JGIM

CLINICAL REVIEW

Skin Biopsy Techniques for the Internist

Patrick C. Alguire, MD, Barbara M. Mathes, M.D.

OBJECTIVE: To review three commonly performed skin bi- metically unacceptable lesions, and provide definitive treat-
opsy procedures: shave, punch, and excision. ment for a number of skin conditions. Skin biopsies are
DATA SOURCES: English-language articles identified through unique because the lesion can be visualized, allowing for
a MEDLINE search (19661997) using the MeSH headings proper selection of biopsy site and technique. Skin biop-
skin and biopsy, major dermatology and primary care text- sies can be performed with minimal risk in critically ill
books, and cross-references. patients, and a timely skin biopsy may avoid other, more
STUDY SELECTION: Articles that reviewed the indications, invasive procedures.
contraindications, choice of procedure, surgical technique, Skin biopsies are infrequently performed by inter-
specimen handling, and wound care. nists.1 This may reflect lack of proficiency, or uncertainty
regarding indications, choice of procedure, specimen han-
DATA EXTRACTION: Information was manually extracted
dling, or subsequent wound care. The purpose of this re-
from all selected articles and texts; emphasis was placed on
information relevant to internal medicine physicians who view is to discuss in detail the three most commonly per-
want to learn skin biopsy techniques. formed biopsy procedures: shave, punch, and excision.

DATA SYNTHESIS: Shave biopsies require the least experi-

ence and time but are limited to superficial, nonpigmented METHODS
lesions. Punch biopsies are simple to perform, have few com-
plications, and if small, can heal without suturing. Closing English-language articles identified through a MED-
the wound with unbraided nylon on a C-17 needle will en- LINE search (19661997) using the MeSH headings skin
hance the cosmetic result but requires more expertise and and biopsy, major dermatology and primary care text-
time. Elliptical excisions are ideal for removing large or deep books, and selected cross-references were reviewed. Arti-
lesions, provide abundant material for many studies, and can cles were selected if they reviewed the indications, con-
be curative for a number of conditions, but require the great- traindications, choice of procedure, surgical technique,
est amount of time, expertise, and office resources. Elliptical
specimen handling, and wound care and were relevant to
excisions can be closed with unbraided nylon using a CE-3 or
internal medicine physicians wishing to learn skin biopsy
FS-3 needle in thick skin or a P-3 needle on the face. All
techniques.
specimens should be submitted in a labeled container with a
brief clinical description and working diagnosis.

CONCLUSIONS: Skin biopsies are an essential technique in BEFORE BIOPSY

the management of skin diseases and can enhance the der-
Indications
matologic care rendered by internists.

KEY WORDS: skin biopsy; shave biopsy; punch biopsy; exci- It is a maxim among dermatologists that more errors
sion biopsy; internists. are made from failing to biopsy promptly than from per-
J GEN INTERN MED 1998;13:4654. forming unnecessary biopsies. Nevertheless, many der-
matosis have nonspecific histopathology, and biopsy can-
not substitute for good clinical skills.24 Biopsy is indicated
in all suspected neoplastic lesions, in all bullous disor-

T he skin biopsy is a relatively simple, but essential

procedure in the management of skin disorders. Prop-
erly performed, it may confirm a diagnosis, remove cos-
ders, and to clarify a diagnosis when a limited number of
entities are under consideration (Table 1).2,4,5 Biopsy can
also serve as the definitive treatment for irritated, in-
flamed, precancerous, or malignant lesions.2,46

Contraindications and Other Considerations

Received from the Division of Internal Medicine (PCA) and the
There are few absolute contraindications to skin bi-
Division of Dermatology (BMM), University of Florida, Gaines-
ville. opsy, but all patients should be told that biopsies leave
Address correspondence and reprint requests to Dr. Alguire: scars, and internists may wish to refer lesions involving
Health Science Center, University of Florida, P.O. Box 100277, the face (particularly the eyelids and nose), or fascia of the
Gainesville FL 36210-0277. palms and soles, to dermatologists or plastic surgeons. In
46
JGIM Volume 13, January 1998 47

Table 1. Indications for Skin Biopsy

Indication Clinical Presentation Possible Diagnosis Biopsy Technique

Diagnosis Rashes or blisters Drug reaction Punch
involving dermis Cutaneous lymphoma
Deep tissue infection
Erythema multiforme
Kaposis sarcoma
Lupus erythematosus
Pemphigoid
Pemphigus
Psoriasis
Vasculitis
Processes involving the Erythema nodosum Excision
subcutis Panniculitis
Diagnosis and Atypical moles and Dysplastic nevi Excision or punch
treatment pigmented lesions Malignant melanoma (for small lesions)
Superficial lesions Actinic keratosis Shave (into dermis for
Basal cell carcinoma suspected malignancy) or
Seborrheic keratosis excision
Pyogenic granuloma
Skin tags
Squamous cell carcinoma
Warts

