they can evaluate the clinical decision-making, the technical approach, the complication management, and the histological outcome in a way that cannot be faked or inflated. Well-documented procedural evidence is the backbone of a credible Dermatology Portfolio Pathway application.

The Portfolio Pathway is built for senior doctors who are already practising at consultant level. In dermatology, that means doctors who are running skin surgery lists, performing independent excisions of malignant skin lesions with clinically appropriate margins, selecting biopsy techniques based on a clinical differential, and correlating their own operative findings with histopathology reports. The application asks you to demonstrate that this is what you are already doing - and the procedural logbook is the primary mechanism through which that demonstration happens.

The audience for this article is primarily the non-substantive Consultant in a UK dermatology post: the locum Consultant, the Trust Grade Consultant, the Specialist Grade doctor running their own skin surgery lists. These are doctors whose day-to-day procedural practice is genuinely at the level the Portfolio Pathway requires. The gap is documentation, not skill. That framing matters, because the solution is not to acquire additional experience - it is to capture existing experience in a way that assessors can read, evaluate, and credit.

How the Dermatology SSG frames procedural competence

The Dermatology SSG published by JRCPTB sets out thirteen CiPs that span the breadth of consultant dermatology practice. Procedural competence sits primarily within the CiPs that govern skin cancer management and dermatological procedures - both core areas of the curriculum that every applicant must demonstrate to an adequate standard. The SSG should be read on the day you begin building your evidence plan; it is available through the GMC and JRCPTB websites and is updated periodically, so any specific indicative numbers cited here may have changed.

What the SSG describes in more stable terms is the quality of evidence required, and that description has several consistent elements. First, procedures must be evidenced as independent practice at Level 4: the applicant made the clinical decision to perform the procedure, selected the technique, executed it without supervision, managed any complications, and followed the case through to histological conclusion and appropriate further management. Evidence of supervised or partially supervised practice contributes less, and the SSG asks assessors to weight independence specifically. Second, the procedural evidence must cover breadth as well as volume - a logbook that shows 80 excisions of basal cell carcinoma but no biopsies, no curettage, and no repairs does not demonstrate the range of procedural competence the curriculum describes. Third, the SSG expects procedural evidence to map to the skin cancer pathway, not to exist in isolation: evidence that an applicant can refer appropriately, operate within the two-week wait pathway, manage histological surprises, and participate in skin cancer MDT meetings carries more weight than a logbook of procedures logged without pathway context.

The SSG also situates procedural dermatology within the skin cancer pathway as a whole. An applicant who performs excisions but does not engage with the two-week wait referral pathway, does not attend the skin cancer MDT, and does not document the multidisciplinary decisions that precede and follow their procedures is presenting only part of the picture. The procedural logbook and the pathway evidence should reinforce each other: the logbook shows what was done, and the MDT and clinic letter evidence shows that it was done in the right pathway context, with appropriate pre-operative assessment and post-operative follow-up.

Skin biopsies: technique, DOPS, and histological follow-through

Skin biopsy is the entry point for most dermatological diagnosis and the first procedural skill assessed in any dermatology logbook. There are four principal biopsy techniques - punch, shave, incisional, and excisional - and a competent consultant dermatologist selects among them based on the clinical differential, the anatomical site, the lesion morphology, and the downstream pathological requirements. That selection process is a clinical decision, and it should be documented as one.

A punch biopsy uses a circular cutting device - typically 2 to 8mm in diameter depending on the lesion - to core through the full thickness of the dermis and into subcutaneous fat. It is the right technique for most inflammatory dermatoses, for suspected interface or lichenoid conditions, for vesiculobullous disorders where the perilesional skin must be included, and for pigmented lesions in certain anatomical sites where an excisional biopsy would be technically difficult. The clinical decision to use a punch biopsy rather than a shave or excisional approach should be documented explicitly in any DOPS entry covering it.

