Biopsy, Skin

Biopsy, Skin

Synonym/acronym: N/A.

Common use

To assist in diagnosing skin cancer.

Specimen

Skin tissue or cells.

Normal findings

(Method: Macroscopic and microscopic examination of tissue) No abnormal tissue or cells.

Description

Skin biopsy is the excision of a tissue sample from suspicious skin lesions. The microscopic analysis can determine cell morphology and the presence of tissue abnormalities. This test assists in confirming the diagnosis of malignant or benign skin lesions. A skin biopsy can be obtained by any of these four methods: curettage, shaving, excision, or punch. A Tzanck smear may be prepared from vesicles (blisters) present on the skin. Skin cells in the vesicles can be evaluated microscopically to indicate the presence of certain viruses, especially herpes, that cause cells to become enlarged and otherwise abnormal in appearance.

This procedure is contraindicated for

  • high alertPatients with bleeding disorders (related to the potential for prolonged bleeding from the biopsy site)

Indications

  • Assist in the diagnosis of keratoses, warts, moles, keloids, fibromas, cysts, or inflamed lesions
  • Assist in the diagnosis of inflammatory process of the skin, especially herpes infection
  • Assist in the diagnosis of skin cancer
  • Evaluate suspicious skin lesions

Potential diagnosis

Abnormal findings related to

  • Basal cell carcinoma
  • Cysts
  • Dermatitis
  • Dermatofibroma
  • Keloids
  • Malignant melanoma
  • Neurofibroma
  • Pemphigus
  • Pigmented nevi
  • Seborrheic keratosis
  • Skin involvement in systemic lupus erythematosus, discoid lupus erythematosus, and scleroderma
  • Squamous cell carcinoma
  • Viral infection (herpes, varicella)
  • Warts

Critical findings

  • Assessment of clear margins after tissue excision
  • Classification or grading of tumor
  • Identification of malignancy

  • It is essential that critical findings be communicated immediately to the requesting health-care provider (HCP). A listing of these findings varies among facilities.

  • Timely notification of a critical finding for lab or diagnostic studies is a role expectation of the professional nurse. The notification processes will vary among facilities. Upon receipt of the critical finding the information should be read back to the caller to verify accuracy. Most policies require immediate notification of the primary HCP, hospitalist, or on-call HCP. Reported information includes the patient’s name, unique identifiers, critical finding, name of the person giving the report, and name of the person receiving the report. Documentation of notification should be made in the medical record with the name of the HCP notified, time and date of notification, and any orders received. Any delay in a timely report of a critical finding may require completion of a notification form with review by Risk Management.

Interfering factors

  • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in establishing a diagnosis of skin disease.
  • Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex or anesthetics.
  • Obtain a history of the patient’s immune and musculoskeletal systems, any bleeding disorders or other symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Note any recent procedures that can interfere with test results.
  • Obtain a list of the patient’s current medications including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure.
  • Review the procedure with the patient. Inform the patient that it may be necessary to remove hair from the site before the procedure. Instruct that prophylactic antibiotics may be administered before the procedure. Address concerns about pain and explain that a sedative and/or analgesia will be administered before the punch biopsy to promote relaxation and reduce discomfort. Explain that any discomfort will be minimized with local anesthetics and systemic analgesics. Inform the patient the biopsy is performed under sterile conditions by an HCP, with support staff, specializing in this procedure. The procedure usually takes about 20 min to complete, and sutures may be necessary to close the site.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids, anesthetics, or sedatives, depending on the type of biopsy.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.

Intratest

  • Potential complications:

  • Bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners) or seeding of the biopsy tract with tumor cells

  • Ensure that the patient has complied with dietary restrictions if ordered by the HCP.
  • Ensure that anticoagulant therapy has been withheld for the appropriate number of days prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Notify the HCP if patient anticoagulant therapy has not been withheld.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Have the patient void before the procedure.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen containers with the corresponding patient demographics, initials of the person collecting the specimen, date and time of collection, and site location.
  • Assist the patient to the desired position depending on the test site to be used, and direct the patient to breathe normally during the local anesthetic and the procedure. Instruct the patient to cooperate fully, follow directions, and avoid unnecessary movement.
  • Record baseline vital signs, and continue to monitor throughout the procedure. Protocols may vary among facilities.
  • After the administration of local anesthesia, use clippers to remove hair from the site if appropriate, cleanse the site with an antiseptic solution, and drape the area with sterile towels.

    • Curettage

  • The skin is scraped with a curette to obtain specimen.

    • Shaving or Excision

  • A scalpel is used to remove a portion of the lesion that protrudes above the epidermis. If the lesion is to be excised, the incision is made as wide and as deep as needed to ensure that the entire lesion is removed. Bleeding is controlled with external pressure to the site. Large wounds are closed with sutures. An adhesive bandage is applied when excision is complete.

    • Punch Biopsy

  • A small, round punch about 4 to 6 mm in diameter is rotated into the skin to the desired depth. The cylinder of skin is pulled upward with forceps and separated at its base with a scalpel or scissors. If needed, sutures are applied. A sterile dressing is applied over the site.
  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis).
  • Place tissue samples in properly labeled specimen container containing formalin solution, and promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Monitor temperature every 4 hr for 24 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Observe/assess for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Observe/assess the biopsy site for bleeding, inflammation, or hematoma formation.
  • Instruct the patient in the care and assessment of the site.
  • Instruct the patient to report any redness, edema, bleeding, or pain at the biopsy site.
  • Assess for nausea and pain. Administer antiemetic and analgesic medications as needed and as directed by the HCP.
  • Administer antibiotic therapy if ordered. Remind the patient of the importance of completing the entire course of antibiotic therapy, even if signs and symptoms disappear before completion of therapy.
  • Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Provide contact information, if desired, for the American Cancer Society (www.cancer.org). Educate the patient regarding access to counseling services.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Inform the patient of a follow-up appointment for the removal of sutures, if indicated. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage him or her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. DNA testing for mutations in the CDKN2A, CDK4, or BRAF V600 genes may be requested to identify those at high risk for developing cutaneous melanoma. The test for TA90 (melanoma-associated antigen) is used to evaluate the status of postoperative patients who have had localized areas of melanoma removed. Methods for these genetic markers include microarray, reverse transcriptase polymerase chain reaction (RT-PCR), and enzyme—linked immunosorbent assay (ELISA). Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include allergen-specific IgE, ANA, culture skin, eosinophil count, ESR, and IgE.
  • Refer to the Immune and Musculoskeletal systems tables at the end of the book for related tests by body system.