most cases, a biopsy should not be done at an infected cause these sites will most likely contain the distinctive
site, although occasionally infection may be the indication pathology. Whenever possible, remove vesicles intact, with
for the procedure. Inquiry should be made regarding al- adjacent normal-appearing skin, because disruption makes
lergies to topical antibiotics, antiseptics, local anesthetics, histologic interpretation more difficult. Similarly, bullae
and reactions to tape. Patients should be asked about should be biopsied at their edge, keeping the blister roof
bleeding disorders, bleeding with previous surgery, and attached. If the differential diagnosis is broad, biopsy sev-
use of drugs known to interfere with hemostasis. With the eral sites to minimize sampling error.
exception of shave biopsies, patients with bleeding disor- Whenever possible, avoid important cosmetic areas,
ders or taking warfarin should be referred to a qualified such as the face, and areas with poor healing characteris-
dermatologist or surgeon, whereas patients taking aspirin tics.4,8,9 Hypertrophic scarring tends to occur over the del-
can generally be managed with careful attention to hemo- toid and chest areas, and delayed healing can be a prob-
stasis and the use of a pressure dressing, described later lem over the tibia, especially in diabetic patients or in
in this review. patients with arterial or venous insufficiency.8 The inci-
dence of secondary infection in the groin and axillae is
high; therefore, biopsy these areas only if other sites are
Site Selection
unavailable.3
One of the more difficult initial decisions is selecting
the biopsy site. Generally, lesions with the most advanced
inflammatory changes should be chosen; evolutionary BIOPSY
changes may take several days and a too-early biopsy
Surgical Safety
may reveal only nonspecific features.24,7,8 For blistering
diseases, the reverse is true; the earlier the lesion, the Performing skin biopsies places the operator at risk of
more specific the histopathology. Consequently, only the blood-borne infections. Accordingly, vaccination for hepa-
newest vesicles and blisters should be biopsied, usually titis B is indicated, and universal precautions should be
within 48 hours of their appearance.24 Older lesions with observed by wearing gloves and eye-guards.10 Double-
secondary changes such as crusts, fissures, erosions, ex- gloving may provide increased protection against blood
coriations, and ulcerations should be avoided since the exposure.11 Shave and punch biopsies are clean, not ster-
primary pathological process may be obscured. For non- ile procedures; mask, gown and sterile gloves are not nec-
bullous lesions, the biopsy should include maximal le- essary.7 A mask is recommended for operators or assis-
sional skin and minimal normal skin. For lesions between tants known to be respiratory carriers of Staphyloccoccus
1 and 4 mm in diameter, biopsy the center or excise the or Streptococcus organisms. Mask, gown, and sterile gloves
entire lesion. For large lesions, biopsy the edge, the thick- are indicated for excisions, and are reasonable for any pa-
est portion, or the area that is most abnormal in color, be- tient at increased risk of infection.7 Recapping used nee-
48 Alguire and Mathes, Skin Biopsy Techniques for the Internist JGIM

dles increases the risk of needle sticks, and should never sion with a surgical marker as it may be temporarily oblit-
be attempted. Used sharp objects (needles, blades, punches, erated following injection of the anesthetic. Marking the
razors) are disposed in approved Occupational Safety and outlines for excisional biopsies can be very helpful for the
Health Administration (OSHA) containers provided by the novice operator. For excisions, place a fenestrated surgi-
pathology laboratory or medical waste disposal company. cal drape over the biopsy site after cleansing, but before
Material that is contaminated with blood or other body anesthesia.
fluids should be disposed in special, red, contaminated- Round wounds tend to be pulled open in the direction
materials plastic bags. of skin tension lines known as Langers lines, which gen-
erally parallel the direction of collagen in the dermis.9,10,12
Tension lines can be demonstrated by gently compressing
Supplies and Instruments
relaxed skin with the thumb and index finger, and wrin-
Increased efficiency can be achieved by gathering to- kle lines on the face are another good indicator. Surgical
gether the necessary supplies and instruments in a bi- incisions placed parallel to tension lines will close more
opsy kit. The kit may be stored in a central location for easily and cosmetically than those placed at right angles
use by many physicians and transported to the hospital (Fig. 1).6,9,10,12
for inpatient biopsies. A nurse can be in charge of ensur-
ing that the kit is always properly stocked. To help with
Anesthesia
this chore, the kit can include an index card listing its
contents (Table 2). The most commonly used local anesthetic is 1% or
2% lidocaine. Because lidocaine is a vasodilator, small
amounts of epinephrine are added to constrict blood
Preparing the Site
vessels, decrease bleeding, prolong anesthesia, and limit
Any common skin antiseptic such as isopropyl alco-
hol, providone-iodine, or chlorhexidine gluconate can be
used to prepare the biopsy site.3,5,7 Mark the intended le-

