Skin Biopsy and Basic Dermatological Procedures
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1 Skin Biopsy and Basic Dermatological Procedures 1 LOU MANCANO MD READING HEALTH SYSTEM - READING, PA DEPT. OF FAMILY AND COMMUNITY MEDICINE PA. ACADEMY OF FAMILY PHYSICIANS JULY 28, 2015 Disclosure Dr. Louis Mancano has no conflict of interest, financial agreement, or working affiliation with any group or organization. 2 Objectives 3 Decide when a skin biopsy is necessary or likely to be helpful Recognize which lesion or which part of a single lesion to biopsy Review how to select the appropriate biopsy technique Illustrate proper preparation, biopsy technique and repair of the biopsy site 1
2 When to consider a biopsy? Lesion suspicious for cancer Skin lesion, bullae or rash of unclear etiology or wide differential diagnosis Lesion or rash not responding appropriately to treatment To identify an infectious organism Symptomatic lesion removal Cosmetic reasons 4 Choosing a Biopsy Site When there are multiple lesions, choose a site where: Resultant scar may be more acceptable or less bothersome If possible, avoid face, fingers, soles of feet, genitalia If possible, avoid areas likely to develop hypertrophic scars or keloids sternum, shoulders, scapula areas, elbows, knees Biopsy sites that lead to fewest restrictions Avoid hands and feet 5 Choose sites where: Infection is less likely Choosing a Biopsy Site 6 Avoid intertriginous areas like axillae, groin, under breasts, if possible Avoid hands and feet, if possible Proper healing is more likely Avoid areas with compromised circulation or sensation - anterior shin, distal extremities in diabetics or PVD 2
3 Choosing the Lesion or Part of the Lesion Find a lesion most free of secondary changes (excoriations, secondary infection, crusts) For inflammatory lesions, biopsy one with characteristic inflammatory changes (erythema) For blistering diseases, biopsy the edge of a characteristic early evolving lesion For lesions < 5 mm in diameter, try to excise the entire lesion For larger lesions, consider biopsy of the edge, the thickest portion, or the area that is most abnormal appearing 7 Some Additional Considerations Ask about upcoming important events and decide if biopsy should or could be postponed Consider options if patient is immunosuppressed, pregnant, anticoagulated, has a pacemaker/defibrillator Ask about allergies to latex, adhesives, topical antibiotics, lidocaine Decide whether to use local anesthesia with or without epinephrine, regional or general anesthesia Confirm contact information for follow up, including travel plans 8 Decide Type of Skin Biopsy/Excision Shave (superficial or scalloped) Curette Punch Elliptical Incisional Biopsy or Complete Excision 9 3
4 Choosing Shave Biopsy 10 Choosing Shave Biopsy/Excision Suitable lesions are either elevated above the skin or have pathology believed to be confined to the epidermis and/or the superficial dermis Biopsy yields a disc-like piece of tissue Requires little time Does not require sutures for closure Bleeding generally managed with pressure, a hemostatic solution (aluminum chloride) and/or electrocautery Anticipate a slightly depressed scar, about the size of the initial lesion, and perhaps hyper- or hypopigmented 11 Choosing Shave Biopsy/Excision Typical lesions are seborrheic keratoses, actinic keratoses, skin tags, verrucae, superficial basal cell or superficial squamous cell carcinomas 12 Seborrheic Keratosis Actinic Keratosis Superficial BCC Superficial shave biopsies/shave excisions should not be used for pigmented lesions where pigment is suspected deeper than the epidermis 4
5 Choosing Shave Scalloped Biopsy/Excision The deeper scalloped approach is useful for some pigmented lesions and suspected BCCs or SCCs that are located on areas where elliptical excision might be impractical or prone to significant scarring 13 Choosing Curette Biopsy 14 Choosing Curette Biopsy/Excision Used least often, especially when sending specimen to pathology as it can damage the tissue Requires little time and no sutures Usually requires only pressure for hemostasis Sometimes is less discomfort if performed quickly and without anesthesia Can be used for superficial lesions such as molluscum contageosum and smaller verrucae 15 5
6 Choosing Curette Biopsy/Excision 16 molluscum contageosum verruca vulgaris Choosing Punch Biopsy 17 Choosing Punch Biopsy/Excision 18 Performed with round, disposable blades typically ranging 2 to 5 mm in diameter The punch is suitable for diagnostic skin biopsy or completely removing small lesions Requires little time 2 or 3 mm punches can heal by secondary intention, but those greater than 3 mm may produce unacceptable scarring and are best closed with sutures 6
