The most commonly performed skin biopsies are the shave biopsy, punch biopsy, and elliptical excisional biopsy. Other less common biopsy types that are rarely needed include incisional biopsy, which is performed like an elliptical excision but does not include the whole lesion, and biopsy by curettage. A deep shave biopsy is also called a saucerization. Most skin cancers can be biopsied using the shave or saucerization technique, and most rashes can be biopsied using a 4-mm punch biopsy.
Saucerization is synonymous with a deep shave biopsy. Elliptical excision is also called a fusiform excision.
Anesthesia is needed before any biopsy is performed. The preferred anesthesia is 1% lidocaine with epinephrine. There is a myth that epinephrine should never be used when doing surgery on the fingers, toes, nose, and penis. This myth is taught in medical school and tested on the boards by those who still believe it is true. In reality, dermatologists, plastic surgeons, and head and neck surgeons use lidocaine with epinephrine safely every day in these areas, and the evidence supports this practice.1-4
There is no evidence to support that lidocaine with epinephrine can cause necrosis in areas with end-arteries, and no case of necrosis has been reported since the introduction of commercial lidocaine with epinephrine in 1948.1 In addition, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia. It also diminishes the chance for lidocaine toxicity, as it slows the lidocaine from being systemically distributed. Epinephrine-supplemented local anesthetics for ear and nose surgery were used without complications in more than 10,000 surgical procedures.1 The relative absence of blood in the operating field significantly reduces the duration of surgery and increases the healing rate, as less electrosurgery is needed.2 Both the nose and the ear have excellent blood supplies and can bleed profusely when surgeries are performed on them without epinephrine.
The addition of epinephrine in digital blocks minimizes the need for the use of tourniquets and large volumes of anesthetic and provides better and longer pain control during procedures.3 Evidence also suggests that one can safely use epinephrine in digital blocks even in patients with vascular disease.4 A Cochrane review in 2015 identified four randomized controlled trials studying the use of epinephrine in digital blocks.5 In these studies, there were no reports of adverse events such as digital ischemia. Although some biopsies on the fingers can be performed with a local anesthetic at the biopsy site only, sometimes it is beneficial to perform a digital block only or first. Another method of providing local anesthetic to a finger or toe biopsy site is to perform the digital block using lidocaine without epinephrine and then use 1% lidocaine with epinephrine locally at the site of biopsy once the digital block is ...