1. Skin Biopsy Kathleen O’Hanlon, M.D. Professor, Family and Community Health JCESOM/Marshall University November 2014

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

9. Site-Specific Recommendations Trunk/BreastPunch or shave EyelidSuperficial shave GingivaShave (may need RF for bleeding) LipPunch or shave Nail bedSmall punch PenisSuperficial shave PinnaShave, punch or curette TonguePunch or curette (+stitch) VulvaHair-bearing shave; mucosal punch

10. Biopsy Techniques Punch Shave Curettage Excisional Wedge (Incisional)

11. 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

12. 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

13. Langer’s Lines

14. 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.

16. 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

17. Can also use … Sgl.-edge Razor BladeFlexible “Biopblade”

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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!

26. 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

27. 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

28. Equipment Suppliers Any office medical supplier should be able to supply basic bx instruments: – Miltex – Acuderm, Inc. – CooperSurgical, Inc. – Curetteblade, Inc.

29. Credits The text on these slides is based on information from “Procedures for Primary Care”, 3 rd ed., Pfenninger & Fowler. All of the photos were derived from Google Images. THANK YOU! *Questions?*