Skin Biopsy Periprocedural Care

Updated: May 23, 2016
  • Author: Chad L Prather, MD; Chief Editor: Dirk M Elston, MD  more...
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Periprocedural Care

Patient Education and Consent

Patients should be informed about the need for biopsy, why it is recommended (eg, to help establish diagnosis and formulate a treatment plan), and the anticipated risks and benefits prior to performing a skin biopsy. In this manner, they can help decide whether or not a biopsy is warranted and give their informed consent. Specifically, patients should be informed of the anticipated healing process following a particular type of biopsy and the degree of scarring that will likely result.

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Equipment

Equipment used to perform a skin biopsy includes the following:

  • Alcohol wipe to clean the area for biopsy
  • Syringe with a 30-gauge needle and anesthetic
  • Gloves
  • Surgical forceps, preferably toothed to minimize crush artifact
  • Pathology container filled with 10% formalin solution or normal saline and laboratory requisition form
  • Gauze, 2 X 2-inch or 4 X 4-inch

Dressing materials include the following:

  • Petrolatum or antibiotic ointment
  • Bandage or nonstick bandage and tape

The following is used for a punch biopsy (see image below):

  • Disposable punch instrument ranging from 2-8 mm in size
  • Scissors
  • Needle holder for suturing
  • Desired size of suture
    Equipment used for a punch biopsy. Equipment used for a punch biopsy.

The following is used for a shave biopsy (see image below):

  • Surgical blade (No. 15) and scalpel handle or disposable razor blade
    Equipment used for a shave biopsy. Equipment used for a shave biopsy.

Supplies for hemostasis include the following:

  • Chemical cauterization: Solution of 20-50% aluminum chloride (Drysol) or ferric subsulfate (Monsel solution)
  • Electrical cauterization: Electrodessication, electrofulguration, or electrocoagulation may also be used
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Patient Preparation

Skin preparation

Alcohol, chlorhexidine, and povidone-iodine solution are the most commonly topical products used to clean the skin in preparation for skin biopsy. These may be used in a simple manner to wipe the immediate area of biopsy.

Anesthesia

Most skin biopsies are performed using a local anesthetic agent injected into the dermal and subcutaneous layers of the skin, usually with a small (1- or 0.5-inch) 30-gauge needle. Local anesthetics are divided into two categories known as the esters and the amides, which differ in structure and method of metabolism. Although allergies to local anesthetics are rare, adverse reactions to the ester class are more prevalent. Therefore, the amide class, which includes lidocaine, is more commonly used. [6] Hemostasis can be improved with the addition of epinephrine in dilutions of 1:100,000, 1:200,000, or 1:500,000. [7] Pain during injection can be decreased by buffering the solution with sodium bicarbonate to achieve a less acidic pH, [5] by warming the anesthetic to body temperature, [8] by using a small needle, and by injecting the anesthetic solution very slowly.

Alternatives to locally injected anesthetics for purposes of skin biopsies include topically applied amide anesthetic creams, topically applied cold agents (eg, ice, ethyl chloride, small amounts of liquid nitrogen), or injection with saline with benzyl alcohol (preservative). [9]

Topically applied creams are the most common method used after injection. Eutectic mixture of local anesthetics (EMLA) cream is a mixture of lidocaine and prilocaine that is an alternative to injection. It must be occluded after application and requires a minimum application time of 60 minutes. Four or 5% lidocaine-only creams are also commercially available, do not require occlusion, and usually require at least 30 minutes of application for effect. Topical anesthesia may be adequate for superficial shave biopsies, but injection is usually faster and more thorough.

Unfortunately, topical creams do not achieve moderate to deep penetration necessary for deeper punch, incisional, or excisional biopsies. As such, they are not alone sufficient for such procedures, but may help ease the discomfort of locally injected anesthetics prior to deeper procedures or in children. [5]

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Preprocedural Planning

The area where the biopsy will be performed may be marked with gentian violet, but this in not required prior to biopsy. High-quality photographs of the area with an adequate resolution to demonstrate clinical appearance and an appropriate field of view that allows the area of biopsy to be seen in the context of surrounding skin or anatomic markings should be obtained prior to biopsy. This assists with relocating the area in the future, after healing, should it need to be reidentified. For example, if the biopsy shows squamous cell carcinoma and further excisional surgery is needed, appropriate clinical photographs may help identify the correct site for surgery on a background of diffusely sun-damaged skin.

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Monitoring & Follow-up

Patients may be sent home for self-care following a skin biopsy and should be advised to do simple local wound care, typically with a gentle wash and topical petrolatum ointment. If sutures are placed, these should be removed in 1-2 weeks as appropriate. Pathology or culture results should be communicated to the patient in a timely manner following biopsy so that further care for the diagnosis can be achieved.

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