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ctas Dermosifiliogr. 2012;103(1):12---20

RACTICAL DERMATOLOGY

asic Concepts in Skin Biopsy. Part I�

. Llamas-Velasco,a,∗ B.E. Paredesb

Departamento de Dermatología, Hospital Universitario de La Princesa, Madrid, SpainDermatopathologie Friedrichshafen, Friedrichshafen, Germany

eceived 13 February 2011; accepted 8 May 2011vailable online 27 March 2012

KEYWORDSSkin biopsy;Pathology;Dermatopathology;Histologicalpreparation;Technique;Surgical complication

Abstract The aim of these reviews is to describe the reasons for performing skin biopsy, toprovide indications for the choice of area to be biopsied and the preparation of the sample, andto summarize the various complications of dermatologic surgery. In addition, we present a guidefor selecting the biopsy technique based on the suspected diagnosis and on the area to be biop-sied. Finally, the various artifacts that can complicate interpretation of results are described,together with the methods used to prevent their appearance insofar as is possible. The aim ofthis guide is to improve the diagnostic yield of biopsies and to highlight the importance of acorrect clinical---histological correlation.© 2011 Elsevier España, S.L. and AEDV. All rights reserved.

PALABRAS CLAVEBiopsia cutánea;Anatomía patológica;Dermatopatología;Preparaciónhistocitológica;Técnica;

La biopsia cutánea: bases fundamentales. Parte I

Resumen En estas revisiones se pretende abarcar las diversas funciones de la biopsia cutánea,ciertas nociones básicas acerca de la elección del área a biopsiar y de la forma de procesar lamuestra, así como las diversas complicaciones de la cirugía dermatológica de una manera breve.Además, se ofrece una guía del método a elegir para la realización de la biopsia en función tantodel diagnóstico de sospecha, como de algunas localizaciones que ofrecen mayores dificultades.

Complicaciónquirúrgica

Por último se analizan diversos artefactos que pueden dificultar la interpretación de las lesionesofreciendo pautas para evitarlos en lo posible. Con esta guía básica pretendemos mejorar larentabilidad de la biopsia y resaltar la importancia de realizar una correcta correlación clínico-histológica.

. y A

© 2011 Elsevier España, S.L

� Please cite this article as. Llamas-Velasco M. Paredes BE. La biopsia c012;103:12-20.∗ Corresponding author.

E-mail address: mar.llamasvelasco@gmail.com (M. Llamas-Velasco).

578-2190/$ – see front matter © 2011 Elsevier España, S.L. and AEDV. A

EDV. Todos los derechos reservados.

utánea: bases fundamentales. Parte I. Actas Dermosifiliogr.

ll rights reserved.

13

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Basic Concepts in Skin Biopsy. Part I

Introduction

The skin is easy to examine clinically and it is also easilyaccessible for carrying out small surgical procedures, whichmust nonetheless be done thoughtfully, not mechanically.1

Biopsy procedures are a key step in medical diagnosis,particularly in dermatology because valuable histopatho-logic information derives from samples that are very readilyobtained.1 In the hands of a trained dermatopathologist skinbiopsy becomes a valuable tool, and often a simple one,that can facilitate the accurate diagnosis and treatmentof diverse dermatoses, particularly tumors. Although mostskin biopsies are of good quality, diagnostic challenges arisewhen an inadequate sample is taken. Therefore, obtainingan adequate biopsy specimen is a complex process involvingsteps that must be followed carefully, starting with selectingthe most appropriate biopsy technique, followed by properpreparation and handling of instruments; the process culmi-nates with a competent dermatopathologist’s examinationof the tissue under a microscope.2

The clinical dermatologist must have clearly establishedindications for the procedure, fully explain the interventionto the patient, obtain informed consent, and finally take atissue specimen that is representative. Clinicians often sub-mit specimens that are too small,3 however, or that havesuperficial defects due to electrocoagulation or inappropri-ate use of forceps, or that show signs of drying before theywere placed in a fixing solution.

