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DERMATOPATHOLOGY
Year : 2012  |  Volume : 13  |  Issue : 1  |  Page : 35-37

Skin biopsy in pediatric age group: Special considerations


Department of Pathology, Government Medical College, Trivandrum, Kerala, India

Date of Web Publication23-Oct-2012

Correspondence Address:
G Nandakumar
Shreenandanam, VARA 746 A, Vattiyoorkavu, Trivandrum
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

A significant percentage of patients attending the Dermatology OPD belong to the pediatric age group. Children can present with a wide range of skin diseases. In many of these cases, a diagnosis can be made on clinical examination alone. But, sometimes, the differential diagnoses are many and therefore a skin biopsy and histopathological examination are done to arrive at a diagnosis. Pediatric skin presents unique problems. Therefore, skin biopsy, although a minor surgical procedure, along with preparation and after care, have to be tailor made. It is important for the dermatologist to be familiar with the many additional aspects faced in this situation and for the pathologist to be properly equipped to face the many challenges that pediatric skin throws up.

Keywords: Skin biopsy, indications, contra indications


How to cite this article:
Nandakumar G. Skin biopsy in pediatric age group: Special considerations. Indian J Paediatr Dermatol 2012;13:35-7

How to cite this URL:
Nandakumar G. Skin biopsy in pediatric age group: Special considerations. Indian J Paediatr Dermatol [serial online] 2012 [cited 2020 Jul 6];13:35-7. Available from: http://www.ijpd.in/text.asp?2012/13/1/35/102810


  Introduction Top


Dermatologists perform a skin biopsy when the clinical examination fails to provide a useful diagnosis or when the patient has not responded to the initial diagnosis and treatment. There is a saying among dermatologists that more errors are made from failing to biopsy promptly than from performing unnecessary biopsies. [1] Nevertheless, many dermatoses have non-specific histopathology, and biopsy cannot substitute for good clinical skills. In this era of evidence-based medicine and litigations, skin biopsy helps in ensuring documentary evidence of the diagnosis made and the basis for the treatments given. [2] Also, most importantly, studies have shown that in a significant number of cases, histopathology contributed to the diagnosis. This is of great importance, as arriving at a definitive diagnosis reduces morbidity and hospitalization of the patient. [3]

The aim in performing a skin biopsy is to obtain a specimen for histopathologic study that will disclose information leading to diagnosis. [4] Skin biopsies are unique because the lesion can be visualized, allowing for proper selection of the biopsy site and technique. [1]


  Indications for Skin Biopsy Top


This can be listed out, including several conditions, but a biopsy is most useful in the pediatric age group in the diagnosis of [1] vesiculobullous diseases, [2] infections such as Hansens disease, viral infections, deep fungal infections, [3] differentiating between papulosquamous diseases, [4] pigmented lesions, [5] metabolic disorders and [6] neoplasms. Biopsy may not be helpful in differentiating between various eczematous dermatoses that are so common in children.

It is worthwhile to remember that biopsy should not be reserved as a last resort, after trying out different systemic and topical medications, when it may not be contributory. When in doubt, try to confirm the diagnosis by a biopsy at the outset.


  Contraindications Top


There are few absolute contraindications for skin biopsy. But, generally, lesions involving the face, palms and soles are better avoided if one has a choice. Frankly infected lesions and older lesions with secondary changes are to be avoided. [5] Pigmented and oily skin tend to have more scar formation than pale dry skin. Children with anemia may have impaired healing due to reduced oxygen transportation in the blood. [6]


  Before Biopsy Top


Inquiry should be made regarding allergies to topical antibiotics, antiseptics, local anesthetics and reactions to tape. Ask about bleeding disorders, bleeding with previous surgeries and use of drugs known to interfere with hemostasis. [1],[5] Obtain verbal and written consent from the child and from the family for the procedure.

The child and the family should be informed about the reason and necessity for the biopsy, what it entails, alternatives, potential risks, duration of the procedure, expected cosmetic outcome and when to expect the results. [7]

One of the most difficult initial decision is in selecting the biopsy site. [1],[4],[5] For papulosquamous conditions, lesions with the most advanced inflammatory changes are selected. For blistering diseases, the reverse is true; the earlier the lesion, more specific the histopathology. [1] When immunoflourescence is to be done, perilesional skin should be included in the biopsy.

