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
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)
Sharp tissue scissors (Metzenbaum)
2 X 2s
Formalin container
Bandaid & antibiotic ointment
• 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
Nail bed
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
Biopsy Techniques
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
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
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
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
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:
– Punch - Stretch skin; twirl punch through dermis to subQ; pick-up &
– 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
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
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
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.
• 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

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