Abstract
Aims
Skin biopsy remains the diagnostic gold standard for assessing melanocytic lesions, yet its use is influenced by provider experience and scope of practice. This study evaluated patient attitudes toward biopsy, barriers such as discomfort and needle phobia, and interest in noninvasive alternatives.
Patients and methods
A cross-sectional survey of 506 adults assessed prior biopsy experience, biopsy-related discomfort, recovery time, anesthesia pain, needle fear and willingness to pay for noninvasive tools.
Results
Twenty-eight percent of respondents had undergone biopsy. Of these, two-thirds reported discomfort and 28% rated it moderate to high. Recovery lasted ≥1 week for 59%, ≥2 weeks for 18%, and ≥1 month for 7%. Anesthesia was moderately to very painful for 33%. Common concerns included pain, scarring, infection risk and prolonged healing. Among those with biopsy experience, 53% expressed strong interest in noninvasive diagnostics, and 82% were willing to pay out-of-pocket.
Conclusions
Patient-reported pain, needle fear and prolonged recovery contribute to hesitancy toward biopsy. Strong interest in noninvasive methods underscores the need to advance alternatives such as reflective confocal microscopy, tape stripping and electrical impedance spectroscopy, while future studies should examine socioeconomic and access-related influences.
Keywords: Skin biopsy, noninvasive diagnostics, melanoma, needle phobia, recovery, pain, scarring
HIGHLIGHTS
Biopsy remains the diagnostic gold standard but is associated with discomfort, scarring and extended recovery times.
Over one-quarter of surveyed patients (28%) had previously undergone a skin biopsy.
More than a quarter (30%) of biopsy patients reported moderate to high procedural discomfort.
Recovery is often prolonged, with 59% healing in one week or more, and 7% taking over a month.
Over half (53%) of patients with prior biopsy experience expressed strong interest in noninvasive diagnostic alternatives.
A large majority (82%) were willing to pay out-of-pocket for noninvasive options not covered by insurance.
Noninvasive tools like confocal microscopy and tape stripping show potential yet are limited by depth of analysis and accessibility.
Biopsy-related fear and anxiety may lead to delays in diagnosis or avoidance of care.
Effective communication and informed consent can reduce biopsy-related anxiety and improve patient satisfaction.
1. Introduction
Biopsy is a common procedure used to diagnose various skin conditions and diseases by obtaining skin samples for histopathological examination and diagnosis. To determine suitability for biopsy, providers often look for signs of atypia within a lesion using visual examination. However, visual assessment can be subjective and may not be sufficient to distinguish between benign and malignant lesions [1]. Histopathologic assessment via skin biopsy remains the gold standard for confirming many dermatologic diagnoses [2].
While generally safe, biopsies carry potential complications influenced by operator skill, biopsy size and location, and patient-specific factors like medical history. These complications can delay healing, prolong discomfort, cause scarring and in cosmetically sensitive areas lead to patient distress or anxiety.
Although biopsies are relatively simple to perform, up to 29% of patients can develop complications [3]. These include preoperative (anesthesia-associated complications), intraoperative (bleeding, pain, damage to other structures, difficulty in closing the biopsy site, inadequate or incorrect biopsy site) and postoperative (immediate – pain, bleeding, swelling and tenderness; delayed – infection and dehiscence; late – scarring) [4].
Different types of skin biopsies include punch, tangential shave, cauterization shave and elliptical biopsies [5]. A punch biopsy takes a cylindrical portion of the skin and creates a full-thickness wound. A tangential shave biopsy removes the surface of a lesion, whereas a cauterization shave biopsy can be used to create a scoop-type removal of tissue for certain atypical lesions and carcinomas. An elliptical biopsy is made via a scalpel and reserved for larger lesions. These biopsy techniques require clinical expertise to obtain an adequate sample for histological testing. Additionally, some of these lesions involve sutures for wound closure. Although generally well tolerated, complications in skin biopsies include anesthetic complications, pain, scarring, or infection [4].
Based on the prevalence of apprehension toward needles and biopsies, this study aims to explore patients’ attitudes of skin biopsy procedures, including their associated discomfort, recovery times, pain associated with anesthesia, interest in evaluation of mole without a biopsy and willingness to pay for noninvasive solutions. Additionally, it seeks to assess patient openness to noninvasive diagnostic alternatives and identify factors, such as biopsy phobia, that may influence their decision-making. By understanding these attitudes and preferences, the study aims to highlight the need for feasible, patient-friendly alternatives to traditional biopsy methods, setting the stage for further exploration in the body of the text. This study aims to fill a critical gap in understanding patient attitudes and approaches toward skin biopsy and openness to noninvasive diagnostic alternatives.
2. Methods
We conducted a cross-sectional descriptive survey to assess patient beliefs and attitudes regarding skin biopsies. The study population included adult patients (≥18 years) presenting to the private practice dermatology outpatient clinic in Sacramento, California, USA or enrolled in the institutional dermatology research registry. The registry was utilized to increase capture responses from respondents who may not have had an acute dermatological condition that would necessitate a clinic visit. Inclusion criteria included English-speaking current or past dermatology clinic patient; exclusion criteria included minors, non-English speaking patients and those declining participation.
