1. Restrain and position patient.

2. Choose site for biopsy.

a. For suspected malignant lesions, choose more atypical areas if unable to excise completely.

b. For large or chronic lesions, obtain specimen from

periphery, including some normal skin.

c. For most dermatoses, choose site of early or fully

developed, but not end-stage, lesion.

d. For acute eruptions and bullous disease, choose an

early lesion, including some normal skin.

e. For discrete small lesions, try to leave 1- to 2-mm

margins of normal skin around the lesions.

f. Avoid excoriated, crusted, or traumatized lesions.

3. Shave hairs, if necessary.

4. Prepare as for minor procedure (see Chapter 5).

5. Inject 0.25 to 0.5 mL of lidocaine (with/without epinephrine) intradermally beneath the lesion. Some techniques

used to minimize pain include: use of a small-bore

(30-gauge) needle, buffering anesthetic with sodium

bicarbonate, pinching of the site during injection, and

applying ice (25–27).

6. Wait 5 minutes for maximal anesthesia. If using lidocaine with epinephrine, maximal vasoconstriction

occurs at 15 minutes.

7. Stretch skin surrounding lesion taut, perpendicular to

relaxed skin tension lines.

8. Carefully place punch over the lesion and twist in

rotary back-and-forth cutting motion until subcutaneous fat is obtained. Biopsy should include epidermis,

full thickness of dermis, and some subcutaneous fat.

9. Remove punch.

10. Use blunt forceps in one hand to grasp the lateral edge

of the biopsy specimen and elevate it, utilizing care to

avoid crush artifact.

11. Use scalpel blade or scissors in the other hand to cut

the punch specimen at its base, as deep into the subcutaneous fat tissue as possible.

12. Place specimen in container with appropriate preservative or transport medium.

13. Label container with patient name, date, and exact site

of biopsy.

14. Control bleeding at site of biopsy with gentle pressure

using sterile 4- × 4-inch gauze square.

15. Approximate wound margins and apply Dermabond.

No further care is required.

16. If suture or Steri-Strips are placed, leave on for 5 days

on face and for 12 days on trunk, limbs, or scalp.

17. Although not recommended by the author, some practitioners allow the wound to heal by secondary intention. If no suture is placed, expect healing by primary

epithelialization in 7 to 14 days, with a residual white

Fig. 23.1. Punch skin biopsy. Top (inset): Disposable biopsy

punch. Bottom (inset): Cutting the dermal pedicle.

Transport Medium Indications

Formalin 10% Routine microscopic evaluation

Michel’s Medium or

Saline-soaked gauze

Blistering or autoimmune disorders (immunofluorence)

Electron microscopy

Immunoperoxidase

Table 23.1 Punch Biopsy Preservatives and

Transport Media

Chapter 23 ■ Punch Skin Biopsy 129

area a few millimeters in diameter if the biopsy

extended to the dermis–subcutaneous fat interface.

H. Complications (6)

1. Infection

2. Unsightly scarring or keloid formation (rare)

3. Excessive bleeding (rare, except in patient with coagulation defect)

4. Pathologic uncertainty

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