Punch and Shave Biopsy For General Practitioners

tomaotes

 

This is content reproduced from the Women in General Practice Conference 2014

Session was run by a Vulvo-gynae/General dermatologist and  Sexual Health Physician

It is intended for Registered Medical Practitioners Only.

This post relates specifically to Vulval Shave and biopsy but the techniques can be widely applied.

When to Biopsy?

1. When in  doubt!

  • if not responding to treatment
  • To exclude VIN Previously called Bowens Info here  ( if untreated 15% will transform into invasive SCC Vulval Cancer ) and other rare differential diagnoses eg Extra Mammary Paget

2.  To confirm a suspected diagnosis that has long term implications

3. For patient s reassurance eg:

Labial Melanosis  Link to Picture

Skin Tag

Seborrheic Keratosis

TYpes of Biopsy

1. Punch Biopsy       

dermal-punch-tool

Recommend

4mm punch biopsy Ideal

4/0 vicryl or chromic dissolving suture   DO NOT USE NYLON ON THE VULVA TOO IRRITATING

Can use silk but will need to remove suture

Advantages  full thickness skin submitted to Pathology

Disadvantages Potential for sampling error.  Ulcers – do the active edge not the center.

2. Shave Biopsy

15 scalpel blade OR

Rectangular flexible blade

Swan-15-300        OR     shave biopsy

ADVANTAGES OF SHAVE BIOPSY

Can obtain a larger surface area compared to punch biopsy

Useful for labial melanosis, removal of seborrheic keratosis or large naevi

DISADVANTAGE

Superficial; limited dermis submitted for pathology, slower healing time

 

Special TIPS from Author.  

  • For labial shave biopsy you will need a nurse assistant and plenty of room
  • Use the 15 scalpel blade without a handle which gives better control
  • The curve of the shave blade can be altered to suit the size of the lesion
  • Will need steady hands for the latter
  • Practice on the thicker skinned roma tomato

3. SNIP BIOPSY

Forceps and fine sharp scissors

useful for pedunculated or protruding lesions eg Mollusca, skin tags, warts

ADVANTAGE

Quick and easy, removes the bulk of the lesion, and rapid healing.

4. EXCISIONAL BIOPSY

Formal excision of entire lesion; defect closed with sutures

ADVANTAGE Entire lesion with margin of normal tissue submitted for pathology

DISADVANTAGE More down time for patient


STEP BY STEP INSTRUCTIONS

 

1.  Identify area to biopsy

AVOID IMMEDIATE PERIANAL AND CLITORAL SKIN IF POSSIBLE as well as obvious vasculature

2. Mark site with marking pen ( does not apply to vulva mucosa)

3. With consent photograph lesion or biopsy site for later reference if further surgery required

Nurse to assist

5. Chlorhexidine prep to skin

6 Local Anesthetic infiltration eg 1% Xylocaine with adrenaline and 30G insulin syringe

7. BIOPSY

(a) 4mm punch biopsy can leave or 4/0 vicryl suture ( or chromic monocryl silk)

2 Minute Youtube Demonstration UQ.

AUTHORS TIPS

Note Swivel the punch biopsy and don’t push the instrument in.

If the specimen gets left inside the punch biopsy tube use a fine needle to dislodge

Try not to damage the skin architecture with this method of  needle removal.

 

(b) Shave biopsy DRICLOR (20% aluminium chloride hexahydrate) applied with cotton tip for haemostasis.

 

2 minute You Tube Shave Biopsy but With caveats

Authors Tips

DO NOT USE A MULTI VIAL ANESTHETIC AGENT  !!!!!!!!!!!! (EVER!!!!)

DO NOT USE TOPICAL ANTIBIOTIC OINTMENT!!!

For the vulval region you will need an assistant to stretch and tent the skin for you

The shave biopsy blade is very very sharp and Dermatologist  indicated it is very easy to cut yourself even with experience

Practice on a tomato

Consider using the flat 15 blade if this is more familiar to you.

8. Submit specimen for Pathology

(a) Formalin pot for Histology

(b) Fresh specimen on saline soaked guaze for direct Immuno florescence if suspicious of immmunobullous disorders

9. Sanitary Pad

10 After Care instructions = Daily showers (wash area with water only) or Saline Sitz baths

As with all procedures operated within your comfort zone.

Know and work within your limitations

Practice on the Roma Tomato.

 

One thought on “Punch and Shave Biopsy For General Practitioners

  1. Reblogged this on FOAM4GP and commented:
    Thanks to Karen Price who has shed some light on the mysterious arts of vulval biopsy from what sounds like a very valuable session at the Women In GP conference last week. Some very handy tips here!

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