The Skin Biopsy

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The Skin Biopsy
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• In no other field of medicine is tissue for
  histologic examination so easily accessible.
• As a result, the skin biopsy has become an
  integralcomponent of dermatologic diagnoses

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• Skin biopsies are performed for a multitude of
  reasons, including
• uncertainty about the clinical diagnosis
• to investigate a poor response to therapy
• to exclude or investigate the evolution of one
  condition into another
• to investigate symptoms in the absence of
  clinically recognizable disease.

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• the process of securing appropriate tissue
  involves more than the mere mechanical removal of
  a specimen

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Pitfalls of Skin Biopsy
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Site Selection

• First step Identify an unadulterated primary
  lesion (Exclude lesions with secondary changes)
• Second Step choose Well developed but Fresh
  Lesion (It show the most characteristic and
  diagnostic histopathology ( Except LCV)

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Site Selection

• 3rd Step Obtain from central aspect of a primary
  lesion (except ulcer or subtle change as
  anetoderma)
• 4th Step selection of a proper biopsy site may
• also be influenced by knowledge of the underlying
  pathology and pathophysiology of the most likely
  diagnoses.

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Biopsy techniques

• Superficial (tangential shave)
• deep shave (saucerization)
• punch
• incisional/excisional

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• the technique
• 1-must obtain tissue from the level of the
  skin or subcutaneous tissue where the pathologic
  changes are expected
• 2- simultaneously balancing concerns of
  cosmesis and morbidity.

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• Panniculitis Do not perform shave biopsy
• Verruca or Skin Tag Do not perform Excision

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Curettage

• a curette 3-5 mm in diameter is held like a
  pencil and drawn with pressure under the
• lesion (if epidermal) or through the lesion
  (e.g. presumed BCC).
• This type of biopsy assumes that healing will be
  by second intention.
• The resulting scar is usually minimal

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Shave Biopsy

• Perform when
• 1-the pathologic process is primarily epidermal
• 2- when removing exophytic benign lesions
• E.g. intradermal melanocytic nevi or pigmented
  actinic keratosis or Bowen's disease versus
  macular seborrheic keratosis)

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Deep shave/saucerization biopsy

• Deeper variant of the superficial shave biopsy
• Often used to biopsy neoplasms (e.g. SCC versus
  hypertrophic AK)
• when properly performed, its diagnostic value is
  nearly equal to most incisional/excisional
  procedures

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Punch biopsy

• Perform when suspected pathology is within the
  dermis
• and
• when a partial sampling will be representative
  of the entire lesion or process.

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Punch Biopsy

• Poor Results
• assessment of deeply infiltrating tumors or the
  full thickness of the subcutaneous fat.
• Partial punch biopsies of melanocytic neoplasms
  can lead to erroneous diagnoses.

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Incisional /excisionalbiopsy

• Incisional removal of a portion of a lesion
  (e.g. Panniculitis)
• Excisional Removal of the entire lesion via a
  scalpel and
• standard surgical techniques
• (e.g. Melanoma)

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Post-procedure handling of the biopsy

• Avoid crush artifact especially for small punch
  biopsy.
• Lymphocytes are particularly susceptible to crush
  artifact, and when present, it may be impossible
  to render an accurate diagnosis.

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• For routine histologic exam place the specimen
  in the formalin container (volume 10x to 20x)
• Microbial culture place in the
  non-bacteriostatic saline container and deliver
  immediately to LAB.
• For DIF Flash Frozen or use Michel Solution

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Other Information

• Age and sex of the patient
• Anatomic site
• Pertinent and precise physical findings
• Differential diagnosis
• Treatments
• Drawings or clinical photographs

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