The clinical dermatologist also often chooses an inap-propriate site or technique, or may fail to provide thepathologist with even minimal clinical information, makingdiagnosis difficult.3,4

Another important problem that is often underesti-mated is the clinician’s lack of experience in interpretinghistopathologic findings, particularly in inflammatory skindiseases.5 The nature of dermatopathologic nomenclature,and the fact that dermatoses can have multiple names,can also lead to misunderstandings between the clinicianand the dermatopathologist. A solid understanding of der-matopathology is therefore necessary if clinicians are tofully take advantage of the possibilities that skin biopsyoffers. One study of biopsies of inflammatory lesions takenby dermatologists and other specialists found that the der-matologists’ specimens more often yielded information thatled to a specific diagnosis (77% of cases vs 41% for nonder-matologists) and that the sites the dermatologists sampledwere more appropriate.6

Some US dermatologists have used extenders----otherphysicians or nurses----to perform biopsies; these dermatol-ogists report that such assistants have a certain tendencyto submit ever smaller specimens of inadequate depth forthe suspected diagnosis.3 Dermatologists themselves, there-fore, should do these procedures in the interest of avoidingdiagnostic and therapeutic delays.6

Bearing these problems in mind, and in spite of thelack of consensus-based practice guidelines to help withdeciding what size of specimen to take or skin biopsy tech-nique to choose,7 we will summarize the principles and

concepts which are important from the perspective of thedermatopathologist and which we believe should be takeninto consideration when a skin biopsy is performed. In thisfirst paper we will cover the following points:

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ermatofibrosarcoma protuberans extending to the deep mar-in of the excisional biopsy.

. Functions of skin biopsy: the role of clinical informationand technical aspects of the procedure

. The biopsy: processing the specimen

. Complications of dermatologic surgery

. Selecting the biopsy site

unctions of Skin Biopsy

kin biopsy is performed mainly to assist in the accu-ate diagnosis of a skin disease. For the diagnosis of skinumors, biopsy provides the best information; biopsy canlso help with prognosis if the tumor proves malignantby showing Breslow depth in melanoma) and can orientreatment, for example in relation to whether or not tumor-ree margins are observed on inspection of the specimenFig. 1). Biopsy information is also useful in inflamma-ory dermatoses, allowing several clinical diagnoses to beeighed and finally confirmed or ruled out.

The specimen may be studied by means of conventionaltaining techniques, direct immunofluorescence, electronicroscopy, immunohistochemical staining, tissue culture,olymerase chain reaction techniques, or fluorescencen situ hybridization.8

Skin biopsies are also taken for legal reasons, such ashen a dermatopathologic diagnosis is needed to supportlinical suspicion,9 and the procedure may also strengthenood physician---patient relations by re-establishing confi-ence that a correct diagnosis has been made.

Finally, skin biopsies are sometimes required for monitor-ng purposes, to obtain objective evidence of clinical course,esponse to treatment, and possible side effects.

linical Information

roviding the dermatopathologist with sufficient clinicalnformation to work with might seem obvious, but unfortu-ately the necessary details are not always communicated.iven that time pressures rule in most clinical settings, too

1 M. Llamas-Velasco, B.E. Paredes

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Table 1 Sites of Common Skin Diseases.

Epidermis andpapillary dermis

Melanocytic nevus, age spots,seborrheic keratosis,fibroepithelial polyps, commonwartSuperficial basal cell carcinoma,melanoma in situ, mycosisfungoides, actinic keratosis, Pagetdisease (mammary andextramammary)Contact dermatitis (allergic andirritant), atopic dermatitis,seborrheic dermatitis, plaquepsoriasis, scabies, lichen ruberplanus, Gibert pityriasis rosacea,vesiculobullous dermatoses

Papillary andreticular dermis

Melanocytic nevus, neurofibroma,hemangioma,glomangioma/glomus tumor,sebaceous nevi (hamartomas ofthe sebaceous follicle), follicularcystsBasal cell carcinoma (solid,sclerodermiform), melanoma,squamous cell carcinomaPhotoallergic dermatitis,phototoxic dermatitis:polymorphic light eruption,scleroderma, morphea, scabieticnodules, leukocytoclasticvasculitis, cutaneous lupuserythematosus, urticaria,granuloma annulare

Reticular dermisandsubcutaneoustissue

Blue nevus, lipoma,dermatofibroma, epidermoid ortrichilemmal cystsMelanoma, cutaneous lymphoma,dermatofibrosarcomaprotuberans, metastasis(melanoma, breast cancer, etc.)Panniculitis, sarcoidosis,rheumatoid nodules, nodularvasculitis, polyarteritis nodosa,

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ittle information is often sent to the laboratory with thepecimen.

