Skin Biopsy: The First Step

What is a Skin Biopsy?

If the physical examination shows evidence of a suspected melanoma, your doctor will recommend a skin biopsy, a procedure to remove all or part of the mole/lesion for evaluation under a microscope.

The biopsy provides important information:

• Whether the mole/lesion is benign or malignant
• If malignant, how deeply the tumor has penetrated the skin and whether there are associated signs of ulceration

A skin biopsy does not take long and is about as uncomfortable as having blood drawn. The physician will clean the area to be biopsied with alcohol and then inject a small amount of local anesthetic. Because the anesthetic makes the skin swell and has a low pH, it burns for about five to 10 seconds. It is similar to the anesthetic used by dentists. Once the anesthetic has taken effect, the doctor will use a scalpel, a razor blade, or a small circular blade called a “punch” to free a small piece of skin. Because the skin is numb, the patient can feel pressure but no pain during this part of the procedure. If a deep biopsy is taken, one or two stitches are used to close the wound. If the biopsy is superficial, the wound is left open to heal like deep scrape. A biopsy is generally easily accomplished in an office visit.

The skin samples are sent to a pathologist or dermatopathologist. Dermatopathologists specialize in skin pathology, a subspecialty of dermatology and pathology. They are highly trained physicians who complete a residency in either dermatology or pathology and then undergo further training in dermatopathology. They are skin pathology experts, and they’re the most qualified to look at your biopsied tissue and decide if it’s melanoma.

Types of Biopsies

Different methods can be used to perform a skin biopsy. Doctors will choose the type of biopsy based on the size of the affected area and the location on the body.

This e-magazine provides an overview of the different ways suspicious pigmented lesions can be evaluated, with a special focus on the potential role for non-invasive tests, including the noninvasive genetic sticker test.

Excisional Biopsy

The doctor cuts out the entire suspicious lesion. An excisional biopsy is the preferred method for small lesions.

Description: Typically, this type of biopsy would happen in the doctor’s office as an outpatient procedure, under a local anesthetic.
What you’ll feel: You will feel a needle stick and about 10 seconds of burning when the doctor anesthetizes the lesion. Once the spot is anesthetized, you may feel pressure, but no pain as the doctor cuts through the skin and removes the tumor. The doctor finishes by sewing the wound together.
How long does it take? A biopsy is generally easily accomplished in an office visit.
Afterwards: Some over-the-counter pain medication will ease any pain coming from the site of the surgery. You’ll probably need a return visit for the doctor to remove stitches and check your healing.

Incisional Biopsy

The doctor may recommend taking just a portion of the lesion, perhaps because the lesion is too large for an excisional biopsy, or because taking it all would destroy important tissue, as on the face or hands, or leave scars.

Description: Incisional biopsies are performed in the doctor’s office under local anesthetic. One type, called a punch biopsy, uses an instrument that resembles a tiny, round cookie cutter with a diameter of 3, 4, or 6 millimeters (1/8″, 1/6″, or 1/4″). Incisional biopsies can also be made with a scalpel which will give you a more elliptical wound.
What you’ll feel: While it is a surgical procedure, you won’t experience much pain. You’ll feel a needle stick and a little burning with some pressure when you receive the anesthetic. The anesthetic will take effect, and you won’t feel any pain as the doctor removes a portion of the lesion with the tool. The doctor finishes by sewing the wound together.
How long does it take? A biopsy is generally easily accomplished in an office visit.
Afterwards: Some over-the-counter pain medication will ease any pain coming from the site of the surgery. You’ll probably need a return visit for the doctor to remove stitches and check your healing.

Superficial Shave Biopsy

This process is used for superficial skin disease when a deeper tissue cut is not required, such as melanoma in situ, skin tags, or seborrheic keratoses.

Description: In a shave biopsy, the doctor numbs the area with a local anesthetic and then “shaves” off the top layers of the skin (the epidermis and a part of the dermis) with a surgical blade.
What you’ll feel: A needle stick and a little burning with some pressure when the anesthetic is injected. It is usually about as uncomfortable as having one’s blood drawn. Once the anesthetic takes effect, you may feel pressure, but no pain, as the physician shaves off of the top layers of skin.
How long does it take? A biopsy is generally easily accomplished in an office visit.
Afterwards: Some over the counter pain medication will ease any pain coming from the site of the surgery.

Superficial Shave Biopsies are DISCOURAGED for suspected melanomas other than melanoma in situ. Suspected melanomas require biopsies of the full thickness of the skin and underlying fat. Superficial shave biopsies may not go deep enough to give an adequate tissue sample in order to determine tumor depth, ulceration, or mitotic index. Other superficial techniques such as freezing and cauterizing tissue samples are also not recommended, for similar reasons.

Deep Shave Biopsy (Saucerization)

This biopsy technique is like a superficial shave biopsy but is used to obtain a deeper specimen and is often used when biopsing lesions suspected of being melanoma.

Description: Saucerization procedures are performed in the doctor’s office under local anesthetic. A doctor uses a surgical blade to “scoop out” the suspicious lesion, and a sufficient depth of skin beneath it to be able to stage the cancer.
What you’ll feel: While it is a surgical procedure, you won’t experience much pain. You’ll feel a needle stick and a little burning with some pressure when you receive the anesthetic. But as it takes effect you won’t feel any pain as the doctor removes a portion of the lesion. The wound is not usually sewn closed but is left to heal from the inside out.
How long does it take? A biopsy is generally easily accomplished in an office visit.
Afterwards: Some over the counter pain medication will ease any pain coming from the site of the surgery.

What to Ask Your Doctor Before a Biopsy

You may find it helpful to print out the questions below and bring them with you to your next doctor’s visit.