Differential Diagnosis for Skin Conditions

Section One

Dermatological Procedures

Chapter I Punch Biopsy

Margaret R. Colyar

CPT Code 21550 Biopsy of soft t issue of neck or thorax 21920 Biopsy of soft tissue of back or flank, superficial 23066 Biopsy of soft tissue of shoulder; superficial 24065 Biopsy of upper arm and elbow area 23066 Biopsy of soft tissue of forearm or wrist. superficial 27040 Biopsy of soft tissue of pelvis and hip area 27323 Biopsy of soft tissue of pelvis and hip area 27613 Biopsy of soft tissue of leg and ankle area 11 I 00 Skin lesion-Depends on the srte, technique, and if benign

or malignant lesions

Biopsy is th e re moval of a small piece of tissue from the skin for m icroscopic exami­ nation. Partial or full thickness of skin over the lesion is removed for evaluation.

OVERVIEW Punch biopsy is used for full and partial dermal lesions such as • Basal cell carcinoma • Squamous cell carcinoma • Actinic lceratoses • Sebonheic keratoses • Lcntigo (freckles) • Lipomas • Melanomas • Nevi • W:1rts- vcrruca vulgaris

i<ATIONALE • 'th co11!hm cti<)logy ollcsion for ll'C11t mcnt • '111 {"ll ahlJ.~h 01· conflr1n n d l .tf11HlS.I~ fo r 1Jr.t1'1111•111 nnd/or itHcrvention

2 3 Section One I Dermatological Procedures

INDICATIONS

• Partial- or full-dermal-thickness lesion no t on the face, eye, lip, or pen is

CONTRAINDICATIONS

• Lesion on eyelid, lip, or penis, REFER ro a physician. • Infection at the site of the biopsy • Bleeding disorder • Lesions that are deep or on the face, REFER to a physician. t !11farmecl consent required

PROCEDURE

Punch Biopsy Equipment

• Antiseptic skin cleanser • Drape-sterile • G loves-sterile • Disposable biopsy punch (Fig. 1.1 ) • Pickups-sterile • Scissors-sharp for the fine tissue-sterile • 3-mL syringe • 27- to 30-gauge, Y2-inch needle • 1% lidocaine • Container with 10% formalin • 4 x 4 gauze

Figure I. I Dl ~f li l~1d th itlllJ!.~Y p1lllclws.

Chapter 1 I Punch Biopsy

• Nonstick dressing (Adaptic or Telfa) • Kl ing • Tape • Steri-Strips (if bio psy w ill be greater than 4 mm) or one suture

Procedure

• Position th e client so thac th e area to be biopsied is easily accessi ble. • C leanse th e skin w ith antiseptic skin cleanser. • Puc on gloves. • Drape the area ro be biopsied. • Anesth etize w ich 1% lidocaine. • W ith the thumb and index finger, spread the skin to apply tens ion opposite

natu ral skin tension lines. This allows a more elliptical-shaped wou nd for easy closure.

• Apply biopsy punch to skin, rotate per manufacturer's directions, and remove tfo:; punch (Fig. 1.2).

• Wi th pickups, pull up loosened skin. • C ut with scissors, and place tissue in tissue container of 10% formalin

(Fig. 1.3). • If k ss chan 2 to 3 mm , ap ply nonstick dressing and pressure dressing. • Ir greater than 4 mm , apply Steri-Srrips and cover with 4 x 4 gauze. • /\ppl y IUing and secure w ith tape.

Client Instructions

• l«.:q) dressing clean, dry, and in place fo r 48 hours to decrease the chance of I>!ced ing and oozing.

• /\ void rouching or contaminating the area biopsied. • ' I(1 prevent the chance of infection, take cephalexin (Keflex) 500 mg three times

11t·1· day or amoxicillin (Amoxil) 500 mg twice a day for 5 days.

- (

I I

I

,._'¥,,) Flg1w~ 1.l Appl)1 hlo1)·~Y pt 111 d1 w skin a11d 1·01 n1u,

4 Section One I D ermacological Procedures

Figure I .l C ut with scissors.

• Some redness, swelling, and heat are normal. Return co the office if symptoms

of infection occur, such as Yellow or green d ra inage

• Red streaks • Pain • Elevated temperature

• Take acetaminophen (Tylenol) or ibuprofe n (Motrin) every 4 to 6 hours as

needed for pain.

BIBLIOGRAPHY c;;;;;;;;;;;:======...::::......; De Vries HJ, Zeegelaar JE, Middelkoop E, et al. Reduced wound comracrion and scar

formation in punch biopsy wo unds. Native collagen dermal substitutes. A clinical study. Br ] Dermatol. 1995;132(5):690-697.

Zuber TJ. Ingrown toenail removal. Am Fam Physician. 2002;65(1 2) :2547-2550.