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
TYpes of Biopsy
1. Punch Biopsy
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
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
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
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
4 Nurse to assist
5. Chlorhexidine prep to skin
6 Local Anesthetic infiltration eg 1% Xylocaine with adrenaline and 30G insulin syringe
(a) 4mm punch biopsy can leave or 4/0 vicryl suture ( or chromic monocryl silk)
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.
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.