5 Chapter 2 I Skin Biopsy

Chapter

CP'T Code 11 300-03

11 305- 08

11400-06 11420-26

11600-06 11620-26

Skin Biopsy Margaret R. Colyar

Shaving of epidermal or dermal lesion; single lesion­trunk, arms, or legs Shaving of epidermal or dermal lesion; single lesion­scalp, neck, hands, feet. or genitalia Excision benign lesions-trunk, arms, or legs Excision benign lesions-scalp, neck. hands, feet. or genitalia Excision malignant lesions- trunk. arms, or legs Excision malignant lesions- scalp, neck. hands, feet. or genitalia

Skin biopsy is the excision of a small piece of living tissue for microscop ic examina­tion. The two major categories of skin biopsy are • Partial dermal thickness-shave and curettage • Full dermal thickness- punch and elliptical excision

H EALTH PROMOTION/PREVENTION • Inspect the skin periodically for lesions. • N ote lesions that change size or color, are irregular, or are painful.

OPTION S • Method / -Shave biopsy

• Use for elevated skin lesions such as • Skin ra gs • Benign nevi (interdermal) • Epit helial tags • S mall basal celJ carcinomas • Condyloma acuminatum • C he rry angiomas • A ctfo lc ken1toses • ~cbo1Thck lcei:atoscs • Lcutlgo (frcddcs) • Vcrnm1 vulguris (warrs)

6 Section One j Dermatological Procedures

• Method 2-Curettage b iopsy • Use for

• Seborrheic keratoses • Superficial basal cell carcinomas • Crusting actinic keratoses

• Method 3-Elliptical excisional biopsy • Use for full-dermal-thiclmess lesions such as

• Basal cell carcinoma • Squamous cell carcinoma • Actinic keratoses • Seborrheic keratoses • Lenrigo • Lipomas •Melanomas •Nevi • Verruca vulgaris (warts)

RATIONALE • To confi rm or make a diagnosis of a skin lesion • To determine d efinitive treatment of a skin lesion • To remove a disfiguring or painful lesion

INDICATIONS • Nonmalignanr skin lesions not on the eyelid, lip, face, or penis

• Superficial skin lesions

CONTRAINDICATIONS • Infection is suspected at biopsy site • Bleeding disorder • If melanoma is suspected, do not use shave o r curettage. Elliptical excision is

preferred. • If on eyelid, lip, face, or pen is, REFER to a physician. • If deep lesions, REFER to a physician. t !11.fimnt'd co11s1'JI/ 1w111ircd

PROCEDURE

Skin Biopsy Equipment • Methods l, 2, and 3

• Antiseptic skin cleanser • Drape-sterile • Gloves-nonsterile • 3- mlsyringe • 27- LO 10-ga11ge, Vi-ii1d1 ntcd lt·

Chapter 2 j Skin Biopsy

1% lidocaine Comainer of 10% formalin Cautery or Monsel's solution Pickups-sterile (opt ional)

• Method I only No. 15 scalpel or sterile scissors

• Method 2 only D ermal curerre

• Med1od 3 only N eedle driver with scissors-ste rile

Suture (see Chapter 23 for information on choosing the appropriate type and size of suture) Tape

Nonstick dressing (Adaptic or Telfa) 4 x 4 gauze Topical antibiotic (Bactroban, Bacitracin , or Polysporin)

Procedure

MlTllOD I-SHAVE BIOPSY

• Posit ion the client for comfort w ith the a rea of the skin lesion easily accessible. • { '.lc:1nse the skin lesion and a 3-inch-diameter circle around the lesion. • I >rape the area. • !>111 on gloves.

• luj l'CI I % lidocaine under t he lesion using a 27- co 30-gauge needle to crcare rt whe:il.

• l1 11 · i .~e lc:si on parallel ro the skin (Fig. 2.1). • l'l:it'l: the tiSSll Cin a conrainer of 10% formalin.

• ( :. 11 11 er i~.c rhe base of the wound or apply Monsel's solution to retard bleeding.

Mt1.'l'11 o n 2-CURETTAGE BIOPSY

• Po~ it i1111 t he patient for comfort w ith the area of the skin lesion easily acccssihlc, • l ' 11'. l l lM.' the skin lesion and a 3-inch-diameter area aro und the lesio n. • I li.l[ll' tl1e area. • 1'111 1111 gloves.

• lu j1·11 I 'Y.• lidocainc unde r the lesion using a 27- to 30-gauge needle ro c reat e a wlh". 11.

