skin lesions

Question 1

Types of biopsies

Answer 1

• Shave
• Punch
• Excision

Question 2

shave biopsy indications

Answer 2

• Seborrheic keratosis
• Verrucous lesions
• Molluscum contagiosum
• Superficial basal cell carcinomas

Question 3

shave biopsy contraindications

Answer 3

• Most pigmented lesions
• Diagnosis of infiltrative dermatoses
• Suspected sclerosing basal cell carcinoma
• Any lesion with a dermal component

Question 4

Shave Biopsy
* Complications

Answer 4

• Bleeding – silver nitrate(tattooing may occur) or hand cautery
• Infection
• Regrowth of lesion
• Scarring - usually lighter area on the face
• Discomfort with anestheti

Question 5

anatomy to keep in mind

Answer 5

• vasculature and nerves of the biopsy site prior to performing the actual biopsy.
• Langer lines must be known to minimize scarring
• Suture lines should be placed parallel to wrinkle lines to improve
  cosmetic appearance

Question 6

materials needed

Answer 6

• # 15 blade
• Forceps
• Formalin container
• Most of the time your clinic or ER will have a biopsy kit that comes
  sterilized. You will need to pick up the specimen container.
• Appropriate documentatio

Question 7

how to perform the biopsy

Answer 7

• Place sterile towels around the site
• Clean site – if using cautery you may want to avoid using alcohol
• Inject with anesthetic so that a wheal is raised – if the lesion blanches
  with injection, mark the margins with a sterile marker
• Hold the #15 blade parallel to the skin. You may need to elevate the
  lesion with your forceps.
• Attempt to shave the base of the lesion completely by shaving into the
  uppermost portion of the dermis

Question 7

follow up care

Answer 7

• Written instructions on wound care
• Keep area clean and dry for 24 hours
• May remove bandage 24hrs later – clean w/soap and H2O
• No f/u appt needed unless concern for infection

Question 8

Punch Biopsy
* Indications

Answer 8

When there is a lesion or dermatosis that covers a large area that needs
diagnosis prior to initiating treatment.

Question 9

punch biopsy contraindications

Answer 9

• Any lesion with highly suspected malignant potential
• Lesions less than 8-10mm regardless of malignant potential

Question 10

Punch Biopsy
* Complications

Answer 10

• Discomfort
• Higher risk of bleeding – due to the incision being down to the
  subcutaneous fat, increasing the risk for small vessel bleeds. Hand
  held cautery can be used.
• Infection rate is higher – slightly more invasive
• Scarring will occur dependent upon the patient’s ability to heal vs. the
  size of the defect

Question 10

punch biopsy materials

Answer 10

• Metric ruler
• Specimen container
• Disposable punch biopsies

Question 11

Performing the Punch Biopsy

Answer 11

• Place a sterile towel around the site – Drape the site
• Clean the area – Same sterile technique no matter the size of the biopsy –
  personal preference
• Mark the margins with a sterile marker
• Inject anesthetic - important to anesthetize the entire depth
• Hold the skin taut perpendicular to the tension lines, wrinkle or skin fold
• Hold the punch perpendicular to the skin, apply downward pressure while
  rotating the punch (one direction to lessen the distortion of the skin cleavage)
• Should extend into the subcutaneous fat
• Lift the specimen and cut at the base
• Suture – placing ½ as many sutures as the size of the punc

Question 12

punch biopsy tips

Answer 12

• If the punch is removed and the pedicle is missing - it may be found
  in two different places
• Most commonly it is inside the punch
• It may also be in the skin

Question 13

punch biopsy follow up care

Answer 13

• Written instructions
• Clean & Dry for 24 hours. Bandage removed at this time.
• RTC (return to clinic) appt in 5-21 days depending upon area biopsied.
• Face and ears 5-7 days
• Neck 7 days
• Scalp 7-10 days
• Trunk & Extremities 7-14 days
• Distal lower extremities 10-21 days
• Inform patient of pathologic results. (call them)
• Depending upon location – limit lifting

Question 14

excisional biopsy indications

Answer 14

• Any lesion that is smaller than 8-10mm and can be completely
  excised.
• Lesions
• Suspected melanomas
• Epidermal inclusion cysts
• Lipomas
• Larger basal cell and squamous cell carcinomas
• Dermal lesions larger than 1 cm

Question 15

excisional biopsy complications

Answer 15

• Again, bleeding is a higher risk due to the depth of the incision.
  Hand held cautery can be used.
• Infection is also higher.
• Scarring is more common
• This technique requires a thorough knowledge of Langer lines.
• This technique is particularly difficult on the face, eyes, forehead, or
  lips due to cosmetic reasons

Question 16

materials needed for excisional biopsy

Answer 16

• Ruler
• # 15 blade
• Specimen container

Question 17

• Mohs surgery is not a procedure PCPs provide. This technique
  requires specialized surgical training.
• Mohs surgery uses a special technique of excising and color coding
  the specimen before histologic examination.
• This method has a higher overall cure rate and lower recurrence
  rate.

Answer 17

extra info

Question 18

Performing the Excisional Biopsy

Answer 18

• Proper anesthetic technique is determined by the size of the area
  being excised.
• The site may warrant direct infiltration, digital block or a field block
• It is also important to adequately anesthetize the entire depth
• Scrub the area with chlorhexidine or povidone-iodine.
• Drape with sterile towels.
• Again, if the lesion blanches, mark the margins.
• Hold the #15 blade like a pencil and perpendicular to
  the skin.
• Use the tip of the blade to incise the corner of the
  ellipse. The belly of the blade is used for the rest of the
  incision
• Continue the incision through the dermis to the subcutaneous fat.
• Use forceps to lift the specimen. Care should always be taken to
  NOT crush your specimen.
• Use your blade to cut the specimen at the base.
• If the lesion is potentially malignant a tag is placed at the corner of
  the specimen. The pathology request should not medial, distal, ect.
  for prompt location of the tag.
• Place in the specimen containe
• To close the incision pull the edges together to estimate the amount
  of tension.
• If excision tension then undermining may be necessary to loosen
  the surrounding connective tissue to lessen the tension.
• The incision is closed with subcutaneous vertical mattress sutures
• Decreases tension, approximates the edges and reduces wound dehiscence

Question 19

special considerations of excisional biopsies

Answer 19

• Allergies
• Use of anticoagulants – if possible should d/c 2-4 days before the
  procedure.
• Children – often very difficult. The child may need to be sedate

Question 20

excisional biopsy follow up care

Answer 20

• Written instructions
• Again clean and dry for 24 hours then may remove the bandage.
• RTC appt in 5-21 days depending on the location of the biopsy site.
• No heaving lifting if it is going to affect the area
• Again, remember the patient is waiting to hear the pathologic
  results