FIGURE 8-31  New onset bullous pemphigoid in a man with a previous history of psoriasis. A shave biopsy of an intact bulla on the arm was performed at the site marked by the surgical marker. Note how the oval marking is drawn around one intact bulla and some perilesional skin. This biopsy specimen is then transected with a blade so that the bulla is sent off in formalin and the perilesional skin is sent for direct immunofluorescence. (Copyright Richard P. Usatine, MD.)

Chest and Buttocks

The chest and buttocks may be considered cosmetic areas and may require particular care to avoid scarring. Keloidal or hypertrophic scarring is common in both of these areas. Large, deep shave biopsies should be avoided if possible.

Scalp (Alopecia)

Biopsy is almost always needed to diagnose the various forms of scarring alopecia (including lichen planopilaris and folliculitis decalvans) (Figure 8-32). Androgenic alopecia, telogen effluvium, and alopecia areata are not scarring and can often be diagnosed clinically without a biopsy. The type of inflammatory infiltrates seen on histology can vary and are used to classify the scarring alopecias:

•Lymphocytic: discoid lupus erythematosus, lichen planopilaris, and central centrifugal scarring alopecia

•Neutrophilic: folliculitis decalvans and dissecting folliculitis

•Mixed: acne keloidalis nuchae.

Usually two 4-mm punch biopsies are preferred so the pathologist can cut one specimen longitudinally and the other vertically. This gives additional information that may be needed for a firm diagnosis.

Diagnosing a “Rash”

For most challenging rashes, a 4-mm punch biopsy will be helpful to make the diagnosis. However, in many instances it may be better to send the patient for a consultation rather than doing a “blind” biopsy because the histology can be very nonspecific.

CONSIDERATIONS FOR SPECIFIC ANATOMIC AREAS

Anterior Shin

The thin skin on the shin makes both excision and punch biopsy more complicated. Shave biopsy is preferred when it is a reasonable alternative.

Hands and Feet

Care must be taken when performing punch biopsies on the hands and feet because of proximity to vessels, tendons, bone, and nerves since the skin is so thin. The sensory nerves along the lateral sides of the fingers lie within reach of a biopsy punch. On the dorsum of the hand, tendons are vulnerable. When a punch biopsy is needed on the palm of the hand to distinguish between palmar psoriasis and hand dermatitis, it is best to choose an area that has sufficient soft tissue between the skin and the bones and tendons. The thenar eminence is a good choice if the rash involves this area.

Ears, Eyelids, Nose, and Lips

Shave biopsies are often preferred on the ears, eyelids, nose, and lips. If a punch biopsy is indicated, use of a 3-mm punch will avoid most problems with dog ears (see Chapter 10). On the ears it is best to avoid cutting into the cartilage unless it is necessary for the diagnosis. On the eyelids, care must be taken to avoid the conjunctival margin and the lacrimal ducts to avoid scarring that will lead to eye dysfunction. On the nose, a

FIGURE 8-32  The patient presented with hair loss of unknown etiology. Two 4-mm punch biopsies were performed. Each biopsy site was marked with a surgical marker around remaining hair follicles. It is important to give the pathologist remaining hair follicles and not completely bald scalp. (Copyright Richard P. Usatine, MD.)

shave biopsy is often preferred if the lesion is not pigmented. A large punch biopsy can distort the anatomy of the nose. On the lips, care must be taken to align the vermilion border if any sutures are used.

HOW TO SUBMIT A SPECIMEN TO THE LAB

To obtain the most accurate diagnosis from the pathologist, it is important to provide all of the relevant information on the submission form that accompanies the specimen. Drs. Boyd and Neldner12 have developed the “five D’s” mnemonic to remember the essential information to include on the requisition form:

•Description

•Demographics

•Duration

•Diameter

•Diagnosis.

Description

The physician should write a description of the appearance of the lesion. Examples of common descriptive terms include erythema, scale, pearly, raised, pigmented, ulcerating, crusted, nodular, papular, macular, vesicular, and bullous.

Demographics

The age and sex of the patient should be noted as well as travel history, ethnicity, family history, etc. Even an occupational history (gardener) or other personal history (extensive tanning bed use) can be immensely helpful.

Duration

How long a lesion has been present will help define the possible diagnoses.

Diameter

Recording the size of the lesion is especially important if the physician has not excised the entire lesion. Pigmented lesions larger than 6 mm are more likely to be melanoma. Unless recorded, the pathologist will not know the size of an incompletely excised lesion. For eruptions, one can record the distribution of the eruption.

