Guide on skin biopsy in inflammatory cutaneous diseases

Mikhail Valivach, MD,Head of cytomorphology division.

Pavlodar Regional Diagnostic Center2015

• Punch biopsy is performed using a circular blade attached to a pencil-like handle.

• Punch diameters can be from 2 to 6 mm.

• Four mm punches are appropriate in most cases of skin biopsy.

Punch

Choice of appropriate time• Many of skin lesions have rapid dynamics.• It is supposed that during first 18 hours since

lesion onset inflammatory changes have not fully developed already.

• Changes reach maximum in 24-36 hours.• In 48-72 hours primary inflammatory infiltrate

can dramatically change (for example, lymphocytes and histiocytes can come instead of neutrophils), and deposited immune complexes can be destroyed by complement.

Choice of appropriate time

• The age of 24-36 hours is optimal for biopsy of inflammatoty lesions!!!

• If this is not possible, then pathologist should choose the most appropriate lesion.

Selection of biopsy area

• Bullous lesions

• Biopsy of the edge of lesion. Even better to make biopsy of erythema before development of bulla.

Selection of biopsy areaBullous lesions

Selection of biopsy areaBullous lesions

Selection of biopsy areaBullous lesions

Selection of biopsy areaDermatitis herpetiformis

• Normally looking skin in 3 mm from a vesicle.

• Better to make 2-3 biopsies.

Selection of biopsy areaDermatitis herpetiformis

Selection of biopsy areaDermatitis herpetiformis

Selection of biopsy areaDermatitis herpetiformis

Selection of biopsy areaPorphyria and pseudoporphiria

• The edge of a fresh vesicle (bulla).

Selection of biopsy areaPorphyria and pseudoporphyria

Selection of biopsy areaPorphyria and pseudoporphyria

Selection of biopsy areaPorphyria and pseudoporphyria

Selection of biopsy areaSuspected lupus erythematosus or

dermatomyositis• Edge of an erythematous lesion. Fresh

elements are preferable. • It is better to take additionally normally

looking skin. • If you want to reveal “lupus band”, you can

expose skin to suberythematous dose of ultraviolet and perform biopsy in 24 hours.

Selection of biopsy areaSuspected lupus erythematosus

Selection of biopsy areaSuspected lupus erythematosus

Selection of biopsy areaSuspected lupus erythematosus

Selection of biopsy areaSuspected lupus erythematosus

Selection of biopsy areaSuspected dermatomyositis

Selection of biopsy areaSuspected dermatomyositis

Selection of biopsy areaSuspected dermatomyositis

Selection of biopsy areaSuspected vasculitis

• Biopsy of a fresh element aged from 16 to 32 hours.

• It is better to take additionally normally looking skin.

• Selection of biopsy area has a critical significance for subsequent histological and immunofluorescent tests. It is better to select the area together with pathologist.

Selection of biopsy areaSuspected vasculitis

Selection of biopsy areaSuspected vasculitis

Selection of biopsy areaSuspected vasculitis

• We also recommend you to read the article Punch Biopsy of the Skin. THOMAS J. ZUBER, M.D. Am Fam Physician.  2002 Mar 15;65(6):1155-1158.

• The article is available online http://www.aafp.org/afp/2002/0315/p1155.html

• Video on punch biopsy technique is available in youtube.com use key words the punch biopsy dermeducation

• Dear colleagues, with questions and suggestions you can address to Mikhail Valivach valivach@mail.ru

• Thank you for your attention!