1. health and fitness
2. disease
3. cancer

Skin Biopsy
Kathleen O’Hanlon, M.D.
Professor, Family and Community Health
JCESOM/Marshall University
November 2014
Goals of this Presentation include
discussion of the following:
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Indications & contraindications of Bx
Guidelines for choosing location & technique
Application of local anesthesia for Bx
Materials needed in your Bx-kit
Steps to proper performance of Bx (didactic and
hands-on workshop)
• Submitting your pathology specimen
• Proper coding & billing
Indications for Biopsy
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Purpose – for histopathology; r/o cancer
If “could be a melanoma” – go for full-thickness
Quick, simple, cost-effective
If entire lesion can be removed may also serve as
treatment (curative or cosmetic)
• Rapid feedback – a GREAT way to learn Derm!
• In rare cases, tissue needed for special studies ie:
immunofluorescent testing
Contraindications for Bx
• Significant coagulopathy (ASA, warfarin and
clopidogrel do not need to be stopped)
• H/o allergy to anesthetic (dental hx)
• Partial-thickness bx discouraged if melanoma is
suspected; if you biopsy for depth bx does NOT
spread disease or compromise future care
• Atypical nevi can be shaved. It is impractical to
remove every nevus with full-thickness excision.
*Written consent usually not indicated
Equipment
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Alcohol wipes
Nonsterile gloves (sterile if sutures are placed)
Lidocaine (0.5 – 1ml, 1% or 2%, w or w/o epi)
Punch, blade or curette (minor surgical tray for excisions)
Pickups
Sharp tissue scissors (Metzenbaum)
2 X 2s
Formalin container
Bandaid & antibiotic ointment
Anesthesia
• 1 or 2% Lidocaine (Xylocaine) – WITHOUT epi takes effect
faster so is the standard for punch or shave
• Very safe! Allergy to this very rare.
• Lido 1% = 10mg/ml; maximum dose is about 5mg/kg; so a 70kg person could tolerate up to 35ml
• In kids or very sensitive –
– You can buffer the acidic “sting” by adding 1:9 parts sterile
sodium chloride 0.9%
– You can apply a topical ie: EMLA , a 5% lidocaine + 5%
prilocaine emulsion which penetrates skin particularly
under occlusion for 60 minutes
Choosing Biopsy Site
• Select a site that is well developed and representative of
the lesion (see next slide)
• Avoid areas of crusting or signs of secondary infection
• It is not necessary to include normal tissue in the sample
except when sampling a vesiculobullous lesion
• Be mindful of patients with keloid tendency
• Areas of poor circulation (ie: pretibial) may suffer from
delayed healing
• There are no actual limitations on what cutaneous or
mucosal part of body you bx, but being a little selective
can improve outcome
Site-Specific Recommendations
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Trunk/Breast
Eyelid
Gingiva
Lip
Nail bed
Penis
Pinna
Tongue
Vulva
Punch or shave
Superficial shave
Shave (may need RF for bleeding)
Punch or shave
Small punch
Superficial shave
Shave, punch or curette
Punch or curette (+stitch)
Hair-bearing shave; mucosal
punch
Biopsy Techniques
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Punch
Shave
Curettage
Excisional
Wedge (Incisional)
The Punch Biopsy
Obtains a full thick-ness cylindrical specimen or “core-sample”
Good choice for small lesions (2, 3, 4 mm)
Good choice for suspected melanoma
Whole lesion does not need to be removed w bx
Technique – Punch Bx
3mm is my standard
Stretch skin opposite to natural lines of tension (Langer’s)
Push unit vertically into the skin & rotate to cut
Once dermis is penetrated there is dec’d resistance
Lift & snip plug
Langer’s
Lines
If you stretch skin
perpendicular to Langer’s
Lines your circular defect
will turn into an ellipse and
heal more readily.
If you need to throw a
stitch, it will be less
puckered.