Diagnosis

A clinician should commit to the most likely diagnosis and record it on the lab requisition. In most cases alternative diagnoses should be included. It is not expected that the diagnoses recorded will be correct all of the time; if they were, the pathologist would not be needed. However, submitting the “best guess” of the differential diagnosis may be helpful to the pathologist. It also helps

the clinician improve diagnostic acumen by obtaining the histologic feedback. Always go back to the differential diagnosis when looking at the final result. This can actually be fun.

Two additional “D’s” to consider include:

Diseases

Knowing of other significant diseases the patient has such as SLE, RA, HIV, or immune suppression can certainly aid the pathologist in discerning the nature of some lesions.

Drugs

Medications (e.g., topical steroids) can alter the appearance of a lesion or be the cause of an inflammatory change (e.g., allergy to neomycin). It is important then to note both what the patient is using/taking (if pertinent) and what may have been used to treat the lesion.

Following the “seven D’s” approach to submitting a specimen will improve communication with the pathologist and maximize the accuracy of the final histologic diagnosis.

CONCLUSION

The choice of biopsy technique can substantially affect the cosmetic result, the diagnostic information obtained, the time required to perform the procedure, and the cost. Shave, punch, curettage, incisional, and excisional biopsies each have advantages and disadvantages. (See Chapters 9, 10, and 11 for further information on these procedures.) Choosing among these biopsy techniques requires consideration of the size and morphology of the lesion in question, its anatomic location, the experience and skill of the physician, and the initial assessment of the diagnosis. It is of utmost importance that clinicians feel comfortable performing skin biopsies and, although it may not affect patient survival with a short delay between diagnostic biopsy and definitive treatment for melanoma, delaying the initial biopsy itself may have grave consequences.13

References

1.Bergfield WF, Pfenninger JL, Weinstock MA. Skin biopsy: selecting an optimal technique. Patient Care. 2001;(March 30):11.

2.Tran KT, Wright NA, Cockrell CJ. Biopsy of the pigmented lesion—when and how. J Am Acad Dermatol. 2008;59:852–871.

3.Achar S. Principles of skin biopsies for the primary care physician.

Am Fam Physician. 1996;54:2411.

4.Oppenheim EB. Failure to biopsy skin lesions prompts litigation.

Medical Malpractice Prevention. April 1990:5–6.

5.Molenkamp BG, Sluijter BJR, Oosterhof B, et al. Non-radical diagnostic biopsies do no negatively influence melanoma patient survival. Ann Surg Oncol. 2007;14(4):1424–1430.

6.Ng PCJ, Garzilai DA, Ismail SA, et al. Evaluating invasive cutaneous melanoma: Is the initial biopsy representative of the final depth? Am Acad Dermatol. 2003;48(3):420–424.

7.McGovern TW, Litaker MS. Clinical predictors of malignant pigmented lesions: a comparison of the Glasgow seven-point

checklist and the American Cancer Society’s ABCDs of pigmented lesions. J Dermatol Surg Oncol. 1992;18:22–26.

8.Lens MB, Nathan P, Bataille V. Excision margins for primary cutaneous melanoma. Updated pooled analysis of randomized controlled trials. Arch Surg. 2007;142(9):885–891.

9.NIH Consensus Conference. Diagnosis and treatment of early melanoma. JAMA. 1992;268:10, 1314–1319.

10.Greene MH, Clark WH, Tucker MA, et al. High risk of malignant melanoma in melanoma-prone families with dysplastic nevi. Ann Intern Med. 1985;102:458–465.

11.Clark WH Jr. The dysplastic nevus syndrome. Arch Dermatol. 1988;124:1207–1210.

12.Boyd A, Neldner K. How to submit a specimen for cutaneous pathology analysis. Arch Fam Med. 1997;(6):64–66.

13.McKenna DB, Lee RJ, Prescott RJ, Doherty VR. The time from diagnostic excision biopsy to wide local excision for primary cutaneous malignant melanoma may not affect patient survival. Br J Dermatol. 2002;147(2):48–54.

Additional Reading

Garcia C. Skin biopsy techniques (Chap 14). In: Robinson JK, Hanks CW, Sengelmann RD, Siegel DM, eds. Surgery of the Skin. Philadelphia: Mosby/Elsevier; 2005.

Habif TP. Dermatologic surgical procedures (Chap 27). In: Clinical Dermatology, A Color Guide to Diagnosis and Therapy. 4th ed. Philadelphia: Mosby/Elsevier; 2004.

Pfenninger JL. Skin biopsy (Chap 32). In: Pfenninger JL, Fowler GC, eds. Pfenninger and Fowler’s Procedures for Primary Care. Philadelphia: Mosby/Elsevier; 2011.

Videos

Pfenninger JL. How to Perform Skin Biopsy: A Guide for Clinicians. Creative Health Communications, www. creativehealthcommunications.com; 2005. Also available through the National Procedures Institute, www.npinstitute.com.