Table 2. Supplies and Instruments

Isopropyl alcohol, povidone-iodine, or chlorhexadine

Sterile gauze, 3 3 3 or 4 3 4, and sterile cotton-tip applicators
Cloth or plastic fenestrated drape
Syringes, 1 and 3 mL
Needles, 22-gauge (to draw up solutions), 30-gauge (for injection)
Lidocaine, 1% or 2%, with and without epinephrine. May
buffer with 1 part NaHCO3 to 9 parts lidocaine, but must
be refrigerated and disposed after 30 days.
Disposable surgical blades, 15 or 15c*
Disposable punches, 4, 6, and 8 mm*
Double-edge razor blade cut in half
Small tissue forceps (Adson 4 3/4 inch, 1 3 2 teeth, 1-mm tip)
Small tissue scissors (Gradle 3 3/4 inch or tenotomy)
Needle holders, 4 1/2 or 5 inch, smooth jaws, small tip (Web-
ster 4 1/2 inch). Consider purchase of disposal suture kits
with needle holders, forceps, and scissors included.
20% Aluminum chloride
4-0 or 5-0 Nylon on C-17 or P-3 needles (4-0 for scalp)
Packaged alcohol swabs or tissues
Antibiotic ointment or plain petrolatum
Spot and rectangular Band-Aid
Nonadherent dressings
Paper tape
Elastic wrap
10% Formalin specimen bottle
Surgical marking pen
Pathology request forms
Patient instructions
FIGURE 1. Compressing the skin of the arm reveals the direction
* Nondisposal instruments can be used but must be autoclaved af- of Langers lines. A diamond-shaped excision is outlined with its
ter use. long axis parallel to the wrinkle lines to facilitate closure.
JGIM Volume 13, January 1998 49

lido-caine toxicity.5,13 Avoid the use of epinephrine for ac- that practitioners receive clinical training before attempt-
ral lesions, tip of nose, or when large quantities are ing an excisional biopsy, or refer patients requiring an ex-
needed, especially in patients with cardiovascular dis- cision to a qualified dermatologist or surgeon.
ease.6,9,13 The onset of vasoconstriction is slower than
that of anesthesia; plan to use this time efficiently by in-
jecting the biopsy site first, then use the subsequent wait- Performing a Shave Biopsy
ing period to select instruments, fill out forms, or explain The shave biopsy can be facilitated by raising the le-
follow-up care to the patient. sion with a wheal of injected anesthetic, allowing the le-
The sting of injection can be minimized by mixing 1 mL sion to be propped up and stabilized between the thumb
of NaHCO3 with 9 mL of lidocaine, using a 30-gauge nee- and forefinger.6,9,15 To shave a lesion, a number 15 blade
dle, and by making the initial injection perpendicular to is held parallel to the skin surface, and the biopsy is per-
the skin.3,5,10 Deep injections sting less than superficial formed by using a smooth sweeping stroke rather than a
injections, but prolong the time to adequate anesthesia.3 sawing motion. Near the end of the excision, place the in-
Small syringes (1 and 3 cc) permit easier injection and are dex finger on top of the lesion to stabilize and prevent
less cumbersome to handle. tearing with the exit of the blade. The depth of the biopsy
For small lesions the anesthetic can be injected di- is controlled by the angle of the blade. Care should be
rectly into, or immediately adjacent to, the lesion. For larger taken to keep the blade parallel to the skin surface, avoid-
lesions, perform a field block by placing a ring of anesthe- ing irregular, deep penetration.
sia around the surgical site, always advancing and injecting A double-edge razor blade cut longitudinally can also
through a site that has been previously anesthetized.10,14 be used for shave biopsies. The razor technique has sev-
eral advantages; it is sharper than most blades, the razor
Selection of Biopsy Procedure can be bent concave or convex with the thumb and fore-
finger to better conform to the surface being cut, and depth
Shave biopsies are quick, require little training, and is easily controlled by increasing or decreasing the con-
do not require sutures for closure. Lesions that are most vexity of the curve (Fig. 2).
suitable for shave biopsies are either elevated above the Curved scissors can be used to perform shave biop-
skin, or have pathology confined to the epidermis.5,7,10,15 sies and tend to give specimens with slightly more depth
Examples include seborrheic or actinic keratoses, skin than a scalpel blade. Curved scissors are an efficient means
tags, warts, and superficial basal or squamous carcino- of removing skin tags and other small, exophytic growths.5
mas. Shave biopsies should not be used for pigmented le- The lesion to be removed is stabilized with toothed for-
sions; if an unsuspected melanoma is partially removed, ceps, then cut at the base.
it cannot be properly staged.4,5,7 With shave biopsies, a
small, depressed scar the size of the initial lesion is likely
to occur.15 Hemostasis
Punch biopsies are performed with round, disposable
Bleeding following small shave biopsies can often be
knives ranging in diameter from 2 to 10 mm, but 3 mm is
controlled with pressure alone. Persistent oozing can be
the smallest size likely to give sufficient tissue for consis-
stopped with 20% aluminum chloride in absolute alcohol.
tently accurate histologic diagnosis.16 The punch is an
Other hemostatic agents, in order of increasing corrosive-
ideal procedure for diagnostic skin biopsy or removing
small lesions, and often provides a better cosmetic result
than a shave biopsy.3,7,15 Punch biopsies can heal by sec-
ondary intention, but punches greater than 3 mm may
produce unacceptable scarring and are best closed with
one or two sutures. Punch biopsies are easily mastered by
most practitioners, are quick, and have a low incidence of
infection, bleeding, nonhealing, or significant scarring.3,7,15
Excisions are reserved for lesions that cannot be re-
moved with a punch owing to size, depth, or location.
Their main advantage is the amount of tissue that can be
excised, allowing for multiple studies (culture, histopa-
thology, immunofluorescence, electron microscopy) from
one biopsy site.3,7 Excisions are especially well suited for
removal of large skin tumors or inflammatory disorders
deep in the skin, involving the panniculus. Excisions re-
quire the greatest amount of expertise and time; they al-
most always require sutures, and are more easily per- FIGURE 2. Half of a razor is curved with thumb and forefinger
formed with an assistant.3,7 It is strongly recommended to perform a shave biopsy.
50 Alguire and Mathes, Skin Biopsy Techniques for the Internist JGIM

