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:
• 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
• 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
• 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 70-
kg 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
• Trunk/Breast Punch or shave
• Eyelid Superficial shave
• Gingiva Shave (may need RF for bleeding)
• Lip Punch or shave
• Nail bed Small punch
• Penis Superficial shave
• Pinna Shave, punch or curette
• Tongue Punch or curette (+stitch)
• Vulva Hair-bearing shave; mucosal
punch
 Biopsy Techniques

• 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 well-
suited 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:
– 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 …

• “7 D’s”
– 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

• 67810 Bx eyelid
• 69100 Bx pinna of ear
• 30100 Bx intranasal
• 56605 Bx vulva or perineum
• 54100 Bx penis, cutaneous
• 41100 Bx anterior 2/3’s tongue
• 11755 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?*