Topline Tips for Shave and Punch Biopsy Techniques
About this video
Biopsy technique starts with a simple question: where is the pathology you are trying to capture? In this hands-on demonstration, Danielle Spatholt, PA-C, walks through shave and punch biopsy technique from setup through specimen handling and wound care, emphasizing how the suspected depth of disease should guide the procedure. She reviews practical details that matter in the room, including site photography, anesthesia, counter-tension, specimen transfer, hemostasis, avoiding crush artifact, and closure, while showing how shave biopsy is generally suited to more superficial lesions and punch biopsy to full-thickness or deeper processes.
The demonstration also addresses situations that require more planning before the biopsy begins. When vasculitis or an inflammatory blistering disorder is in the differential, an additional specimen may be needed for direct immunofluorescence, with transport medium determined by laboratory protocol. For deeper inflammatory disease involving the subcutis, Spatholt discusses extending the biopsy to the necessary depth. Across both techniques, the focus remains the same: match the procedure, specimen depth, and tissue handling to the clinical question so the dermatopathologist receives tissue capable of answering it.
Question: A patient has tense blisters and itchy, hive-like plaques on the trunk, and you’re thinking bullous pemphigoid. You plan two punch biopsies. How should you send them?
Rationale:The lesional biopsy goes in formalin for routine pathology. The DIF sample should come from the skin next to the blister, not the blister itself, and it can’t go in formalin. Use Michel’s or saline, depending on your lab. Biopsying the blister for DIF can give you a false negative.
Question: A patient has tender, deep red nodules on the lower legs, and panniculitis is on your list. Which biopsy is most likely to give you an answer?
Rationale: Panniculitis lives in the fat, so if your biopsy doesn’t reach it, you’ll miss the diagnosis. A shave or a punch that stops in the dermis won’t get there. The video shows a double (“cake topper”) punch to get deeper, and many dermatopathologists prefer a deep wedge biopsy for these cases.