ness, are Monsels solution (ferric subsulfate), trichloro- sies bleed profusely and usually require the presence of
acetic acid, and silver nitrate. Although Monsels solution an assistant.18
is more effective than aluminum chloride, it also causes Wounds 3 mm or less can be treated with a hemo-
more tissue destruction and, like silver nitrate, can result static agent and allowed to heal by secondary intention.4
in skin pigmentation.3,10,17 For hemostatic agents to be ef- Larger wounds require one or two sutures to produce a
fective, the wound must be as dry as possible, following better cosmetic result.3,7,15 If sutures are to be used, do
which the agent is applied with a cotton applicator using not apply a hemostatic agent. Contraindications to sutur-
firm pressure with a twisting motion.10 In general, excel- ing include biopsies in infected or poorly healing skin;
lent hemostasis following shave biopsies can be achieved these wounds may heal better by secondary intention.7
in patients with bleeding disorders or in those taking war-
farin or aspirin with the combined use of aluminum chlo-
Performing an Excision
ride and several minutes of direct pressure over the wound.
After performing a field block, determine the direction
of the skin tension lines. Align the long axis of the exci-
Performing a Punch Biopsy
sion parallel to the skin tension lines. Using a surgical
Begin by determining the direction of the skin tension marking pen, draw an ellipse around the lesion to be ex-
lines at the biopsy site. Raise an intradermal welt with the cised, with 308 angeles at each apex, the length three
anesthetic, and select the appropriate size punch. Stabi- times the width, and a 2- to 5-mm margin of normal skin
lize the skin with the thumb and forefinger, stretching it around the lesion.5,6 Holding the scalpel with a number
slightly perpendicular to the normal skin tension lines. 15 blade like a pencil, begin the incision at one apex with
This will produce an oval rather than a round wound, fa- the blade perpendicular to the skin. As the incision
cilitating closure.46 Place the punch perpendicular to the progresses, use more of the belly of the blade, raising it to
skin and apply firm and constant downward pressure the perpendicular again at the next apex.6 For excisions
with a circular motion (Fig. 3). Avoid a back-and-forth larger than 1 cm, the blade should be angled away from
twisting motion, and do not remove the punch to check the lesion, slightly undermining the wound edge. This will
the progress, as this may result in a ragged wound and a allow for easier eversion of the wound edge during clo-
shredded biopsy sample.10,15 When the punch reaches the sure, improving the cosmetic result and decreasing the
subcutaneous fat, there is a definite give indicating that risk of dehiscence. Avoid crosshatching the incisions at
a full-thickness cut has been made. Remove the punch, the apices, and nicking the sample. Although it is not
and apply downward finger pressure at the sides of the necessary to go through the entire thickness of dermis
wound to pop up the core. Completely elevate the core on the first stroke, ultimately the incision must be deep
with gentle use of forceps or a needle tip, and excise it at enough to see subcutaneous fat when the sample is re-
its base with small tissue scissors. Apply pressure to the moved. Once the ellipse has been incised, carefully lift the
wound with gauze in preparation for closure. Punch biop- sample edge with fine forceps and completely undermine
sies of the scalp are best accomplished by using a 5-mm the sample at the level of the subcutaneous fat with scal-
punch, and holding it at 208 to the surface of the scalp, pel or scissors. Do not remove more tissue at the center
roughly along the axis of the hair follicle.7,18 Scalp biop- than at the apices. Apply pressure to the wound with
gauze in preparation for closing.
For some physicians, it will be technically easier to
perform a diamond-shaped excision for small lesions, and
a hexagonal-shaped excision for larger lesions.4 The lines
of the excision can be marked with a surgical marker
prior to anesthesia (Fig. 4). For diamond excisions, the
blade is inserted vertically into the skin to make the four
straight-line incisions of the diamond. For the hexagon,
two straight and parallel lines are incised on either side of
the lesion and then connected at each end by two more
straight incisions to form the hexagon.