Hypertrophic scarring tends to occur over the deltoid and chest areas, and delayed healing can be a problem over bony prominences. The incidence of secondary infection in the groin and axillae is high; therefore, biopsy these areas only if other sites are unavailable. [8]


  Choice of Biopsy Procedure Top


There are various techniques of performing a skin biopsy, and any particular one is based on the type of the lesion, site of the lesion and also on the proficiency of the dermatologist. [9] The various techniques available are shave biopsy, saucerization, punch biopsy and surgical incision/excision/wedge biopsy.

Shave biopsies are quick, require little training and do not require sutures for closures. Lesions that are elevated above the surface or have pathology confined to the epidermis are suitable for shave biopsy. Saucerization biopsy is ideal for vesiculobullous disorders and for epidermal neoplasms. [1],[5]

When the full thickness of the skin needs to be assessed and analyzed, a punch biopsy is performed. The punch (0.3-0.4 mm) is an ideal procedure for diagnostic skin biopsy and for removing small lesions, and often provides a better cosmetic result than a shave biopsy. [6],[8],[10] Punch biopsies can heal by secondary intention, but punches greater than 0.3 mm are best closed by one or two sutures. Incision/excision biopsies are suitable when a larger amount of tissue is required (culture, histopathology, immunofluorescence, electron microscopy), in inflammatory disorders involving the panniculus and for larger tumors. [8]


  Parental Role Top


The child's parent/carer may remain with the child during the procedure, adopting an appropriate method of distraction.


  Performing the Procedure Top


Oral sedation may be required. An aseptic non-touch technique should be employed throughout the procedure. A topical local anesthetic may be applied to the biopsy site prior to the procedure (pilocarpine/lidocaine patch). Studies have shown that the anesthetic patch was significantly more effective than placebo in reducing pain at the injection site. No serious side-effects were observed. [11] Special precautions may need to be taken with known atopic children. The local anesthetic cream/patch should be removed and wiped dry with a tissue or gauze after confirming with the child regarding effective numbness of the skin. The biopsy area should be cleaned for 30 s with an alcohol-based cleaning solution and allowed to dry for another 30 s.


  Positioning the Child Top


The child should be positioned in a most comfortable and reassuring manner, with dignity maintained. Small children/infants can lie or sit on an adult's lap.


  Anesthesia Top


The most commonly used local anesthetic is 1% lidocaine. Because lidocaine is a vasodilator, small amounts of epinephrine are added to constrict blood vessels, decrease bleeding, prolong anesthesia and limit lidocaine toxicity. Epinephrine should be avoided in acral lesions, tip of nose or when larger quantities are required. [5],[12]

Subcutaneous infiltration of local anesthetic will sting or cause a burning sensation. This can be minimized by mixing 1 mL of NaHCO 3 with 9 mL of lidocaine and by making the initial injection perpendicular to the skin. [5],[8] Subsequently, it is infiltrated subcutaneously using the spider technique, lifting a skin fold to ensure that the subcutaneous injection is achieved. Wait for 2-3 min before proceeding.

After the tissue has been removed, hemostsis achieved and, if required, sutures placed, a dry, preferably low adherent, dressing is applied. A clean wound should be left untouched, leaving the exudates to nourish the healing process. Immunocompromised children should be prescribed a prophylactic topical antibiotic, first application done after hemostasis achieved and second application after 48 h when the dressing is removed. The biopsy site should be kept dry and left untouched for 48 h. [13]

A written instruction sheet on the care of the biopsy site must be given and explained to the parent on sending the child home.


  Complications Top


Although rare, major complications that can occur with skin biopsy include bleeding, injection and allergic reactions. Most bleeding can be controlled by simple pressure. If this is not successful, a single suture or tying of the culprit vessel will help. [5] Infection is usually the result of Staphylococcus, Streptococcus or Candida. If the wound is frankly purulent or has an associated cellulitis, culture the discharge and begin oral antibiotics. [14]

Occasionally, patients will develop allergic/irritant reactions to topical antibiotics, dressings or tape. The area will be red and itchy and may show vesicles. Avoidance of the suspected agent and application of topical corticosteroid ointment will be sufficient in most cases. [15]

The child and family must be informed of the result of the procedure as soon as possible.


