Biopsy in Wound Care: Insights from A Leading Dermatologist

Robert Kirsner, MD:
I'm Robert Kirsner. I'm Chair of Dermatology at the Dr. Philip Frost Department of Dermatology and Cutaneous Surgery at the University of Miami.

Well, the beauty of taking a biopsy is you can control what you're biopsying. The depth and the location of where you want to take a biopsy. So in dermatology, if we see something that we think is a skin cancer we'll take a very superficial biopsy, because the pathology is very high. Many times in wounds we want to go deeper. We want to go into the dermis and into the subcutaneous tissue. So generally we'll use a scalpel and take a biopsy with a scalpel. Typically, from the ulcer edge. One of the pearls of taking a biopsy is when we give the anesthesia, is to start away from the ulcer. If you come at a patient with a needle right into their ulcer, you're not going to have a friend.

But if you start a normal skin, diverting attention by putting pressure or stretching the skin, and then inserting the needle quickly and delivering the anesthesia slowly away from the ulcer. And then working towards the ulcer as the skin you've anesthetized is numb. And then you can put the needle in where the skin is already numb, it'll be much more pleasant for both you and the patient.

There's an old saying in dermatology in the world. And it relates to a famous bank robber, Willie Sutton. And they said, "Willie, why do you rob banks?" And he says, "That's where the money is." So we look for where we think the pathology is. So oftentimes if we see a very prominent rash near an ulcer, we'll take a biopsy of that rash, whether it's palpable purpura, or livedo reticularis, or something like that, in addition to taking a biopsy of the ulcer edge. So I think going where the money is and not being scared to take one or two, or more biopsies.

The other thing is that what you do with the biopsy. And we typically take a specimen and send some of it for histologist to a pathologist, and choosing the right pathologist is critical. But we also may send it to the microbiology lab. And in some situations we may even take a biopsy and then send it for immunofluorescence, looking for immunoreactants and people who have ulcers from vasculitis. Or have ulcers from blistering diseases. So understanding what to do with the biopsy is almost as important as taking the tissue itself.

You shouldn't be scared to take a biopsy. People say, "Well, I have a wound, I'm going to make it worse." But we know that for the vast majority of wounds, even non-healing wounds, if you take a biopsy, the ulcer will heal back to where originally was. And you're not going to make the situation worse. And I can't think of a time when a patient blamed me for taking a biopsy, even if their wound wasn't doing well.