Lack of detail may be of little importance if the patientas seborrheic keratosis or if an intradermal nevus haseen removed for cosmetic reasons. However, the situations quite different when inflammatory dermatoses or rareeoplastic lesions are involved.6 In such cases differentialiagnosis demands the careful consideration of correlationsetween clinical and histopathologic data; hence the der-atopathologist will need to know the patient’s age and sex,

he biopsy site, the clinical presentation and time course,he signs and symptoms, and the various local or systemicreatments the patient was using or had used in the past.4

In certain situations, knowledge of earlier biopsy find-ngs might also be useful: this is particularly true in cases ofecurrent or persisting melanocytic nevi or other skin tumorshat have not been fully excised. Previous biopsy findingsan also reveal histologic changes (eg, psoriasis vulgaris,ityriasis rubra pilaris, seborrheic dermatitis, atopic der-atitis, or mycosis fungoides) that prove indispensable for

rienting a treatment approach for generalized exanthemserythroderma).

Some events in the patient’s medical history, such asaving received a transplant, must be reported, howeverrrelevant they might seem, because they are associatedith certain dermatoses.

Photographs of the lesions may also prove useful, partic-larly when the tissue specimen is sent for analysis to anxternal laboratory.10

echnical Aspects of Biopsy Procedures

nowledge of certain basic principles of dermatopathologyre essential for selecting the best biopsy site and tech-ique.

The level of the lesion in the skin must be known (involve-ent of the epidermis, dermis or subcutaneous tissue) and

he specific characteristics of skin at the biopsy site must benderstood (Table 1). These considerations are not trivial.or example, dermatopathologists often receive superficialiopsy specimens that contain only the stratum corneum,aken from the palms or soles, where that layer is of greaterhickness. Likewise, scalp biopsies often fail to includeubcutaneous tissue (making assessment of the hair bulbmpossible), and sometimes only the dermis of the lowerimbs might have been biopsied in patients with clinical sus-icion of panniculitis (Fig. 2).3

Various skin biopsy techniques are available, as follows:

. Tangential cut, with scissors.

. Curettage, with a spoon-shaped curette.

. Shave biopsy.

. Punch biopsy, with a circular blade.

. Elliptical biopsy, which may be either incisional or exci-sional, according to whether the lesion is partially orcompletely removed.

angential Cut, With Scissorshis procedure is optimal for removing superficial lesions,specially pedunculated ones such as pendulous fibromaspolyps, acrochordons, or fibroepithelial papillomas) or

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eborrheic keratoses (Fig. 3). A local anesthetic is rarelyecessary and the wound is usually confined to the papillaryermis.

urettageurettage can be useful in dermatology for removing super-cial lesions confined to the epidermis. Examples areeborrheic dermatoses, epidermal nevi, common warts,olluscum contagiosum, actinic keratoses, and superfi-

ial basal cell epitheliomas. When many small lesions are

resent, curettage may provide an adequate sample forermatopathologic diagnosis, although the fragmentation ofhe specimen or incomplete excision of a tumor may openp questions of malpractice later on.

Basic Concepts in Skin Biopsy. Part I 15

Figure 2 A, Hematoxylin---eosin, original magnification ×20. Suspected diagnosis, erythema nodosum. Slight perivascular lympho-cytic infiltrate. Adipose tissue is scarce and a specific diagnosis cannAdvanced erythema nodosum with septal panniculitis, granulomatou

Figure 3 Scissors are used to make a tangential cut biopsy of

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tfiiblade cuts a cylindrical specimen, which can then be pulledup out of the skin, though scissors may be required to sep-

a fibroma.