Pigmented Lesions
An important caveat regarding removal of pigmented
lesions is the possibility of malignant melanoma. With
FIGURE 3. The skin is stabilized with thumb and forefinger and this in mind, small lesions indicative of melanoma can be
stretched slightly perpendicular to the skin tension lines. A removed by a punch technique, provided that the lesion
punch is held perpendicular to the skin, and is rotated into the can be completely removed, whereas larger lesions require
skin with a firm, constant pressure. an excisional technique. In either case, the initial speci-
JGIM Volume 13, January 1998 51

tion of the lesion. The latter is especially critical if more

than one lesion is removed. The specimen label must
match the pathology request form and the description in
the medical record. On the request form, list the clinical
diagnoses and give a short clinical history and description
of the lesion or rash.4,5 If a tumor has been removed, re-
quest that the margins be checked for tumor. Whenever
possible, submit the specimen to a dermatopathologist.3

FIGURE 4. Elliptical, diamond, and hexagonal excisions and

sites of initial suture placement.
Preparing the Wound for Suturing
Prior to closing excisional wounds, the edges of the
wound may need to be undermined either sharply with a
men must be removed at the level of subcutaneous fat,
scalpel or bluntly with scissors. Blunt dissection is per-
which allows for proper staging in the event it is a mela-
formed by advancing the closed scissors under the wound
noma. As a corollary, such pigmented lesions should
edge, and quickly spreading them open. The width of un-
never be destroyed by cryosurgery or removed by a shave
dermining varies with the size of the wound, but for most
technique because this impairs the ability to make an ac-
wounds, 5 to 10 mm is sufficient. Undermining allows the
curate diagnosis or properly stage the tumor. If a mela-
skin edges to evert more easily and reduces tension on
noma is diagnosed, the amount of tumor-free margin is
the sutures.3,6,7,10,14
determined by the depth of tumor invasion. In practical
terms, this means that the original excision must be re-
vised, usually creating wider tumor margins and extend- Choice of Suture and Needle
ing the level of excision down to the deep muscle fascia,
The qualities most important in suture are flexibility,
even if the margins of the original biopsy are free of tu-
strength, secure knotting, and infection potential.19 The
mor. Practitioners who have no clinical training in exci-
two major categories of suture are absorbable and nonab-
sions, or in removing melanomas, should refer these pa-
sorbable. Absorbable suture is made from synthetic polymer
tients to a qualified dermatologist or surgeon.
or mammalian-derived collagen (gut). Common synthetic
absorbables include polyglactic acid (Vicryl), polyglycolic
Processing the Biopsy Sample acid (Dexon), and polydixanone (PDS). Absorbable su-
tures are usually placed deep in larger wounds to reduce
For light microscopy, the specimen should be placed
skin tension for the final closure.
in a 10% buffered formalin solution provided by pathol-
Nonabsorbable sutures are used for skin closure and
ogy; each specimen should be placed into a separate bot-
permanent internal placement, such as cardiac valves.
tle and identified. Special studies require special handling
Common nonabsorbable sutures include silk, nylon (Ethi-
and are listed in Table 3. Specimens less than 1 cm in
lon), and polypropylene (Prolene). Silk and nylon suture
greatest dimension can be adequately fixed in 30 mL of
can be braided, adding strength and improving knotting
formalin, but larger specimens will require more formalin
potential, but are more likely to harbor infection. Polypro-
and should be sectioned to ensure adequate fixation. If a
pylene and unbraided nylon are monofilaments, and are
specimen is to be sectioned, clue the pathologist to the lo-
less likely to harbor infection, but knots are less secure
cation of the lesion by sectioning through its center and
and more difficult to tie.9,19 Silk and gut, as natural mate-
marking the normal skin borders with surgical marker.
rials, cause considerable tissue inflammation and have
Careful attention must be paid to labeling the speci-
been largely replaced by synthetic suture material.9,19
men. Include patient and physician name, date, and loca-
Suture size is indicated by the code 0; the more 0s,
the smaller the suture diameter. Generally, 4-0 or 5-0
monofilament nylon can be used on the body and scalp,
Table 3. Special Studies for Skin Biopsies and 6-0 nylon on the face.6,10 Polypropylene can be con-
Study Fixative or Solution
sidered for the scalp, primarily because it is blue and easy
to see. Suture needles are made of noncorrosive stainless
Histopathology 10% Buffered formalin
steel, especially forged to achieve maximum strength and
Direct immunofluorescence Michels solution
(blistering diseases and
ductility, the ability to bend under pressure without break-
lupus erythematosus) ing.19 Suture needles have an eye, body, and point. Most
Electron microscopy Electron microscopy needles have a swaged eye where the metal of the needle
fixative; glutaraldehyde is molded around the end of the suture. This part of the
Bacterial or fungal cultures Sterile container with needle is soft and likely to bend or break if mishandled.
nonbacteriostatic saline The body of the needle is designed for great strength and
Viral cultures Viral transport media
secure grasping; it is usually flattened with slight convex
52 Alguire and Mathes, Skin Biopsy Techniques for the Internist JGIM