A shave biopsy - tangential excision with a blade or razor at the level of the superficial or mid-dermis - is appropriate for exophytic, pedunculated, or epidermal lesions where deep sampling is unnecessary and where the clinical concern is predominantly about a superficial or papular pathology. It is not appropriate for pigmented lesions that might be melanoma, because transecting a melanoma at the base compromises Breslow thickness measurement and staging accuracy. This contraindication is a knowledge test as much as a technical one: a DOPS entry that shows the assessor commented on the applicant's choice of shave for a pigmented lesion, and why that choice was clinically appropriate or inappropriate, carries more evidential weight than an entry that simply records the procedure.

Incisional biopsy - taking a representative piece of a larger lesion rather than excising it in full - is appropriate when complete excision is not immediately feasible, when the lesion is large and the diagnosis uncertain, or when the clinical context requires diagnostic confirmation before planning definitive surgery. In practice, incisional biopsy of a suspected SCC or morphoeic BCC before definitive surgical planning is a common and clinically sound approach. Document the reasoning: why was a partial biopsy chosen, what information was needed from the histology before the surgical plan could be finalised, and how the histological result changed or confirmed that plan.

Biopsy of pigmented lesions

Pigmented lesion biopsy deserves specific attention in Portfolio Pathway evidence because it is one of the highest-stakes procedural decisions in dermatology. The choice between excision biopsy (complete removal with a 2mm margin as a diagnostic excision), incisional biopsy, and punch biopsy for a pigmented lesion involves clinical risk assessment, dermatoscopic findings, anatomical site constraints, and knowledge of how histological staging of melanoma is affected by technique. DOPS entries covering pigmented lesion biopsy should capture the dermatoscopic assessment (with specific reference to the features observed and the level of clinical suspicion), the technique chosen and its rationale, the orientating marking of the specimen, the histological result including the Breslow thickness where relevant, and the subsequent management decision including referral under the two-week wait pathway or skin cancer MDT discussion where appropriate.

Linking biopsy evidence to skin cancer pathway evidence in this way - where the biopsy result triggers a specific next step that is itself documented - creates a chain of evidence that demonstrates consultant-level clinical responsibility from the initial assessment through diagnosis to management planning. That chain is what the assessors want to see, and it is what generic logbook entries that record only the procedure type and site do not provide.

Surgical excisions: margins, repairs, and skin cancer pathway evidence

Surgical excision of skin cancer is the procedural core of consultant dermatology practice, and it is the part of the procedural logbook that receives the most sustained scrutiny from assessors. A well-documented excision entry tells a complete surgical story: the clinical and histological diagnosis, the margin selected and its justification, the repair technique chosen and the anatomical reasoning behind it, the histological clearance result, and the subsequent management plan.

Excision margins for non-melanoma skin cancer (NMSC) are governed by NICE guidelines and BAD multidisciplinary guidelines. For basal cell carcinoma, NICE NG12 and the BAD guidelines for BCC stratify margin requirements by tumour subtype and site: a low-risk nodular BCC on the trunk typically requires 4 to 5mm margins, while a high-risk morphoeic or infiltrative BCC, or any BCC on the face, may require wider margins and specialist assessment. For squamous cell carcinoma, the BAD guidelines stratify margins by risk: low-risk SCC (well-differentiated, small, on sun-exposed trunk or limb) typically requires 4 to 6mm margins, while high-risk SCC (poorly differentiated, perineural invasion, size over 2cm, immunosuppressed patient, or high-risk anatomical site) requires wider clearance. Melanoma margins are defined by NICE NG14 and its updates: 1cm for pT1 lesions and 2cm for pT2 to pT4 lesions, with reconstruction as needed.

Your logbook should record the margin selected for each excision and the clinical reasoning that informed it. An entry that records "excision 5mm margin" without documenting whether the lesion was a low-risk nodular BCC on the back or a high-risk SCC on the ear leaves assessors unable to evaluate whether the margin was appropriate. When the margin is non-standard - wider because of a complex or poorly defined lesion, narrower because of anatomical site constraints with a plan for Mohs or incomplete excision follow-up - that reasoning should be documented explicitly.

Repair techniques as evidence

The repair design after a skin cancer excision is itself a clinical decision that reflects anatomical knowledge, aesthetic judgement, and awareness of oncological priorities. A direct closure on the trunk differs from an advancement flap on the cheek, which differs from a full-thickness skin graft on the nasal tip, which differs from a rotation flap on the scalp. Each technique is a clinical choice with reasons, and those reasons should appear in the logbook.