This technique can be used after application of acryoanesthetic spray (such as ethyl chloride or liquid nitro-gen) or a local anesthetic. The lesion should be graspedfirmly between the thumb and index finger with enough pres-sure to allow a level cut to be made. If the operator cuts toodeeply, below the papillary dermis, the incision may leavea scar.11 Essential for executing the technique properly isto hold the lesion firmly enough with one hand to immo-bilize it and to work deftly with the operating hand. Thecurette should preferably be held like a pen and rotatedwith the fingers (the ‘‘fountain-pen’’ technique) or can begrasped with the fingers against the palm of the hand sothat the metacarpophalangeal joints can move the blade

(the ‘‘potato-peeler’’ technique----in fact, practicing with apotato can help in adjusting the depth of the slice).12

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ot be made. B, Hematoxylin---eosin, original magnification ×40.s inflammation, and fibroplasia.

Curettage is contraindicated when a melanocytic lesion isuspected or in any neoplastic lesion of uncertain diagnosis.

have Biopsy fine shaving-like motion is made tangential to the surfacef the lesion,13 using either a blade (mounted or not on acalpel handle) or a disposable curette.

To avoid tissue shrinkage on submerging the specimen in formol solution, which can make interpretation difficult,lace it on a piece of filter paper before fixing.

A shave biopsy is indicated for superficial lesions thatre usually exophytic, and excellent cosmetic results cane obtained14 with no need for sutures.

This technique should not be used in inflammatory der-atoses and it is formally contraindicated when melanoma

s suspected.

unch Biopsyircular blades for punch biopsies are available in diame-ers from 2 to 8 mm. Small diameters (eg, 2 mm), whichre used only exceptionally, are reserved for cosmeticallyensitive sites such as the face. A punch of 4 mm is usuallyarge enough.15 Smaller sizes are challenging to the diag-osing dermatopathologist, leading some authors to suggestunches of 6 mm, particularly if complementary microbi-logic procedures and/or direct immunofluorescence areoreseen, as these will require division of the material.8,11

Punch biopsy is typically performed under local anes-hetic; the skin to be biopsied is pinched between twongers, parallel to the skin tension lines, and the punch

s applied perpendicularly. When the punch is rotated, the

rate it from the base. The resulting wound can be suturedf necessary, although the wound may sometimes be left to

16

Figure 4 Hematoxylin---eosin, original magnification ×20.Epidermal and dermal necrosis with thrombi and parietalhyalinosis, findings compatible with a diagnosis of livedoid vas-culopathy. Vessels at the dermal---hypodermal junction show focioy

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f segmental fibrinoid necrosis indicating a diagnosis of pol-arteritis nodosa.

eal by secondary intention, especially when a small diam-ter punch has been used.

lliptical Biopsyhe main reason for choosing to perform an ellipticaliopsy is to fully excise a tumor, whether benign or malig-ant. This procedure is also highly useful in non-neoplasticermatoses such as panniculitis, scarring alopecia, and vas-ulitis (especially in conditions affecting larger vessels,uch as polyarteritis nodosa or thrombophlebitis, in whichn excessively superficial biopsy could lead to diagnosticrror)16 (Fig. 4). An elliptical biopsy is also called for whenlceration is present and it will be useful to compare healthynd diseased skin.

The endpoints of the incision should be noted on the skinith a sterile marker. After injection of local anesthetic into

he area, an incision is made perpendicular to the surfacend deep enough to reach subcutaneous tissue.17 The angleetween the first and second incision should not exceed0◦ and the width between the 2 cuts should be no morehan a third the length in the interest of preventing exces-ive tension once the wound is closed. The incisions shouldollow the skin tension lines and aesthetic units should beespected.18 Other than taking care to follow these basicrinciples, the operator should consult more specialized lit-rature for information on such surgical techniques as flapnd graft repairs of biopsy sites.

he Biopsy: Processing the Specimen

he tissue sample should be removed carefully with forcepsr a hypodermic needle to avoid damage. Tissue that is to betained with hematoxylin---eosin should be fixed in a 10% for-ol solution (4% formaldehyde in water) for about 24 hours,

hough the time required can vary according to the thicknessf the specimen.

If possible, use transparent containers for transport sohat the contents can be seen easily.

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M. Llamas-Velasco, B.E. Paredes

Ideally the formol-to-volume ratio should be 20:1, or ateast 5:11; therefore, a variety of collection containers muste on hand in the clinic. To avoid confusion, each biopsyhould be placed in a separate, properly labeled receptacle.

