Maximizing diagnostic outcomes of skin biopsy specimens

Abstract

Skin biopsy is a common dermatologic procedure that is typically required to assess cutaneous neoplasms and to evaluate indistinct skin eruptions for which a clinical differential diagnosis is considered. Although plenty of literature exists on the histopathologic features of different skin diseases, clues and methods that help maximize the diagnostic results and avoid common pitfalls in the processing of skin biopsies have received little attention. In cutaneous biopsy, interpretation is very important, as is the process of choosing the appropriate biopsy technique. As soon as the decision to perform a skin biopsy is taken and until microscopic slide evaluation occurs, multiple opportunities for error may arise, any of which may disadvantage the pathologist in efforts to reach a definitive diagnosis. Therefore, it is exceptionally important that clinicians work closely with pathologists to optimize biopsy results. The purpose of this review is to increase awareness of the potential for error in the course of obtaining and interpreting biopsy specimens. The process consists of several steps that refer to, respectively: choice of biopsy site; choice of technique; tissue fixation; tissue processing; the pathologist's interpretation; and clinicopathologic correlation. Avoiding these pitfalls may, in turn, maximize the pathologist's ability to make the correct diagnosis and thus provide better patient care.

Improving diagnostic accuracy of skin biopsies

“…Generally, established lesions with the most primary inflammatory change should be chosen, as early lesions may reveal nonspecific features. [1][2][3] An exception to this is blistering (bullous) disorders, pustular eruptions and suspected vasculitis, where early lesions biopsied within 48 hours of appearance show more specific features on histopathology. 1,2,4,5 Older lesions with secondary skin changes such as crusting, scarring, regeneration and infection should be avoided, as they will have a lower yield.…”

“…[1][2][3] An exception to this is blistering (bullous) disorders, pustular eruptions and suspected vasculitis, where early lesions biopsied within 48 hours of appearance show more specific features on histopathology. 1,2,4,5 Older lesions with secondary skin changes such as crusting, scarring, regeneration and infection should be avoided, as they will have a lower yield. [1][2][3] Avoid biopsying lesions that have been excoriated, traumatised or recently treated, as the underlying pathological process will be obscured.…”

“…1,2,4,5 Older lesions with secondary skin changes such as crusting, scarring, regeneration and infection should be avoided, as they will have a lower yield. [1][2][3] Avoid biopsying lesions that have been excoriated, traumatised or recently treated, as the underlying pathological process will be obscured. 3 For small, inflammatory lesions (<4 mm), a punch excision could be performed.…”

“…For large inflammatory lesions, choose the edge of an expanding lesion, the area of most colour change, or the thickest portion of the lesion. [1][2][3] Annular plaques should be biopsied at the elevated edge of the lesion. 6 With an ulcer or ulcerated lesion, include a portion of normal adjacent tissue, because tissue from the ulcer bed alone often yields nonspecific findings.…”

Diagnoses of hospitalized patients with skin abnormalities prompting biopsy by consulting dermatologists: A 3‐year review from a tertiary care center

“…Thus, prompt and accurate diagnosis and treatment can affect outcomes. Skin biopsies are an indispensable tool for aiding dermatologists in making accurate diagnoses and recommending appropriate treatments for hospitalized patients . While a broad spectrum of dermatologic findings is seen in hospitalized patients, little is known about the conditions most commonly prompting skin biopsy to aide in diagnosis.…”