Portfolio Pathway assessors look for breadth of repair technique across the logbook as a whole. A logbook that shows 40 direct closures and nothing more may satisfy the excision volume requirement but leaves questions about competence in the more technically demanding repairs. Advancement flaps, bilobed flaps, rotation flaps, rhomboid flaps, and full-thickness skin grafts (FTSGs) are all techniques that a consultant dermatologist is expected to perform or supervise independently. Your logbook should include a range, with DOPS entries for the more complex techniques documenting the repair design process and the anatomical reasoning behind the choice.

The connection between repair type and anatomical site also matters. Repairs on the face - particularly around the nose, eyelids, and lips - carry aesthetic and functional stakes that repairs on the trunk do not. If your logbook is weighted toward excisions on low-complexity anatomical sites, assessors may question whether you have adequate experience at sites where the repair design is more demanding. If the true clinical picture is that your post has few facial skin cancer cases, address this directly in the portfolio narrative and consider how supplementary sessions at a unit with higher facial skin cancer volume might be arranged.

Curettage, cautery, and cryotherapy documentation

Curettage and cautery (C&C) and cryotherapy occupy a different position in the procedural logbook from surgical excision. They are high-volume treatments in any active NHS dermatology unit, applied to seborrhoeic keratoses, viral warts, superficial BCCs, Bowen's disease (SCC in situ), actinic keratoses, and other superficial lesions. The clinical decision to treat a lesion with C&C or cryotherapy rather than excision - or rather than observation - is itself a clinical competency, and it should be documented as such.

For C&C, the logbook should capture the indication, the lesion type, whether histology was sent (and if not, why not), the number of treatment cycles, and the outcome at follow-up. The decision about histology is a clinical one: a clinically obvious seborrhoeic keratosis on the trunk in a patient with multiple seborrhoeic keratoses does not require histological confirmation if the clinical diagnosis is secure. A superficial BCC on the trunk treated with C&C in a patient with a confirmed diagnosis from prior biopsy or from strong clinical and dermatoscopic evidence is a different situation from a lesion where the diagnosis is uncertain. Your logbook should reflect this differential approach to histological sampling.

Cryotherapy documentation should record the clinical indication, the treatment parameters (freeze time, number of freeze-thaw cycles, and treatment technique - open spray versus contact probe), the expected healing course discussed with the patient, and the outcome at follow-up where available. Cryotherapy for actinic keratoses, Bowen's disease, and low-risk superficial BCCs is a legitimate and guideline-endorsed first-line treatment. Evidence that you are selecting the right cases for cryotherapy - and that you are following them up to confirm treatment success or escalating to excision when treatment has failed - is part of what the logbook should demonstrate.

Histological correlation: closing the evidence loop

Histological correlation is the process of systematically comparing the clinical diagnosis or diagnostic impression at the time of the procedure with the histopathological result that follows it. In Portfolio Pathway terms, it means that your logbook entries do not stop when the procedure is completed. They continue until the histological result is received, compared with the clinical impression, and the appropriate next clinical step is taken and documented.

This matters for several reasons. First, it demonstrates that you are practising in the way that a consultant dermatologist should - not simply performing procedures, but following them through to diagnostic conclusion and clinical management. Second, cases where the histology did not match the clinical impression are the most evidentially valuable in the logbook, because they show diagnostic uncertainty, appropriate response to unexpected findings, and clinical flexibility. Third, histological correlation allows assessors to evaluate the quality of your clinical diagnosis over time: a logbook with strong clinical-histological concordance across a large and varied case mix demonstrates diagnostic accuracy as well as procedural skill.

The practical implication is that every logbook entry should include a field for the working clinical diagnosis before the procedure, the histological diagnosis after it, and a comment on whether they agreed and what happened next. This is not a burdensome addition to a logbook format - it is three short data points per case. Over a logbook of several hundred cases, those data points create a picture of clinical performance that no other evidence type can replicate.