Tumor excision biopsies must be inspected to ensure theyre complete and that the borders of the lesion are included.ne side of the prepared specimen should be marked, usu-lly by placing a suture to designate the cephalad border,rying to leave the strand loose enough so that the specimenemains undamaged when the suture is removed; otherwisevaluation may be difficult. Once the suture is removed inhe laboratory, the specimen is marked again and cut intoross-sections. If there is residual lesion, it will be possibleo verify its exact location.

When material is to be used for immunofluorescence, thepecimen must be divided into 2 parts. One will be processeds already described, by fixing it in formol. The other por-ion will be wrapped in gauze moistened with normal salineolution and placed in an appropriate receptacle, which doesot need to be filled with saline since it is only necessary toeep the tissue moist. If transporting the specimen to anxternal laboratory will take more than 24 hours, it shoulde placed inside a larger, isothermal carrier packed with dryce. The specimen might also be placed in Michel’s transportedium (an ammonium sulfide, N-ethylmaleimide, and mag-

esium sulfate solution), which will preserve the specimenell for as long as 10 days.19

For diagnosis on the basis of frozen specimen sections,s in Mohs micrographic surgery, the tissue is preserved in

special medium, usually an optimum cutting temperatureOCT) medium composed of water-soluble glycols and resins;he specimen is embedded and then frozen for cryostat sec-ioning.

A specimen to be studied by electron microscopy muste placed for 2 hours in a 0.5% Karnovsky solution (0.5%lutaraldehyde, 2% paraformaldehyde in a 0.2 M cacodylateuffer at a pH of 7.3) and later fixed in osmium tetroxide inhe same buffer solution.20 In this technique, the specimenust be dried before cutting into thin sections for staining

eg, with uranyl acetate); this treatment is useful, for exam-le, for immune phenotyping of amyloidosis in abdominal fatiopsies.20

When obtaining specimens for microbiology, a sterileeceptacle should be used and the tissue wrapped in gauzeoaked in normal saline (ie, a nonbacteriostatic solution).amples for viral culture can be transported in a liquidedium. Contact the microbiology laboratory for specific

nstructions if in doubt.

atient Considerations and Complications ofermatopathologic Surgery

s a well informed patient is more cooperative, the der-atologist should explain the reasons for the biopsy, the

urgical technique that will be used, and the possible sideffects.

Dermatologic surgery does not usually lead to life-hreatening complications, although anaphylactic reactionsr arrhythmias may occur; therefore, it is important to beeady to perform basic resuscitation maneuvers if need be.21

Basic Concepts in Skin Biopsy. Part I 17

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Figure 5 Exposed internal jugular vein during surgery toremove a cervical sentinel lymph node.

Most complications involve bleeding, infection andunsightly scars or changes in pigmentation. In taking themedical history, therefore, it is important to note predispos-ing factors such as malnutrition, advanced age, metabolicdisease or genodermatoses, medication, smoking or alcoholintake, or previous therapeutic procedures.21

The possibility of doing a shave biopsy should be dis-cussed, particularly if a melanocytic tumor is suspected,considering the cosmetic advantages of this technique butalso the medical disadvantages.

The possibility of injuring delicate anatomical structures,such as large vessels, nerves or articular capsules might con-stitute a relative contraindication.14 Particular care must betaken when working near large pulsatile vessels in the trunkor head and neck (Fig. 5). The presence of structures deepto the biopsy site (such as neurovascular bundles and evenspinal fluid) must also be taken into consideration (Fig. 6).Thorough knowledge of the anatomy of the biopsy site istherefore essential.21

Disinfection of the Site

Alcohol reduces skin flora by 75% within a minute of appli-cation and is usually adequate for disinfection, but it is

mainly effective against gram-positive microorganisms. Apovidone---iodine solution’s effect is slower than that ofalcohol,1 but its antibacterial spectrum is broader, as itacts against some gram-negative microorganisms as well as

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igure 6 Exposure of the fascia covering the flexor tendonsf the hand during excision of a melanoma.

ram-positive ones. Chlorhexidine, which is also effectivegainst both types, has a rapid onset of effect that lasts foreveral hours. This disinfectant should not be used near theye to avoid irritation, but it is the most effective antisepticgent both for prevention and for application on the surgicaleld.22

Several antiseptics can be used in combination.

nesthesia

he biopsy site can be adequately anesthetized with an infil-ration anesthetic such as lidocaine, to which epinephrine1:100 000) can be added to prolong the effect and curbleeding; mepivacaine and bupivacaine are possible alter-atives. The local anesthetic can also be combined with these of a cryogen or topical anesthetic, for example, EMLAream (an eutectic mixture of prilocaine and lidocaine) or% lidocaine cream.

