Punch Biopsy

Indications/Contraindications

Indications: Obtain skin sample for diagnostic testing (small melanocytic lesion, rash, blister, hair loss), excision for curative purposes, deep tissue culture

Contraindications: Significant coagulopathy (relative), allergy to materials/anesthetics

Materials and where to find them:

Most supplies can be found in Clean Utility Room (Code 888). For locked drawers/cabinet, use key located in drawer labelled “pens scissors tape” (located above drawer D).

Supply Quantity Where to find
10cc syringe 1 Bins
18g needle (pink) 1 Bins
25g needle (blue) 1 Bins
Chlorhexidine 2 Bins
Lidocaine 1% w/ epi 1 vial use key with yellow dot to open drawer with yellow dot
Skin marker 1 ask MA
Sterile gloves 1 Bins
Sterile towel 1 Bins
Punch biopsy (3mm, 4mm, or 6mm) 1 Bins
Forceps (without teeth) 1 Bins
Scissors 1 Bins
10% buffered formalin (red cap) # of samples Soiled utility room
Gauze 1-2 In patient room
Sutures (4-0 or 5-0, nonabsorbable or absorbable) 1 drawer next to drawer labelled “D”
Band aid 1 Bins

Labs to order:

  • Pathology, surgical (Try to include the 6 D’s of demographics, description, diseases/drugs, duration of condition, diameter of lesion or eruption, and diagnoses (in order of likelihood)

Punch biopsy steps:

  1. Obtain patient consent
  2. Meds:
    1. With one of the 10cc syringe and an 18g needle, draw up 4cc of 1% lidocaine with epi
  3. Remove 18g needles (and dispose in sharps container)
  4. Patient Positioning: Make the patient comfortable while also providing easy access to lesion
  5. Use skin marker to circle lesion (with 1-3mm borders)
  6. Prepare site with chlorhexidine x1
  7. Set up sterile tray (place sterile towel onto field, drop tools onto tray).
  8. Attach the 25g needle to your lidocaine syringe
  9. Administer lidocaine wheal at site of lesion
  10. (optional) Re-clean site with chlorhexidine x1
  11. Put on sterile gloves
  12. Perform biopsy
    1. Determine direction of skin lines
    2. Stabilize skin with thumb and forefinger, streching skin perpendicular to skin lines to create ellipse
    3. With punch biopsy, apply firm downward pressure, circular motion until reaching sub-Q fat
    4. Gently elevate lesion with forceps (DO NOT crush skin), cut with scissors at base
    5. Place sample into formalin cup, place patient label, write in location of lesion
    6. Repeat for additional lesions
  13. Apply pressure with gauze for hemostasis
  14. If 4mm punch or smaller, can consider aluminum chloride, gel foam, or steri strips
  15. If larger punch, place interrupted sutures for closure (perpendicular to skin lines)

What to do in Epic:

  • Under med/orders, enter skin biopsy first lesion (aka punch biopsy) (code 11100)
  • If applicable, enter skin bx ea addtl lesion (code 11101)
  • If problem focused visit + procedure:
    • Enter normal encounter level (e.g. E3)
    • Under modifiers, type “25”
  • If just a procedure visit:
    • Bill as procedure for visit type