or concave sides to avoid rotation in the holder while su- around the holder, then grasp the free end of the suture
turing. Three types of needle points are common: cutting, with the holder and pull through, tightening the knot. At
tapered, and blunt. Cutting needles allow for easy pas- this point the needle end and free end of the suture
sage through tough tissue and are ideal for skin. A code should have switched sides relative to the beginning. The
has been developed to denote the purpose of the needle. process is repeated as needed, reversing the position of
For skin (FS) and cutting needles (CE) are used on thick the free end and needle end of the suture with each knot.
skin, whereas plastic (P), plastic skin (PS), and premium Approximate, dont strangulate acknowledges the im-
(PRE) are used for cosmetic closures. The size of the nee- portance of proper tension on the suture. Excessive ten-
dle is ranked by a number, with higher numbers identify- sion can be recognized by blanching of the wound edges,
ing larger needles. Needle curvature is measured in terms and may indicate the need for subcutaneous sutures or
of proportion of a circle, with one-quarter, one-half, and simply less tension on each suture.
three-eights curves available. Most biopsy wounds in thick Placement of sutures for elliptical excisions can be fa-
skin can be closed using an FS-3 or CE-3 needle, and P-3 cilitated by following the rule of halves.10 The wound is
can be used for the face, all with a three-eighths curvature. divided in half by the initial suture placement, and each
C-17 needles were developed specifically to close punch half is itself halved by the subsequent placement of su-
biopsies, and are less expensive than FS, CE, P, or PRE tures. Similar halving continues until all wound edges are
needles. When in doubt, consult the needle package, which approximated. Starting the initial suture at an apex rather
is illustrated with a full-size diagram of the enclosed needle. than the middle runs the risk of dog ears at the opposite
When wound closing seems more difficult than ex- apex owing to the creation of uneven wound edges.
pected, reassess the appropriateness of the instruments. In large wounds, the skin tension can be reduced by
Needle selection is often a prime factor in the ease of su- placing a temporary initial suture at the midpoint of the
turing and final cosmetic result.14 A larger needle may de- wound, but farther from the edge than usual. At a later
crease the difficulty of the job. time, this suture can be removed as the wound is approx-
imated with the permanent sutures.
Diamond and hexagonal excisions are easily closed by
Closing
placing the initial sutures at the two opposing points of
Primary closure of a punch wound can be accom- the diamond or four opposing points of the hexagon, then
plished with one or two, single-layer, interrupted sutures. adding other sutures as necessary to completely approxi-
Excisions can be closed in one or two layers, with two- mate the wound (Fig. 3). The straight lines of the diamond
layer closures giving better cosmetic results in the larger and hexagon provide better approximation of edges for
wounds. the beginner than do the curved surfaces of the ellipse.4
The most common closure technique is a simple, in-
terrupted suture.10 To begin, grasp the needle with the
needle-holder at midpoint or about one third the distance AFTER BIOPSY
from the eye. This will provide maximum driving force and
diminish the likelihood of bending or breaking the needle.
Wound Dressing
A palm grip is recommended to increase the driving force Wounds heal faster when moist, and under an occlu-
of the needle through the skin. Place the handle of the sive or semiocclusive dressing.17 All biopsy wounds can
holder in the palm, wrap the thumb and fingers around be dressed with a thin film of an antibiotic ointment (bac-
the handles, and extend the index finger down over the itracin, polysprin, mupirocin) or plain petrolatum to pre-
tip of the holder near the needle. The needle point is vent crust formation, then covered with a Band-Aid or other
placed perpendicular to the skin surface about 2 mm nonadherent covering, and topped with a gauze dressing
away from the wound edge, and is driven down, then up and tape.10,17 The dressing should be removed in 12 to 24
into the center of the wound. A second insertion begins in hours and thereafter cleaned with soap and water twice
the center of the wound, and exits the skin on the oppo- daily. After cleaning, the wound should be covered with
site side, 2 mm from the wound edge, perpendicular to an antibiotic ointment or petrolatum. Wounds healing by
the surface. If done properly, the suture will make a flask- secondary intention need to be redressed after each clean-
shaped loop; the loop beneath the skin surface is farther ing until healed over, or for at least 5 days, whereas this
apart than the entry and exit points on the surface. For is optional for sutured wounds. For sutured wounds, show-
small excisional wounds, and for most punch wounds, a ering is permitted after 24 hours, but use of hot tubs is
needle exit in the middle of the wound is not necessary, prohibited until the sutures are removed.20
but depends on the size of the needle and the ease that
the wound edges can be approximated and everted.
Suture Removal
The instrument tie is fast and efficient. To begin, hold
the needle holder parallel to the long axis of the wound There is a balance between the tendency for wound
with the free end and needle end of the suture on either dehiscence or stretching if the sutures are removed too
side of the holder. Wrap the needle end of the suture twice early, and the production of suture marks if they remain
JGIM Volume 13, January 1998 53