No product is risk-free and there have been reports ofrythema, contact urticaria, irritative dermatitis, and morearely, methemoglobinemia and purpura in association withMLA cream.23

rophylactic Antibiotic Therapy

ound infection is one of the factors that can delay heal-ng. Presurgical antibiotic therapy to prevent endocarditis isot recommended in patients undergoing surgery on clean,oninflamed skin under any circumstances.22 However, pro-hylaxis is recommended for high-risk patients (those withrosthetic valves or a history of endocarditis or complexyanotic congenital heart disease) when surgery will affectucosas, central areas of the face, or genitalia; prophy-

axis is also recommended before Mohs micrographic surgerynvolving evaluation of fresh tissue.22

Prophylaxis should cover the usual skin flora, mainlyram-positive microorganisms (staphylococci and strepto-

occi). Oral cephalexin (2 g before surgery and 500 mg

hours later if indicated) is the treatment of choice,lthough it is also possible to use amoxicillin (2 grally) or cloxacillin (2 g orally). In allergic patients,

1 M. Llamas-Velasco, B.E. Paredes

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TcmuetwWstrlijvarioliformis acuta) and may initially be nonspecific (Fig. 8).Several biopsies may therefore be required before a precisediagnosis can be made. For annular lesions (eg, granuloma

8

se erythromycin (1 g orally before surgery and 500 mgfterwards), azithromycin (500 mg orally), clarithromycin500 mg orally), or clindamycin (600 mg orally).22 The presur-ical dose should be given 30---60 minutes beforehand.22 Theecision to prescribe prophylaxis for patients who haveecently (within the past 2 years) been implanted with arosthesis should be made on a case-by-case basis after dis-ussion between the dermatologist and surgeon.22

Similar infection rates have been reported in patientssing bacitracin or mupirocin cream on the biopsy site andhose using petroleum jelly.24

If oral antibiotics are prescribed, they should be reservedor cases in which there will be flap or graft repair in therea around the nose, the wound closure will be subject toension, or the surgeon will be acting on infected lesions21

r on sites at higher risk of infection or where functionalonsequences could be significant (eg, the hand).22

nticoagulant and Antiplatelet Therapy

mportant factors to take into account are whether theatient is taking oral anticoagulants or has a systemicisease that increases the risk of coagulation disorders,hrombocytopenia, or immune system compromise. Theresence of diabetic angiopathy, lower limb edema orhronic venous insufficiency should also be taken intoccount, particularly when the biopsy site is on the lowerxtremities.

In a recent review, Bassas et al.25 concluded that war-arin therapy should not be suspended before dermatologicurgery, although the surgical technique should be plannedarefully, with strict hemostatic measures, and there shoulde adequate postoperative follow-up. An international nor-alized ratio between 2.5 and 3 would be acceptable inatients treated with warfarin who are candidates for der-atologic surgery.25,26

Less is known about the use of antiplatelet therapy (withcetylsalicylic acid or other cyclooxygenase inhibitors).lthough it seems that combined use of clopidogrel andcetylsalicylic acid increases the risk of complications inohs surgery,27 suspending therapy does not seem to beecessary.25,28

electing the Biopsy Site

nflammatory skin diseases have successive phases. For thateason it is not always possible to perform biopsies during ancute episode, when the most information will be obtainedecause the later changes present in advanced lesions areften nonspecific and do not contribute to the diagnosisand may even make it more difficult). The patient does notlways seek care as soon as lesions appear, however, andiopsy is sometimes delayed.6

Certain biopsies can be avoided, such when cutaneousastocytosis is suspected after Darier’s sign is elicited; in

his disease, degranulating mast cells are barely discernibleven with immunohistochemistry.

