Skin Biopsy 101: Shave, Punch, & Excisional


Skin Biopsies Are a Common Dermatologic Procedure

My doctor says I need a biopsy of a mole. Do I really need it? Is it going to hurt? Will I be disfigured forever and have to exile myself to the woods?

The answer to those questions are yes, maybe, and definitely not (unless you went to a butcher and not a board certified dermatologist). Your dermatologist used ABCDE and is either going to be doing a shave, excisional, or punch biopsy. There are different indications for doing each and for some lesions the biopsy may even be the treatment if the pathologist report says the margins were clear of anything bad.
First, let’s begin with an introduction of the different types of biopsy. All of the following procedures will begin with the injection of lidocaine (local anesthetic) into the skin around and under the area to be biopsied.

skin-biopsy-101-shave-punch-excisional-skin-cancer

Shave biopsy:

This is used on lesions that stick out of the skin because the doctor is able to take a blade and cut parallel to your skin to remove a piece or the entire thing. This is a superficial cut so all layers of the skin will not be included. The pathologist will only be able to see epidermis and the top layer of the dermis. There are no sutures needed to close, and blood flow will be stopped by using a solution containing aluminum chloride, silver nitrate, or ferric subsulfate (Monsel). This is a great option because the wound is easy to care for, the cosmetic results are good, and it’s cheap to do.

Indications: warts, skin tags, superficial basal cell carcinomas, actinic keratoses, seborrheic keratoses

Contraindications: suspicious pigmented lesions that could be melanoma

Punch biopsy:

This is used on lesions that require a full thickness analysis of the layers of the skin to determine what it is or the depth of invasion. This type of biopsy can extend down to the subcutaneous fat. It requires a special tool that looks like a thin pencil with a circle blade at the end. The blade can be different diameters depending on how much specimen your doctor thinks the pathologist will need. These holes are deeper and tend to bleed more so your doctor can either use the solutions described above or close with 1-2 small stitches.

punch biopsy tool

Punch biopsy tools of increasing diameter.

Indications: anytime your doctor doesn’t know what a lesion is. This is the most commonly performed procedure.

Excisional biopsy:

This type of biopsy requires your doctor to completely remove the lesion of interest and some of the skin around it. In order to be able to close this chunk of skin afterward, the doctor will cut in the shape of an ellipse. If your doctor suspects melanoma, he/she will probably remove 1-2mm of skin around the borders. Closing the defect your doctor made will require stitches. You will have to return in about 2 weeks to have those removed. In the meantime, make sure you aren’t putting excessive tension on the wound so as to slow down healing. Keep your wound away from the sun. After healing, keep your newly formed scars away from the sun unless you want them to look even worse. As always, sunscreen, sunscreen, sunscreen.

Indications: suspicious pigmented lesions

Contraindications: uncomfirmed lesions that may be benign.

After the Biopsy:

After your procedure, the lidocaine will wear off, and you will probably experience pain at the site of your biopsy. You can get by on over the counter Tylenol, Motrin, Advil, meditation, or whatever floats your boat.

If you’re worried about the cosmetic results, either because it’s on your face, your doctor found it necessary to cut out a big chunk, or let’s face it we’re just vain, there’s some absolute must do’s for follow up care.

Don’t Smoke

Ideally you stopped smoking 8 weeks before your procedure because you realized the dangers to your health and the sensitive skin of your face, but stopping smoking even 2 weeks beforehand can help healing. Smoking slows down and impairs the healing process so just don’t do it.

Avoid Sun Exposure

Cover up and shield yourself from the sun. In this case, sunscreen alone probably won’t cut it. Especially for biopsies that have to be down on the face, try to wear a hat and sunscreen at all times. Sunlight is not good for healing and causes increased scarring with possible pigmentary changes.

Cover the Wound

Keep the area covered for as long as your doctor tells you to. Believe it or not, letting your cuts “breathe” is an old wives tale. Healing occurs better when you keep the skin moist. I’m not talking about keeping an occlusive dressing on, but keep it covered and moisturized for at least the first day.

Soap and Water

This is simple. Soap helps remove and kill bacteria. Water washes away said soap and bacteria. Avoid a nasty infection by keeping the area clean. It will be painful yes, but way less painful than a skin infection.

Have you ever had a skin biopsy done? What was your experience like? Post your thoughts below!

References:

  1. Pickett, H. Shave and Punch Biopsy for Skin Lesions. Am Fam Physician. 2011 Nov 1;84(9):995-1002.

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