too long.9,19 Generally, sutures on the face can be removed matologic care rendered by internists, it cannot replace
in 3 to 5 days, followed by the application of semiperme- clinical knowledge. Shave biopsy requires the least experi-
able adhesive strips to reduce wound tension.10,17,19 Su- ence and time, but its use is limited to superficial lesions
tures on the chest, abdomen, arms, and scalp can be re- and should not be used for pigmented lesions. Punch bi-
moved in 7 to 10 days, and those on the back and legs in opsy is the primary diagnostic procedure in dermatology,
12 to 20 days.10,17,19 Physicians should remove sutures is simple to perform, has few complications, and small bi-
from their patients to learn first-hand the results of their opsies can heal without suturing. Although closing with
suturing technique and wound healing. Any crust should sutures improves the cosmetic result, it requires more ex-
be washed away with wet gauze, then the suture is gently pertise and time. Excisions are ideal for removing large or
lifted near the knot, and one side cut close to the skin deep lesions, provide abundant tissue for multiple stud-
surface. The suture is removed by pulling across the ies, and can be curative for a number conditions includ-
wound surface; pulling away from the would puts tension ing cancer. However, excisions require the greatest amount
on the wound and may cause dehiscence.10 of expertise, time, and office resources, and are associ-
ated with more complications, including bleeding and in-
fection. Because of its complexity and complication poten-
Complications
tial, clinical training is highly recommended prior to
The major complications include bleeding, infection, attempting an excisional biopsy. For the interested nov-
and allergic reactions. Most bleeding can be controlled ice, a number of learning resources and workshops are
with simple pressure on the wound.4 If this is not suc- available to enhance knowledge, proficiency, and confi-
cessful after 5 minutes, a single suture may be sufficient. dence.10,12,14,2426
If bleeding remains uncontrolled, remove the suture, find
and tie off the bleeding vessel, then resuture.
Bleeding and hematoma formation can be minimized REFERENCES
by using a pressure dressing directly over the wound.17
1. Wigton RS, Blank LL, Nicholas JA, Tape TG. Procedural skills
Tape a folded 4 3 4 gauze pad tightly over the wound, or
training in internal medicine residencies. A survey of program di-
secure it with an elastic bandage or self-adhering wrap. rectors. Ann Intern Med. 1989;111:9328.
An ice pack applied for 3 to 5 minutes several times dur- 2. Fitzpatrick TB, Bernhard JD. The structure of skin lesions and
ing the first 24 hours will also help decrease bleeding, he- fundamental of diagnosis. In: Fitzpatrick TB, Eisen AZ, Wolff K,
matoma formation, pain, and edema.17 Infection, though Freedburg IM, Austen KF, eds. Dermatology in General Medicine.
3rd ed. New York, NY: McGraw-Hill; 1987:47.
relatively uncommon, is usually the result of Staphylococ-
3. Pariser RJ. Skin biopsy: lesion selection and optimal technique.
cus, Streptococcus, or Candida.21 If the wound is frankly Mod Med. 1989;57:8290.
purulent, or has an associated cellulitis, culture the dis- 4. Pinkus H. Skin biopsy: a field of interaction between clinician and
charge and begin oral antibiotics. Infected wounds in the pathologist. Cutis. 1977;20:60914.
hands, feet, and intertriginous areas are often infected 5. Arca MJ, Bierman JS, Johnson TM, Chang AE. Biopsy techniques
for skin, soft-tissue, and bone neoplasms. Surg Oncol Clin North
with Candida and can respond to topical antifungal oint-
Am. 1995;4:15774.
ments.21 Occasionally patients will develop reactions to 6. Bart RS, Kopf AW. Techniques of biopsy of cutaneous neoplasms.
topical antibiotics.22 The wound will be red, itchy, and J Dermatol Surg Oncol. 1979;5:97987.
may have vesicles. If this occurs, stop the antibiotic and 7. Peters MS, Winkelman RK. The biopsy. Dermatol Clin. 1984;
apply a topical corticosteroid ointment. Tape reactions are 2:20917.
8. Krull EA, Babel DE. Diagnostic procedures of the skin, part two:
usually irritant rather than allergic and improve simply
skin biopsy and other tests. J Fam Pract. 1976;3:42731.
by not taping, or sometimes by changing the direction of 9. Harrison PV. A guide to skin biopsies and excisions. Clin Exp Der-
the tape on the skin.23 matol. 1980;5:23543.
10. Dinehart SM, Hanke CW, Geronemus RG. Dermatologic Surgery
for Medical Students. Schaumburg: Association of Academic Der-
Documentation matologic Surgeons; 1993.
11. Cohen MS, Do JT, Tahery DP, Moy RL. Efficacy of double gloving
All procedures must be documented in the medical as a protection against blood exposure in dermatologic surgery. J
record. Minimal content includes location and nature of Dermatol Surg Oncol. 1992;18:8734.
the lesion, indications for procedure, what was done, and 12. Snell G. Skin biopsy. In: Pfenninger JL, Fowler GC, eds. Proce-
how it was performed, specimen disposition, and instruc- dures for Primary Care Physicians. St. Louis, Mo: Mosby-Year
Book; 1994:206.
tions to and follow-up plans for the patient. The appendi-
13. Ritchie JM, Greene NM. Local anesthetics. In: Gilman AG, Rall
ces contain examples of patient instructions and proce- TW, Nies AS, Taylor P, eds. The Pharmacological Basis of Thera-
dure notes. peutics. 8th ed. New York, NY: Pergamon Press; 1990:31131.
14. Epperson WJ. Laceration and incision repair. In: Pfenninger JL,
Fowler GC, eds. Procedures for Primary Care Physicians. St. Louis,
SUMMARY Mo: Mosby-Year Book; 1994:711.
15. Grekin RC. Simple dermatological surgical procedures. Res Staff
Skin biopsy is an essential technique in the manage- Phys. 1989;35:617.
ment of skin diseases, and although it can enhance der- 16. Todd P, Garioch JJ, Humphreys S, Seywright M, Thompson J, du
54 Alguire and Mathes, Skin Biopsy Techniques for the Internist JGIM