  Documentation Top


All procedures must be documented in the medical record. Minimum content includes location and nature of the lesion, indications for the procedure, what was done, how it was performed, specimen disposition and instructions to and follow-up plans for the patient. [16],[17]


  Summary Top


Pediatric skin differs from adult skin not only with regard to the group of diseases affecting it but also in its healing properties, chances of scarring, development of irritation and allergy, and also shows many variations in its histology. Skin biopsy, when judiciously used, with good clinicopathological correlation, is rewarding. Even though skin biopsy is a minor surgical procedure, one should remember that it is a major event for the child as well as the parents. The clinician should take that extra effort in counseling and should be well versed about the precautions to be taken, choice of site and lesions, techniques, tackling of possible complications and optimum utilization of the biopsy specimen obtained.

 
  References Top

1.Fitzpatric TB, Bernhard JD. The structure of skin lesions and fundamentals of diagnosis. In: Fitzpatric TB, Eisen AZ, Wolff K, Freedberg IM, Austen KF, editors Dermatology in General Medicine. 3 rd ed. New York, NY: Mc Graw-Hill; 1987. p. 47.  Back to cited text no. 1
    
2.Nischal U, Nischal Kc, Khopkar U. Techniques of skin biopsy and practical considerations. J Cutan Aesthet Surg 2008;1:107-11.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Grace D'Costa F, Bendale KA, Patil YU. Spectrum of pediatric skin biopsies. Indian J Dermatol 2007;52:111-5.  Back to cited text no. 3
  Medknow Journal  
4.Caro MR. Skin biopsy technique AMA. Arch Dermatol 1957;76:1-2.  Back to cited text no. 4
[PUBMED]    
5.Pinkus H. Skin biopsy: A field of interaction between clinician and pathologist. Cutis 1977;20:609-14.  Back to cited text no. 5
[PUBMED]    
6.Mc Claren S. Nutrition and wound healing. J Wound Care 1992;1:45-55.  Back to cited text no. 6
    
7.Hainey SP. Helping children through painful procedures. Am J Nurs 1991;11:20-4.  Back to cited text no. 7
    
8.Pariser RJ. Skin biopsy: Lesion selection and optimal technique. Mod Med 1989;57:82-90.  Back to cited text no. 8
    
9.Wigton RS, Blank LL, Nicholas JA, Tape TG. Procedural skills training in internal Medicine residencies. A survey of programme directors. Ann Intern Med 1989;111:932-8.  Back to cited text no. 9
    
10.Todd P, Garioch JJ, Humphrey S, Seywright M, Thompson J, du Vivier AW. Evaluation of the 2 mm punch biopsy in Dermatological diagnosis. Clin Exp Dermatol 1996;21:11-3.  Back to cited text no. 10
    
11.Flora B. de Waard-vander Spek, Paul GH Mulder, Arnold P Orange: Pilocarpine/Lidocaine patch as a local premedication for skin biopsy in children. J Am Acad Dermatol 1997;37:418-21.  Back to cited text no. 11
    
12.Harrison PV. A guide to skin biopsies and excisions. Clin Exp Dermatol 1980;5:235-43.  Back to cited text no. 12
    
13.Harper J. Handbook of pediatric Dermatology. 2 nd ed. London: Butterworth Heinemann; 1990.  Back to cited text no. 13
    
14.Bennet RG. Microbiological considerations in cutaneous surgery. In: Bennet RG, editor. Fundamentals of cutaneous surgery. St Louis, Mo: CV Mosby Company; 1988. p. 136-78.  Back to cited text no. 14
    
15.Gette MT, Marks JG, Maloney ME. Frequency of postoperative allergic contact dermatitis to topical antibiotics. Arch Dermatol 1992;128:365-7.  Back to cited text no. 15
    
16.Alguire PC, Mathes BM. Skin biopsy technique for the internist. J Gen Intern Med 1998;13:46-54.  Back to cited text no. 16
    
17.Zoe Wilks. Melanie McSweeny Clinical Information. Skin Biopsy: Punch Method. Great Ormond Street Hospital for Children NHS Trust 2011.  Back to cited text no. 17
    




 

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  In this article
Abstract
Introduction
Indications for ...
Contraindications
Before Biopsy
Choice of Biopsy...
Parental Role
Performing the P...
Positioning the ...
Anesthesia
Complications
Documentation
Summary
References

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