Smaller Formalin Containers Could Slash Toxic Waste in Skin Biopsy Clinics

Every day, in dermatology clinics around the world, thousands of small pieces of skin are snipped, shaved, or punched away from patients and dropped into little plastic cups filled with formalin, the formaldehyde-based solution that preserves tissue for microscopic diagnosis. The ritual is so routine that few clinicians pause to consider what happens to the excess chemical sloshing around each container after the specimen settles to the bottom. A new analysis from Penn State Dermatology suggests they should, because the difference between the containers a clinic chooses may amount to thousands of liters of toxic, carcinogenic liquid needlessly purchased, handled, and discarded over the course of a decade.

The study, published as a short report in the Archives of Dermatological Research, examined every skin biopsy performed across the Penn State Dermatology clinic network between January 1 and December 31, 2024, a total of 11,284 specimens. Rather than running a new laboratory experiment, the research team, led by Rachel Anderson of the Department of Dermatology at Penn State College of Medicine, conducted a theoretical cost and waste assessment built on real institutional biopsy volumes and pricing. They compared three commonly available sizes of prefilled formalin containers: a 20 mL cup filled with 10 mL of formalin, a 40 mL cup filled with 20 mL, and a 60 mL cup filled with 30 mL. The arithmetic behind the comparison is straightforward but consequential, because most skin biopsies are tiny, typically a few millimeters across, and require far less preservative than even the smallest standard container provides.

The numbers reveal a striking mismatch between container size and clinical need. At Penn State’s biopsy volume, the 20/10 mL container carried the lowest annual cost at $5,303.48, compared with $6,996.08 for the 40/20 mL option and $6,883.24 for the 60/30 mL container. Notably, the 60/30 mL container is currently the standard across the clinics, meaning the institution has been paying a premium of roughly $1,580 per year for the privilege of buying and disposing of formalin that never touches a specimen. Extrapolated over ten years, the researchers project that switching to the smallest container would save approximately $17,000 while eliminating 2,256.8 liters of formalin waste. For a single academic dermatology department, those figures are modest; scaled across the thousands of clinics and offices that perform skin biopsies worldwide, they hint at a substantial and largely overlooked reservoir of chemical waste.

The case for change rests on more than accounting. Formalin is an aqueous solution of formaldehyde, a small, highly reactive molecule that cross-links proteins and nucleic acids, which is precisely why it fixes tissue so effectively and why it is so hazardous to people. Formaldehyde is classified as a human carcinogen, and chronic occupational exposure is associated with respiratory irritation, sensitization, and elevated cancer risk. In anatomic pathology workflows, airborne formaldehyde monitoring is a recognized component of occupational health programs, and regulatory frameworks govern both the handling of the concentrated solution and the disposal of used and unused volumes as biomedical waste. Every milliliter of formalin that a clinic buys but does not need becomes a milliliter that must be poured out, transported, and treated as hazardous waste, with all the environmental and financial burdens that entails.

Why, then, do oversized containers persist? The answer lies partly in habit and partly in the logistics of clinic design. Prefilled containers arrive from suppliers in a limited range of sizes, and once a particular format is stocked in procedure rooms, it tends to remain the default. Larger containers also carry a psychological margin of safety: clinicians and staff may feel that a bigger volume guarantees full immersion of the specimen and adequate fixation. Yet fixation chemistry does not demand generous excess. For the small tissue samples typical of dermatologic practice, a 10 mL fill provides ample volume to submerge the specimen and maintain the formalin-to-tissue ratio needed for complete penetration and cross-linking. The study’s central insight is that the standard container size, rather than any biological requirement, is what drives the waste stream.

The Penn State team also addressed the practical concerns that might accompany a downsizing effort. Smaller containers are lighter and more prone to tipping on crowded procedure trays, and a spilled cup of formalin in a clinic is both a safety hazard and a cleanup burden. To counter this, the researchers describe new clinic racks designed to secure the smaller containers upright, reducing the risk of tipping and potential spills and thereby enhancing, rather than compromising, workplace safety. The intervention, in other words, is not merely a swap of one product for another but a small redesign of the physical workflow, pairing the smaller vessels with holders that keep them stable during procedures and transport to the laboratory.

The financial analysis was structured to project costs and waste over one, five, and ten-year horizons using institutional pricing, giving administrators a realistic picture of the cumulative effect of a seemingly trivial procurement decision. Over a single year the savings of roughly $1,700 may look like rounding error in a large health system’s budget. Over a decade, the compounded effect of lower purchasing costs, reduced hazardous waste disposal fees, and diminished staff exposure to a carcinogenic chemical becomes harder to dismiss. The study frames this as a model of environmentally conscious clinical decision-making, an argument that sustainability initiatives in medicine need not involve expensive technology or sweeping policy changes but can begin with something as mundane as the cup on the procedure tray.

The report also points toward a further step: formalin recycling. The authors note that additional gains could be realized through the adoption of formalin recycling systems, an approach that has begun attracting attention in surgical pathology more broadly. Recent work published in the journal Pathology evaluated recycled formalin as a tool to mitigate the environmental impact of routine practice, suggesting that used fixative can be reprocessed and returned to service without sacrificing diagnostic quality. Combined with right-sized containers, recycling could shrink the formalin footprint of a busy dermatology or pathology service even further, closing the loop on a chemical that is currently purchased, used once, and discarded in enormous aggregate quantities.

The broader context is a growing movement within laboratory medicine to confront its environmental toll. Dermatopathology laboratories have been identified as sites of significant opportunity for green initiatives, and audits of biomedical waste in laboratory medicine have long emphasized that waste reduction begins with choices made long before a specimen reaches the bench. Alternative fixatives that avoid formaldehyde altogether are under investigation, including efforts to prolong the fixation performance of formalin-free agents using standard laboratory protocols, though formalin remains deeply entrenched because of its reliability, low cost, and compatibility with decades of diagnostic experience. Against that backdrop, the Penn State proposal stands out for its pragmatism: it changes nothing about the fixative, the fixation protocol, or the diagnostic pathway, only the volume of the same chemical that flows through the clinic.

For clinicians and clinic managers, the message is unusually actionable. The researchers, who declare no competing interests and received no external funding for the work, describe the switch to smaller containers as a simple, effective intervention to cut costs, reduce toxic waste, and improve safety in dermatology practice. The analysis was deemed not human subjects research by the Penn State College of Medicine Institutional Review Board, reflecting its focus on operations rather than patients, and no datasets were generated or analyzed beyond the institutional biopsy counts and pricing that underpin the projections. That simplicity is the point. In a field where sustainability proposals often stall under the weight of cost, complexity, and clinical inertia, the humble 20 mL formalin cup offers a rare example of an intervention that is simultaneously cheaper, safer, and greener, waiting only for clinics to think small.

Subject of Research: Reducing formalin waste and cost in dermatology clinics through smaller prefilled biopsy containers

Article Title: Think small: a smarter approach to formalin use in dermatology clinics and offices

Article References: Anderson, R., Washington, A., Multani, S., Anderson, B., & Helm, T. (2026). Think small: a smarter approach to formalin use in dermatology clinics and offices. Archives of Dermatological Research, 318(1), Article 470. https://doi.org/10.1007/s00403-026-04900-4

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04900-4

Keywords: formalin, dermatology, skin biopsy, formaldehyde, medical waste, sustainability, dermatopathology, specimen fixation, healthcare costs, occupational safety, green initiatives, clinical practice