Pfenninger JL. Common Office Dermatologic Procedures. Creative Health Communications, www.creativehealthcommunications. com; 2005. Also available through the National Procedures Institute, www.npinstitute.com.

9 The Shave Biopsy

RICHARD P. USATINE, MD

The shave biopsy is one of the most useful approaches for obtaining tissue for diagnostic purposes and for the removal of benign surface neoplasms. It is especially fast, easy, and effective when the lesion is raised above the skin surface. The shave biopsy is also valuable for diagnosing many cutaneous malignancies, including basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs). It is also an effective tool for removing benign lesions such as intradermal nevi and seborrheic keratoses. After a shave biopsy, hemostasis is easily obtained with aluminum chloride. The surface is allowed to heal naturally, and no sutures are needed. The excision site usually heals well with a good cosmetic result.

INDICATIONS

The following lesions are among those that are frequently diagnosed by shave biopsy:

•BCC (Figure 9-1)

•SCC (Figure 9-2)

•Keratoacanthoma (KA) (Figure 9-3)

•Dysplastic nevus (Figure 9-4).

Shave excision can also be used to remove the following benign lesions:

•Benign melanocytic nevus

•Seborrheic keratosis (Figure 9-5)

•Sebaceous hyperplasia

•Pyogenic granuloma (PG) (Figure 9-6)

•Skin tag with a broad base

•Single large wart

•Neurofibroma.

When a pigmented lesion appears to be benign and its removal is for cosmetic reasons, it is acceptable to use a shave excision. However, it is essential to send biopsies of all potentially suspicious lesions for review by a pathologist. A typical skin tag does not need to be sent to pathology.

CONTRAINDICATIONS

There are no contraindications for shave biopsy based on location of the lesion. The use of a shave biopsy to diagnose a melanoma is controversial with a wide range of opinions. A superficial shave biopsy of a suspected melanoma runs the risk of losing important depth information used for staging and margin determination. However, if the melanoma is thin and the shave biopsy gets below the tumor, then nothing is lost. On the other

hand, if a punch biopsy is performed of a large lesion and the punch misses the area with melanoma, this false-negative result can lead to missing the diagnosis of the melanoma. Although doing a complete fullthickness biopsy of a small suspected melanoma is optimal, this may be too deforming for a large superficial pigmented lesion on the face that might possibly be lentigo maligna melanoma (LMM) but appears more consistent with a solar lentigo (Figure 9-7). A broad scoop shave biopsy of LMM (Figure 9-8) may give a better tissue sample than one or more punch biopsies and will not cause the cosmetic deformities of a large full-thickness biopsy. It is also common practice to use a broad scoop shave to remove an atypical mole suspected of being a dysplastic nevus.

In reality, the biopsy type is based on suspected diagnosis, size, location, patient preferences, and time considerations. It is better to diagnose a melanoma by shave biopsy than to lose a patient with melanoma to follow-up because you did not have the time to do an elliptical biopsy.

ADVANTAGES OF A SHAVE BIOPSY

The advantages of a shave biopsy can be broken down into two categories: those that are related to the clinician and those that are related to the patient. Advantages of a shave biopsy for the clinician include the following:

•Can be performed rapidly.

•Sutures are not needed.

•Procedure is relatively easy to learn.

•Multiple lesions can be easily excised at one time.

•An assistant is not required.

•Strict sterile procedure is not required.

The following advantages of a shave biopsy benefit the patient:

•There are no sutures that need to be removed.

•Wound care is usually simple.

•Restriction of activities is not needed during wound healing.

•The risks of infection and bleeding are reduced.

•It may give a better cosmetic result than a fullthickness excision.

•Even if a change in pigmentation occurs, it is easily covered by cosmetics.

A number of studies have shown the shave biopsy to produce a better cosmetic result than the punch biopsy and the fusiform diagnostic excision.1–3

FIGURE 9-1  Elevated pearly lesion in the nasolabial fold with telangiectasias. A shave biopsy is performed to rule out a BCC. (Copyright Richard P. Usatine, MD.)

FIGURE 9-3  A keratoacanthoma on face is appropriate for a shave biopsy. (Copyright Richard P. Usatine, MD.)

FIGURE 9-4  Dysplastic nevus can be shaved with a deep shave for diagnosis and treatment. (Copyright Richard P. Usatine, MD.)

FIGURE 9-2  Shave biopsy of SCC on the lip. (Copyright Richard P. Usatine, MD.)

FIGURE 9-5  Shave excision of a verrucous-appearing seborrheic keratosis on the forehead. (Copyright Richard P. Usatine, MD.)