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10 – The Punch Biopsy
Richard P. Usatine, MD
The punch biopsy is an easy method for removing a round full-thickness skin specimen. It is often used to diagnose
skin lesions of uncertain etiology. The main advantage of the punch biopsy over the shave technique is that it yields
deeper tissue with preserved architecture for pathologic evaluation. It is also easier to perform on flat lesions for
clinicians who have not mastered the art of the shave biopsy for lesions that are not elevated.
Flat lesions that are amenable to punch biopsy include inflammatory skin conditions such as drug eruptions,
dermatoses, psoriasis, and cutaneous lupus (Figure 10-1). Infiltrative skin conditions such as sarcoidosis and
granuloma annulare also can be diagnosed with a punch biopsy (Figure 10-2). In addition, a punch biopsy may be
used to diagnose all types of skin cancers including melanoma and cutaneous lymphomas (Figure 10-3).
A punch biopsy is one option in the diagnosis of melanoma if the entire lesion is large, making it too difficult to
remove the whole lesion at the time of biopsy. In this case, the diagnostic yield will generally be best if a biopsy is
performed on the darkest, most elevated, and/or most suspicious areas (Figure 10-4). Using a dermatoscope may
help identify a suspicious area for the punch biopsy (see Chapter 32, Dermoscopy). If the suspicion for melanoma
is high, excising the entire lesion is preferred, when possible, to improve the diagnostic yield. There are also times
when a broad scoop shave may provide better tissue for the pathologist. The highest risk of using a punch biopsy to
diagnose a melanoma is the risk of a false-negative result. If the lesion remains suspicious for melanoma and a
punch biopsy was performed with a negative result, the remainder of the lesion should be excised for histology (see
Chapter 8, Choosing the Biopsy Type).

FIGURE 10-1 Cutaneous lupus (discoid lupus) with hypopigmentation and skin atrophy. The best method for diagnosis is a 4-mm
punch biopsy.

(Copyright Richard P. Usatine, MD.)

1/23/2013 11:22 AM

FIGURE 10-2 Cutaneous sarcoidosis on the face of a black woman.) FIGURE 10-3 Mycosis fungoides. a new 4-mm punch biopsy detected cutaneous T-cell lymphoma.. Usatine.do?method=. a 4-mm punch biopsy was used to confirm the diagnosis./The Punch Biopsy/Indications 2 of 6 http://www. When the skin disease did not respond to topical steroids and subsequently worsened. (Copyright Richard P.com/expertconsult/b/book. (Courtesy of Debra Henderson..expertconsultbook. Although this is likely to be sarcoidosis by its appearance. A previous biopsy years before was read as atopic dermatitis. MD. MD.) 1/23/2013 11:22 AM .

) 1/23/2013 11:22 AM . psoriasis. MD. The full melanoma was excised with 1-cm margins and the depth was unchanged when the full lesion was evaluated histologically.do?method=. Usatine.expertconsultbook. (Copyright Richard P..) Indications Punch biopsy can be used to diagnose any skin condition or disease. FIGURE 10-5 Bullous pemphigoid on the back of a 57-year-old man with many intact bullae. and vasculitis Infiltrative diseases such as cutaneous sarcoidosis and granuloma annulare Melanoma and cutaneous lymphomas (including nail melanoma) Oral lesions such as lichen planus (Figure 10-7) Vulvar diseases including vulvar intraepithelial neoplasia (VIN) (Figure 10-8). A 4-mm punch biopsy was performed on the edge of an intact bulla and the diagnosis was confirmed. (Courtesy of Eric Kraus./The Punch Biopsy/Indications 3 of 6 http://www. It was too large to be fully excised easily. FIGURE 10-4 A lesion suspicious for melanoma on the arm. The following are amenable to punch biopsy for diagnosis: • • • • • • • Bullous diseases (Figure 10-5) Cicatricial alopecias (Figure 10-6) Inflammatory skin disease such as dermatoses. so a punch biopsy was performed of the darkest most raised area and the lesion was determined to be a superficial spreading melanoma with a 0.. MD.25-mm depth.com/expertconsult/b/book.

(Copyright Richard P.expertconsultbook. Usatine. FIGURE 10-6 A 4-mm punch biopsy of the scalp is performed in this young woman with scarring alopecia. Usatine.. A suture is rarely needed and is generally more uncomfortable for the patient. (Copyright Richard P. a 4-mm punch biopsy of the buccal mucosa can be performed. The presence of Wickham's striae bilaterally in the mouth makes lichen planus likely.do?method=.) FIGURE 10-7 Lichen planus with a lacy white pattern on the buccal mucosa.) 1/23/2013 11:22 AM .com/expertconsult/b/book. The patient was determined to have lichen planopilaris. MD./The Punch Biopsy/Indications 4 of 6 http://www. To establish a diagnosis histologically. Subcutaneous fat is visible at the base of the biopsy.. Hemostasis can be achieved with aluminum chloride or electrocoagulation. MD.

This photograph shows the vulva after two punch biopsies were performed. but a punch biopsy can be an acceptable alternative: • • All types of nonmelanoma skin cancers and precancers (Figure 10-9) All benign skin neoplasms. MD./The Punch Biopsy/Indications 5 of 6 http://www. (Copyright Richard P. FIGURE 10-8 A 59-year-old woman with a long history of condyloma acuminata has suspicious areas of leukoplakia of the vulva.com/expertconsult/b/book.do?method=. Usatine.) The following types of conditions may be diagnosed with a shave biopsy.. Both areas were found to have vulvar intraepithelial neoplasia 2 (VIN 2). 1/23/2013 11:22 AM ..expertconsultbook.

Some clinicians use a punch incision to remove small lipomas (see Chapter 12. FIGURE 10-9 Nodular BCC on the back. Read our Terms and Conditions of Use and our Privacy Policy.do?method=. A punch instrument can be used to create an opening in an epidermal inclusion cyst for a minimally invasive cyst removal. Usatine. MD. a shave biopsy would have been adequate and less invasive. However.com/expertconsult/b/book. Cysts and Lipomas). For problems or suggestions concerning this service. The following lesions are often removed using this technique: • Small nevi • Small dermatofibromas.com 1/23/2013 11:22 AM .. please contact: online. All rights reserved. (Copyright Richard P. A punch biopsy was used to establish the diagnosis.help@elsevier./The Punch Biopsy/Indications 6 of 6 http://www.expertconsultbook. Copyright © 2013 Elsevier Inc..) Punch biopsy can be used to remove any small skin lesion.