boards fodder

Biopsy techniques
by Jen Seyffert, DO, and Puja Kathrotiya, MD

Disease H&E DIF Comments

Transport: Transport: Culture: Non-
Formalin Normal saline, bacteriostatic saline
Michel, Zeus, or EM: 2.5% glutaraldehyde
LN2 solution
Flow cytometry: fresh
specimen on saline
soaked gauze or RPMI
medium
Autoimmune Saucerized intact Perilesional skin Avoid lower extremities.
bullous disease bulla, OR <1cm from bulla Trunk skin is preferred.
Broad sauceriza- Saline is superior to other
tion of peripheral DIF transport mediums if
bulla delivered to lab within 48
hours.
Epidermolysis Saucerized intact Avoid blisters >12hrs old.
bullosa bulla, OR Can induce fresh blister
Broad sauceriza- on nearby clinically unin-
tion of peripheral volved skin
bulla

Vasculitis Punch or deep Punch or deep Specimens should show

shave of lesion shave of acute both post capillary venule
>72hrs old lesion<24hrs old and deep plexus

Panniculitis Deep incisional 6mm punch is the small-

biopsy at edge of est size that can be divided
necrotic focus for culture and H&E.

Jen Seyffert, Lupus >4mm Punch Punch biopsy of

DO, is a PGY-3 at biopsy of lesion lesion >6 months
KCUMB-Advanced >6 months old old that is still
that is still active active
Dermatology and
Cosmetic Surgery
Dermatology
Residency of Dermatomyositis >4mm Punch Punch biopsy of
Orlando. biopsy of lesion lesion >6 months
>6 months old old that is still
that is still active active

SJS/TEN/SSSS Shave or punch Can submit desquamating

biopsy of acute sheets
lesion including
full thickness of
epidermis

Scarring Two >4mm >4mm punch Two biopsies: 1 for verti-

Alopecia punch biopsies biopsy of a lesion cal and one for horizontal
of a lesions >6 >6 months old sectioning.
Puja Kathrotiya, months old that that is still active Avoid active advancing
MD, is an attending are still active border
physician at Place punch at same angle
as emerging hairs
KCUMB-Advanced
Dermatology and Pattern Alopecia Two >4mm Two biopsies: 1 for verti-
Cosmetic Surgery or Telogen punch biopsies cal and one for horizontal
Effluvium from an estab- sectioning.
Dermatology lished area of Submit transverse section
Residency of alopecia or intact specimen for lab
Orlando. to section with HoVert or
Tyler techniques

p. 4 • Winter 2018 www.aad.org/DIR

 boards fodder
Biopsy techniques (continued)
by Jen Seyffert, DO, and Puja Kathrotiya, MD

Disease H&E DIF Comments

Boards
Transport:
Formalin
Transport:
Normal saline,
Culture: Non-
bacteriostatic saline
Fodders
Michel, Zeus, or
LN2
EM: 2.5% glutaraldehyde
solution online!
Flow cytometry: fresh
specimen on saline
soaked gauze or RPMI
medium
Alopecia Areata Two >4mm Two biopsies: 1 for verti-
or Syphilis punch biopsies cal and one for horizontal
of active lesions sectioning.
with recent onset Submit intact
In addition to this
issue’s Boards Fodder,
you can download
the new online
NMSC Shave or punch Use more superficial shave Boards Fodder at
biopsy with techniques on convex sites
enough depth or thin facial skin
www.aad.org/
to demonstrate Directions.
invasive pattern
and detect peri- Go online for two
neural invasion
new special Boards
Suspected Complete exci- Saucerization is acceptable Fodder exclusives,
Melanoma sional removal Consider scoring or tag-
ging at 12 o’clock for
Cysts and
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Agnetta Vlatka, MD.

To view, download,
or print every Boards
Fodder ever
published, check out
DFSP Deep incisional
the archives at
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boardsfodder.

CTCL Broad shave Broad shaves are superior

biopsy below the to punch biopsies
depth of DEJ Consider sending speci-
mens from multiple ana- Ready to pay
tomic sites
it forward?
Primary Deep incisional Punch biopsy or sauceriza-
Cutaneous biopsy tion are superior to shave
B-Cell biopsies
Lymphoma

Nail Matrix Punch biopsy or Total or partial nail plate

horizontal distal avulsion is usually done
matrix elliptical prior to nail matrix biopsy.
excision with Punch biopsy <3mm does
Vicryl closure not need sutured closure Ready to pay it
forward? You can
Nail Bed Punch biopsy Nail plate avulsion is usu-
help future residents
or longitudinal ally done prior to nail bed by helping the AAD
elliptical exci- biopsy, but is not neces- ensure access to
sion with Vicryl sary resident education.
closure
It’s important.
See why at
1. Bolognia, Jean L., Jorizzo, Joseph L., Schaffer J V. Dermatology. Third. Elsevier; 2012.
www.aad.org/
2. Elston DM, Stratman EJ, Miller SJ. CONTINUING MEDICAL EDUCATION Skin biopsy Biopsy issues in specific diseases. J Am Dermatology. 2016;74:1-16. Resident
doi:10.1016/j.jaad.2015.06.033 EducationGrant
A Publication of the American Academy of Dermatology | Association Winter 2018 • p. 5