7 Choosing Punch Biopsy Examples of suitable lesions: Look-alikes 19 Tinea Incognito Erythema Annulare Centrifugum request a PAS or other fungal stain Choosing Punch Biopsy Small pigmented lesions (might require re-excision after punch) 20 Lesions involving hair Choosing punch biopsy 21 Central Centrifugal Cicatricial Alopecia Discoid Lupus 7
8 Choosing Elliptical Biopsy/Excision 22 Choosing Elliptical Biopsy/Excision 23 Elliptical excisions are performed with the goal of complete removal for diagnostic or therapeutic purposes Complete excisions allow for histopathologic examination of an entire lesion Elliptical incisional biopsies sample lesions that require a more extensive biopsy than with a punch Larger amount of tissue can allow for multiple studies (culture, immunofluorescence) from one biopsy site Require more time and expertise Require suturing Might require an assistant Choosing an Elliptical Excisional Biopsy 24 This pigmented lesion has several darker areas. Where would be the best location to biopsy? It would be best to excise the entire lesion. 8
9 Choosing an Elliptical Incisional Biopsy An elliptical incisional biopsy would sample the tissue, be easier to close, and would probably be more comfortable for the patient while awaiting definitive surgery 25 Obtain Informed Consent 26 After making your biopsy decision, discuss your reasoning along with benefits, risks and alternatives Usual risks include bleeding, infection, discomfort, scarring Ask patient about existing scars, hyperpigmentation, hypertrophic scars, keloids Disclose that a biopsy might not yield a specific diagnosis, but can rule out some conditions Discuss that depending on biopsy results, additional procedures could be necessary Answer questions Document informed consent Document Biopsy Location(s) Consider photographs (include in consent form) If more than one biopsy, mark the edges and label them prior to the photograph 27 9
10 Preparation for Biopsy or Excision 28 Lie the patient down when possible because vasovagal reactions are not uncommon Mark the edges Clean the field with chlorhexidine, isopropyl alcohol or povidone iodine Chlorhexidine is often preferred as it has broad spectrum activity again G + and G organisms and fungi Allow to dry Local Anesthesia Check for lidocaine allergy or sensitivity to epinephrine Follow universal precautions Draw up usually 1% or 2% lidocaine with or without 1:100,000 epinephrine 29 Maximum dose is 5 mg/kg (17.5 cc of 2% if 70 kg) If lidocaine allergy, injectable diphenhydramine (50 mg/cc) infiltrated locally is effective Local Anesthesia Lidocaine is Pregnancy Category B Lidocaine can be mixed 9:1 with NaHCO3 to reduce burning For shave biopsies, local anesthesia can help raise the lesion 30 10
11 Biopsies, Excisions, and Repairs 31 Hands on component Shave Biopsy Sterile #15 blade, safety razor, or Dermablade Forceps Cotton swabs Aluminum Chloride and cotton swabs 4 x 4 sponges Electrocautery machine (avoid use with alcohol and caution with pacemaker/defibrillator) Pathology specimen container 32 Shave Scalloped Biopsy 33 Place tension on skin #15 blade is commonly used 11
12 Shave Scalloped Biopsy The objective is to see no visible lesion, no pigment, and to see pinpoint bleeding indicating you ve shaved through the papillary dermis 34 Shave Scalloped Biopsy Consider electrosurgical and curettage feathering to smooth the edges using fine brush strokes with the electrode, or with a curette or blade edge after electrofulguration Eliminates sharp wound edges and contours the wound to the surrounding skin 35 Apply pressure with a dry or saline soaked sponge Do not apply alcohol to the bleeding site Apply Aluminum Chloride with a cotton swab or use light electrocautery Hemostasis Strategies 36 12
13 Aftercare used for Various Biopsies Apply petroleum jelly to the area (antibiotic ointment is not necessary) Cover with a dressing Typically keep dry for 24 hours Cleanse daily and gently with soap and water Dry gently and reapply petroleum jelly daily to keep the area from becoming too dry Give patient written instructions 37 Curette Biopsy/Removal Round or oval sharp looped instrument Cuts through epidermis easily, but less so through dermis Used for raised or friable lesions (note: pathology specimen is typically damaged) Used after electrodessication if pathology evaluation is determined to be unnecessary (for example, for typical SKs) 38 Curette Biopsy/Removal 39 13