Vivier AWP. Evaluation of the 2-mm punch biopsy in dermatologi- APPENDIX B

cal diagnosis. Clin Exp Dermatol. 1996;21:113.
Sample Procedure Notes
17. Telfer NR, Moy RL. Wound care after office procedures. J Dermatol
Surg Oncol. 1993;19:72231. Shave Biopsy
18. Stengel FM. Indications and technique of biopsy for diseases of
the scalp. J Dermatol Surg Oncol. 1978;4:1701. The possible diagnosis of basal cell carcinoma and need for bi-
19. Moy RL, Waldman B, Hein DW. A review of sutures and suturing opsy confirmation was discussed with the patient, and consent
technique. J Dermatol Surg Oncol. 1992;18:78595. for a shave biopsy of the left ear was obtained. The skin was
20. Noe JM, Keller M. Can stitches get wet? Plast Reconstr Surg.
prepped with alcohol; local anesthesia was obtained with 1%
1988;81:824.
lidocaine with epinephrine and NaHCO3. A shave biopsy into the
21. Bennett RG. Microbiological considerations in cutaneous surgery.
dermis was performed with a razor and hemostasis was achieved
In: Bennett RG, ed. Fundamentals of Cutaneous Surgery. St.
Louis, Mo: CV Mosby Company; 1988:13678. with AlCl3. The biopsy specimens were submitted to pathology in
22. Gette MT, Marks JG, Maloney ME. Frequency of postoperative al- formalin. A Band-Aid dressing was applied. Wound instructions
lergic contact dermatitis to topical antibiotics. Arch Dermatol. were given. The patient will return in 2 weeks for a wound check,
1992;128:3657. and review of pathology results.
23. Grolnick M. Factors involved in the production of adhesive plaster
irritation. Am J Surg. 1940;50:6378.
24. Mathes BM. Common Office Skin Biopsy Techniques [videocas- Punch Biopsy
sette]. Gainesville, Fla: University of Florida, Department of Der-
A possible diagnosis of lupus was discussed with the patient and
matology; 1996.
25. Stawiski M. Skin Biopsy Techniques [videocassette]. Ann Arbor, the need for two biopsies reviewed. Consent for the procedure
Mich: University of Michigan, Department of Dermatology; 1979. was obtained. The skin of the right upper, inner, and outer arm
26. Meek TJ. Elliptical Excision and Suture of Cutaneous Lesion. [vid- was prepped with Hibistat and alcohol, and local anesthesia was
eocassette]. Baton Rouge, La: Louisiana State University, Depart- obtained with 1% lido-caine with epinephrine and NaHCO3.
ment of Dermatology; 1978. Punches of 3 mm were obtained from the outer and inner right
arm to the depth of the subcutaneous fat, and each was closed
with a 4-0 nylon suture. The specimen from the outer arm was
APPENDIX A
placed in formalin and from the inner arm into Michels solution
Sample Patient Instructions for Wound Care
and submitted to pathology. Band-Aid dressings were applied.
Open Wounds Wound care instructions were given. The patient will return in 10
days for suture removal and review of pathology results.
The biopsy done today will heal from the bottom up and sides in-
ward. Remove the Band-Aid in 12 to 24 hours, and clean it twice
per day with soap and water. Apply a thin coat of antibiotic oint- Elliptical Excision
ment such as bacitracin or polysporin, unless otherwise in- Description: atypical nevus 8 3 4 cm left upper back. The possi-
structed, then cover with a Band-Aid. This type of wound heals ble diagnosis, procedure, need for biopsy, potential complica-
faster when covered. If you have a lot of itching, redness, drain- tions, side effects and scarring were discussed with the patient,
age of pus, swelling, or pain, call the office. Tylenol or ice packs and consent for the procedure was obtained. The patient was
may be used for pain control. placed in the prone position, local anesthesia was achieved using
1% lidocaine with epinephrine and NaHCO3, and the skin was
Sutured Wounds prepped and draped in the usual sterile fashion (with povidone-
iodine [Betadine] and alcohol). The lesion and a 2-mm clear mar-
The biopsy done today has stitches that will need to be removed gin was excised in an ellipse to the depth of the subcutaneous tis-
in __ days. Beginning tomorrow, remove the dressing, wash twice sue. Wound edges were undermined bluntly, three 4-0 Vicryl in-
daily with soap and water, then apply a thin film of antibiotic verted mattress sutures were placed in the dermis. The wound
ointment such as Bacitracin or Polysporin. Band-Aids are op- was closed with five 4-0 nylon sutures. A pressure dressing was
tional. Call the office if you experience significant redness, pain, applied. Wound care instructions were given. The specimen was
itching, swelling, or drainage of pus. If you are unable to keep sent to pathology in formalin. Final specimen length 2.5 cm. The
your appointment for suture removal, call the office. Tylenol or ice patient tolerated the procedure well. She will return in 14 days
packs can be used for pain control. for suture removal and review of pathology results.
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