The Histopathology evidence article covers the assessor perspective from the pathology side - the requirements for consultant histopathologists building a case log - but its discussion of how histological results function as evidence is directly relevant to dermatologists. The pathological correlation between your clinical impression and the microscopic diagnosis is a data point that assessors use to evaluate both your diagnostic accuracy and your understanding of dermatopathology, which is an expected knowledge domain for a consultant dermatologist even if you are not a practising dermatopathologist yourself.

Mapping procedural evidence to the four GMC domains

Every element of your procedural logbook maps to the GMC's four domains: Knowledge, Skills and Performance; Safety and Quality; Communication, Partnership and Teamwork; and Maintaining Trust. A Dermatology Portfolio Pathway application that is rich in Domain 1 procedural evidence but thin in Domains 2, 3, and 4 will not produce a clean pass.

Domain 2 deserves specific attention for procedural dermatology because it is the domain where audit and quality improvement evidence connects most directly to the procedural strand. An audit of your department's excision margin adequacy against BAD guidelines, a quality improvement project that reduced the incomplete excision rate for facial BCCs, or a significant event analysis of a case where a pigmented lesion biopsied by shave was subsequently confirmed as melanoma with a compromised Breslow thickness - these are all Domain 2 evidence items that are procedurally specific and carry far more weight than generic clinical audit.

Domain 3 evidence in the procedural setting includes consent documentation, MDT participation, and teaching. If you are running your own skin surgery list and training junior colleagues in punch biopsy, excision technique, or repair design, this is teaching evidence worth capturing. A DOPS entry where you are the assessor, combined with a reflective note on your teaching approach and what the trainee achieved, contributes to Domain 3 and demonstrates leadership - another expected attribute of consultant-level practice.

Thin vs convincing procedural logbook entries

The most common reason procedural dermatology evidence is queried or underweighted at assessment is not insufficient volume - it is insufficient documentation within each entry. Many experienced dermatologists submit logbooks containing hundreds of procedures with entries that record only the date, procedure type, anatomical site, and a single-word outcome. These entries prove that procedures were performed; they do not demonstrate that the procedures were performed at independent consultant level, with appropriate clinical reasoning at every stage, and with systematic follow-through to histological outcome.

Addressing these gaps does not require performing additional procedures. It requires improving the documentation of procedures you are already performing. Adding a histological result field to your logbook template, committing to completing DOPS for complex procedures at the time they are performed rather than retrospectively, and ensuring that your logbook entries cross-reference MDT discussions where relevant - these are documentation changes, not clinical practice changes. The clinical work is already there. The task is to capture it in a form that assessors can evaluate.

Building a complete procedural evidence log

The following approach is not prescriptive - the SSG is the definitive guide to what is required - but it reflects the structure that tends to produce a logbook assessors can read efficiently and credit fairly.

The building your evidence library article covers the general architecture of Portfolio Pathway evidence organisation - how to structure the portfolio so assessors can navigate it without searching - and the five-year rule article explains what to do when some of your procedural evidence predates the current evidence window. Both are worth reading alongside the SSG before you begin formally compiling your portfolio.

For applicants who trained or practised extensively overseas before moving to the UK, the translating overseas evidence article addresses the specific challenges of contextualising non-UK procedural evidence within a Portfolio Pathway application. The short version is: overseas procedural experience is creditable, but NICE-compliant margins, NHS skin cancer pathway working, and histological correlation under UK histopathology reporting standards all need to be evidenced from UK practice where possible. If your procedural experience is primarily from the UK but your knowledge-based evidence (teaching, publications, audit) is from an overseas institution, that is a different challenge and requires a different documentation approach.

The structured reports article is also relevant here: a structured report from a senior colleague who can speak specifically to your procedural competence - attesting to the quality of your surgical planning, your technical execution, your histological follow-up practice, and your MDT engagement - is among the most valuable single pieces of evidence in a Dermatology Portfolio Pathway application. A generic reference that describes you as a safe and competent colleague adds far less. Brief your referees on what specific procedural evidence you want them to attest to, and give them the relevant logbook sections to review before they write.

All 18 specialisms

The Portfolio Pathway covers 18 specialisms. Each has its own Specialty Specific Guidance and its own procedural and evidence expectations. Use the links below to find the relevant overview or deep-dive for your specialism.