• 11 l ol[H' tlt l' lesio n with tbe curette (Fig. 2 .2). • Jll,11 ' tl tt' tissue in a container of 10% fo rmalin.

• l ollil !' iln · t he h:ise o f rhe wound or apply Monsel's solution to reta rd blecd l11g.

!l 11 1'11rni J –lu.1P'l'I CAL Exc1s10NAL B i opsy

!1 ' 1111 I) HllMAJ. T 1ll C l( NlSS)

I l'n~ ltl1 1 11 1h t· p111 le111 for eo111fo rt wi th 1lic t1rl'a o l' thc skin 1<.:sion easil y ;1 i; ·c.~.~lh l r.1• I )11 w 1111 n11 tl itw ol' iii ~· tx pn:tt•d lndNlo n In t lw d ln·t'1lo 11 o f' die skin 1rn.9l1111

111 11,, 'f'ln• 01 1tl l1w 11 luJ1tld lw tl11·~·c 1l11w~ 1011111·1 1'1 .ir1 It 1.~ wlrk.

8 9 Section One I Dermatological Procedures

Figure 2 . 1 Shave biopsy. Incise parallel to the skin.

Figure 2.2 Curettage biopsy. Scrape the lesion with the curene.

• Cleanse the skin lesion and a 3-inch-diameter area around the lesion. • Put on gloves. • Inject 1% lidocaine under the lesion using a 27- ro 30-gauge needle to crea1 c ;1

wheal that covers the encire area of the proposed incision. • Drape the area. • Incise around the ou d im: wi1h the scalpel (Fig. 23). • Pul l 11 p :1 co rner or skin wil h pk kups.

Chapter 2 I Skin Biopsy

Figure 2.3 Elliptical excisional biopsy. Incise arou nd the oudine wi 1h the scalpel.

11)(1111· 2.4 Undermine the edges of the wound to release tension.

• 1'11 II 1bsm: as you excise just below fi.tll thickness of the tissue. • S1.1 r1 :II o nc co rner and work to the center. • ( ;n lo 1he orhcr corner and work toward the center. • P111 al l ('Xc iscd tissue in a co ntainer of J0% formali n. • ( 'lm111'l'

II .1 .~ 111:111 lesion , si mple single-layer closure with nylon s uture is appropriHl <.' (M'l' t :hapt1.:r 22) .

• ll bi1111 is larger wirh 1·1.:nsion • l l11der111il 1e t he e<lges orrhe wo11nd 10 l l' k;1 .~t the iension (Fig. 2.li) . • 1111 l ~l' tlw ~ 11 hc11 1ane01 1 s tiss1u.· dw l'Jltl11• lrn111 h o f' end1 sid c nl' du: wou11 tl

wlI h 1I1 t• '' .ii1wl.

10 Section One I Dcrmacological Procedures

Figure 2.5 Spread the incised subcutaneous tissue w ith scissors.

• Spread the incised subcutaneous tissue with scissors (Fig. 2.5). • Suture using the simple single-layer technique. If a larger, deeper lesion with tensio n • Undermine the subcutaneous tissue as just described. • Close subcutaneous tissue with absorbable suture and inverted knot (see

Chapter 22) . • Close skin using simple closure technique. • Apply copical antibiotic, nonstick dressing, cover with 4 x 4 gauze, and

secure with tape.

Client Instructions • Some inflammation (redness, swelling, and p ain) is normal. • To prevent infection, keep the dressing in p lace for 24 hours, then remove the

dressing and keep rhe area clean and dry. After the second day, you may wash the area gently with soap and water. Monitor for signs of infection, such as • Yellow and green drainage ~ Red streaks

Excessive pain Elevated temperamre

• Recurn to rhe office immediately if infection occurs. • Some bleeding and oozing are normal for the first 24 to 4 8 hours. If your

bandage becomes soaked w ith blood, reapply dry gauze and pressure. If the bleeding does nor stop, notify your practitioner.

• Avoid tensio n co the wound area by limiting movement. Tension may cause the wound to pull apart. If the wound does pull apart, notify the practitioner.

• Take Tylenol No. 3 (acetaminophen with codeine) every 4 to 6 hours as needed fo r pain. When t he pain lessens, take Tylenol or ib1.1p rofe n ( Mo1rin) ~·vcl'y It ro 6 hou rs as needed.

• Rccurn ro the ofnce (in _______) fo r st it ch 11' l1Hw,1l ( 1li•1111111 ~ 011 siir SI I ru reel i St'C '!:ti ii<,: 22. I ).