Shave Biopsy
Best-suited to remove raised
skin lesions when full-thickness
not required
Not advised if melanoma suspected
Dermal infiltration of anesthetic
can help elevate lesion
Can use blade +/or RF loop (or both, use RF
to “feather-out” borders of defect)
Apply topical hemostatic agent to
achieve hemostasis (see later slide)
Good for: tags, SKs, AKs, compound nevi,
lentigines, small BCs
Can also use …
Sgl.-edge Razor Blade
Flexible “Biopblade”
The Deep Saucer-Shave
Central aspect of biopsy is sampled into
mid-dermis
Will heal with a depression vs. flat
Goal is to entirely remove lesion
Not a choice if melanoma suspected
Good for: dysplastic nevi, AKs, DFs
Curettage
Disposable curettes are best, sharp
Scrape or scoop, multiple fragments
Dermis will feel gritty & will see
punctate bleeding
Partial-thickness sample wellsuited for soft tissue ie BC, SKs
or molluscum
Can be used with hyperkeratotic
lesions ie warts or AKs
Excisional Biopsy
Used to remove entire lesion, full-thickness
Will require undermining and suture closure
Not my technique of choice due to time-limitations
and variance in margin recommendations:
Benign lesions 1-2mm
BC 3mm
SC 5mm
MIS 10mm
Incisional (Wedge) Biopsy
Removes a portion of an
abnormal lesion
Close with an absorbable
subq suture
*I think a punch would be
quicker; so this is a technique
I would not recommend
Achieving Hemostasis
• Topical hemostatic agents can help you be
more efficient & lessen need for cautery
• Best cosmesis: Aluminum Chloride 30%
(Drysol) - colorless; no tatooing; apply with
cotton-tipped swab
• Silver Nitrate sticks: black tatoo*
• Monsel’s 20% (ferric subsulfate): Looks like a
pasty dijon mustard but dries dark; tatoos*
* Not good choice in fair-skinned/cosmetic areas
Biopsy Procedure:
• Alcohol prep skin & Lidocaine bottle stopper
• 1 ml tuberculin syringe w Lidocaine
– shave or curette – intradermal wheal
– punch – deeper SQ
• Complete Path form
• Perform procedure:
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– Punch - Stretch skin; twirl punch through dermis to subQ; pick-up &
snip.
– Shave - shave using a sawing-type action or sharp snip
– Curettage – scrape w cutting edge of dermal curette
Place sample(s) in formalin
Apply pressure with 2 x 2 gauze
Topical hemostatic agent if needed
Bacitracin/Bandaid
Post-Procedure Patient Education
• Punch/Shave require moist healing
• Cleanse qid w soap/water & apply ab
ointment to keep wound moist
• Pain should be insignificant. Itch is usually a
reaction to ointment or dressing.
• Scarring possible. Punch can leave an acne
pock-mark.
Submitting Path Specimen
• Danger: Telling pathologist too little …
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“7 D’s”
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Description – papule, vesicle, macule
Demographics – location of lesion
Diseases – pertinent PMH (ie: Lupus)
Drugs – applied or taken orally which could change lesion
Duration – how long lesion has been present
Diameter – size of lesion
Diagnosis – Your BEST guess!
CPT Code by Anatomical Site
• 11100 Skin Bx, one lesion
• 11101 Skin Bx, each additional lesion
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67810
69100
30100
56605
54100
41100
11755
Bx eyelid
Bx pinna of ear
Bx intranasal
Bx vulva or perineum
Bx penis, cutaneous
Bx anterior 2/3’s tongue
Bx nail unit
ICD Diagnostic Codes
• Per Internat’l Classification of Diseases …
• I usually use “Benign Lesion” code 216,
followed by decimal & “location”:
– Skin of face 216.3
– Skin of trunk 216.5
– Skin of ear 216.2
– Skin of eyelid 216.1
Equipment Suppliers
• Any office medical supplier should be able to
supply basic bx instruments:
– Miltex
– Acuderm, Inc.
– CooperSurgical, Inc.
– Curetteblade, Inc.
Credits
• The text on these slides is based on
information from “Procedures for Primary
Care”, 3rd ed., Pfenninger & Fowler.
• All of the photos were derived from Google
Images.
• THANK YOU!
*Questions?*