14 Punch Biopsy Obtains a cylinder of skin from epidermis to deep dermis, sometimes to fat Take caution and consider other methods over areas with tendons, nerves or little subcutaneous fat 40 Punch Biopsy 41 Create a sterile surgical field Infiltrate area with local anesthetic To improve cosmesis, stretch the skin perpendicular to skin tension lines to create a resultant elliptical, instead of a round, defect using the elasticity of the surrounding skin to your advantage Press the punch firmly to the site and rotate it in one direction until you feel a give in the resistance (don t need to go down to the hub of the punch each time) Punch Biopsy 42 14
15 Lift the specimen gently with a forceps or use a needle point to lift the specimen, stretching it upward Do not crush the specimen Cut the specimen at the base and place it in a formalin container Usually requires a suture or 2 to achieve hemostasis Punch Biopsy 43 Punch Biopsy 44 Patient will need to return for suture removal Elliptical Incisional/Excisional Biopsy 45 Incisional biopsy is used to obtain an adequate representative sample of tissue, when removing the entire lesion is impractical Excise the tissue sample, usually extending down to fat If removal of the entire lesion is practical, than that is usually the better option 15
16 Needle Holders Forceps Excisional Biopsy Instruments Skin hooks (sometimes) Scissors Appropriate non-absorbable and/or absorbable suture material 46 Langerhans Lines Keep skin lines and function in mind before marking the area 47 Langerhans Lines 48 16
17 Mark the Lesion and/or Excision Site 49 Length is typically about 3 times the width 50 Follow skin lines Mark the area with a surgical pen Elliptical Incisional/Excisional Biopsy 51 Cleanse the area Be aware of the local anatomy and avoid significant underlying structures (nerves, arteries, tendons) 17
18 Undermine when Appropriate 52 Get Edges as Opposed as Possible 53 Suturing the Wound 54 Choose Suture Material and Needle Size Oppose and evert the edges If necessary, use absorbable suture material for subcutaneous closure. Examples are: Gut (Chromic) - fast absorbing, tensile strength is lost in days Polyglactin 910 (Vicryl) Poliglecaprone 25 (Monocryl) Non-Absorbable Sutures Nylon (Dermalon, Ethilon, Surgilon) Polypropylene (Prolene, Surgilene) Silk (good for mucosa) 18
19 Suture and Needle Sizes in Ambulatory Settings 6-0 commonly used on the face 5-0 used for flexural surfaces and skin under low tension 4-0 used for areas under moderate skin tension 3-0 used when there is higher tension on the tissue The more tissue to oppose, typically the larger the needle size needed 55 Simple Interrupted Advantages Strength Good approximation of superficial tissue Disadvantage Can leave suture marks Recommend usually make the bite deeper than wider 56 Vertical Mattress 57 Advantages Greater strength for higher tension areas Enhances wound eversion and possible improved scarring over simple interrupted sutures Disadvantage Additional time Extra suture marks possible 19
20 Advantage Horizontal Mattress Good strength for high tension wounds Disadvantages 58 Higher potential to compromise blood supply, so higher risk dehiscence or scarring Additional time Corner Stitch Similar principle to horizontal mattress suture Occasionally used for Z-plasty or other less commonly shaped biopsies (also star lacerations) Make it your last suture so the area is under low tension Stay superficial to avoid tissue strangulation 59 Running Suture Advantages Less time Tie only 2 knots, one at each end Disadvantage Can be difficult to evert edges Not for high tension areas If one suture breaks, they all break 60 20
21 Running Locked Suture Advantages Less time than interrupted Tie only 2 knots, one at each end Stronger than running unlocked technique Disadvantages Can be difficult to evert edges If one suture breaks, the wound could dehisce 61 Suture Removal Timeline Guidelines Area/Removal time (in days) will vary based on age, specific location, and comorbidities Face - 3 to 5 Neck - 5 to 8 Scalp - 7 to 9 Upper extremity - 8 to 14 Trunk - 10 to 14 Extensor surface hands 12 to 14 Lower extremity - 10 to Summary 63 Perform skin biopsies or lesion excisions when tissue diagnosis is needed Appropriately choose the lesion or component of the lesion to biopsy Select the biopsy technique that best suits the clinical situation Suture the biopsy site using the suture technique or combination of techniques most likely to balance strength and proper healing with good cosmesis 21
22 References 64 Mayo Clinic.com/healthlibrary aafp.org/images emedicinehealth.com
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