Bullous dermatoses (bullous pemphigoid, pemphigus vul-aris, dermatitis herpetiformis, etc) often begin with anrticarial rash that has a histologic pattern of eosinophilicpongiosis affecting the epidermis and papillary dermis.

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igure 7 Hematoxylin---eosin, original magnification ×40.ncipient juvenile xanthogranuloma.

his pattern can also be seen in other conditions: allergicontact eczema, nummular eczema, dermatitis medica-entosa, bites from insects and other arthropods, scabies,

rticaria, incontinentia pigmenti, and Leiner disease (toxicrythema).29,30 Bear in mind that after the site has beenreated with corticosteroid creams the eosinophil countill decrease and diagnosis may become more difficult.hen diagnosing blistering diseases, examination of the

ite of cleavage can be useful. If biopsy has been delayed,he only observations may be erosion and ulceration, orepair processes or signs of bacterial colonization. Histo-ogic findings vary according to the phase when the biopsys performed in certain diseases (leukocytoclastic vasculitis,uvenile xanthogranuloma [Fig. 7] or pityriasis lichenoides et

igure 8 Hematoxylin---eosin, original magnification ×100.erivascular lymphocytic infiltrate with leukocytoclasia. Leuko-ytoclastic vasculitis was suspected and later confirmed afterdditional biopsies.

Basic Concepts in Skin Biopsy. Part I 19

Figure 10 A, Hematoxylin---eosin, original magnification×400. Long and oval-shaped structures, bluish in color, cor-responding to Malassezia species, can be seen in the stratumcorneum. B, Periodic acid---Schiff stain, original magnification×s

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Figure 9 A, Hematoxylin---eosin, original magnification ×100.A, Actinic porokeratosis. B, Periodic acid---Schiff stain, originalmagnification ×100.

annulare, dermatomycosis, erythema chronicum migrans,erythema annulare centrifugum, cutaneous lupus erythe-matosus, porokeratosis and others), tissue must be sampledfrom the active border (Fig. 9).

From either a clinical or histologic perspective, an eti-ologic diagnosis is hard to achieve in erythroderma, alsoknown as exfoliative dermatitis. When taking the medicalhistory, questions about medication and substance use mustbe included as well as investigation of previous skin diseases.A thorough physical examination should include palpation todetect masses, organomegaly, and lymphadenopathy. Evenso, several biopsy procedures are necessary for diagnosisin over half the cases, and the diagnosis usually rests on acombination of histopathologic and clinical factors.31

Whenever possible, the operator should take samplesfrom several representative sites on the trunk or proximalextremities, given that skin on the distal lower extremitiesnearly always shows a degree of inflammatory infiltrate andchanges related to superimposed stasis dermatitis; more-over, surgical wounds in distal areas will heal more slowly.32

For the accurate diagnosis of panniculitis lesions, biopsyplays a crucial role. Deep incisional biopsies are requiredto ensure taking an adequate sample of adipose tissue. Ifthe operator chooses to do a punch biopsy, the blade shouldbe at least 6 mm in diameter. To interpret the findings, itwill be important to know the location or distribution ofthe infiltrate (predominantly lobular or septal), the pre-dominating cell populations, and the presence or absenceof vasculitis.33,34

To study pigmentation changes, particularly postinflam-

matory hypopigmentation or vitiligo, the operator shouldtake a sample that contains both lesional and healthy skin(for comparison within the same specimen). Specific stains,such as Masson---Fontana stain, and immunohistochemical

40. Hyphae can be observed in the stratum corneum: diagno-is, tinea infection.

nalysis (eg, with S-100, Melan-A) can help pinpoint theiagnosis. Periodic acid---Schiff (PAS) staining should also beerformed to rule out or identify fungal infections (mainlyityriasis versicolor) (Fig. 10). PAS staining can also helpdentify hyphae and spores when pigmentation changes areresent in patients who have been treated with antifungalgents.

onflicts of Interests

he authors declare that they have no conflicts of interest.

eferences

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4. Ackerman AB. Proper biopsy. In: Stamathis G, editor. Histologicdiagnosis of inflammatory skin diseases. An algorithmic method

based on pattern analysis. Baltimore: Williams & Wilkins; 1997.p. 99---103.

5. Rampen FH. General practitioners and skin biopsy. BMJ.1992;304:575.

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