The survey was designed to evaluate beliefs and attitudes toward skin biopsies. The survey was administered to all participants electronically in the private practice dermatology clinic in Sacramento, California or through email to the research registry. The Allendale IRB approved this study. The study was exempt from requiring informed consent documentation as no personally identifying information was captured from the participants. The data was collected anonymously, and patients were provided study information with an opt-out option. A single survey of participants was distributed between June 2022 and November 2022.
Owing to the lack of available literature on attitudes and beliefs toward skin biopsies, the survey questions were created with input from a board-certified dermatologist: Dr. Raja Sivamani. A survey with 18 questions regarding previous biopsy experience, beliefs about biopsy and perceived pain and alternatives was distributed via an electronic tablet to patients in a dermatology clinic and research registry through email. Those who underwent prior biopsy responded to all 18 questions, whereas those who did not skipped to question 13 (Table 1). Some clinic patients who were asked to take the survey verbally declined prior to survey distribution. Patients over 18 years of age who were literate in English were invited to complete the survey after clinic intake paperwork and prior to their dermatology consultation. If patients consented to taking the survey, they were given an electronic tablet with the survey. Responses were collected and stored using Survey Monkey. Prism and Microsoft Excel were utilized for data analysis.
Table 1.
Survey questions and total number of respondents.
| Question | Total respondents | |
|---|---|---|
| 1 | Have you ever undergone a biopsy procedure? | 506 |
| 2 | On what part of your body was the biopsy performed? | 116 |
| 3 | How much overall discomfort did you experience with the skin biopsy procedure? | 116 |
| 4 | How long did it take you to recover from the skin biopsy? | 116 |
| 5 | On a scale of 1–5, how would you describe the pain caused by the injection of anesthesia prior to the skin excision? | 116 |
| 6 | On a scale of 1–5, how concerned were you about the procedure and discomfort of biopsy? | 115 |
| 7 | On a scale of 1–5, how concerning was the risk of infection from the skin biopsy? | 116 |
| 8 | On a scale of 1–5, how concerning was the risk of scarring from the skin biopsy? | 116 |
| 9 | Did you experience any scarring? | 116 |
| 10 | On a scale of 1–5, how difficult was the healing from skin biopsy? | 116 |
| 11 | If your doctor recommended a test to evaluate your mole without needling a biopsy, how likely would you be to choose it? | 116 |
| 12 | If the test wasn’t covered by your insurance and you would need to pay for it, would you still consider it instead of biopsy? | 114 |
| 13 | How much pain do you associate with a skin biopsy procedure? | 298 |
| 14 | How long do you believe recovery from skin biopsy takes? | 298 |
| 15 | On a scale of 1–5, how serious do you think the procedure and discomfort of a biopsy is? | 298 |
| 16 | On a scale of 1–5, how high do you believe the risk of infection is from a skin biopsy? | 297 |
| 17 | On a scale of 1–5, how concerning is the risk of scarring from a skin biopsy? | 297 |
| 18 | On a scale of 1–5, how difficult do you believe the healing process is from a skin biopsy? | 298 |
Question tree was determined by the answer to the first question. If the response was “no,” respondents skipped to 13.
3. Results
Data values were rounded to the nearest appropriate unit using conventional rounding rules. Five hundred and twenty-four (524) subjects were approached and a total of 506 subjects (97%) provided survey responses. Among those that responded, 143 (28%) had previously undergone a skin biopsy. One hundred and sixteen (116) respondents reported on potential discomfort. Of those, two-thirds reported experiencing some discomfort (discomfort levels 2 to 5; Figure 1), with 28% noting moderate to high discomfort during the procedure (discomfort levels 3 to 5; Figure 1).
Figure 1.
Level of Discomfort during Skin Biopsy Procedure – The highest proportion of respondents reported minimal discomfort, with 34% selecting “1 – No Discomfort” and 39% selecting 2. Moderate discomfort (3) was reported by 16%, while higher discomfort ratings were less common—9% for 4 and only 3% for “5 – High Discomfort.” Overall, reported discomfort was generally low.
On a scale of 1 to 5, 38 respondents out of 116 (33%) rated the administration of anesthetic before skin excision as moderately to very painful (pain levels 3, 4 and 5; Figure 2), while 67% Not or very mild pain (1 and 2; Figure 2).
Figure 2.
Subjective reporting of pain from anesthesia injection prior to biopsy – On a scale of 1–5, 38 respondents out of 116 (33%) rated the administration of anesthetic before skin excision as moderately to very painful.
When asked based on their recovery, 69 respondents out of 116 (59%) took 1 week or more to recover, whereas 21 (18%) took at least 2 weeks to recover, and 8 (7%) reported 1 month or longer to recover (Figure 3).
Figure 3.
Reported recovery time after a skin biopsy – Responses were evenly split between “1–3 days” and “1–2 weeks” at 41% each, showing most respondents anticipate taking action within two weeks. Smaller proportions indicated “2–3 weeks” (11%) or “1–2 months” (7%), suggesting that the majority expect to act promptly.
The majority of patients with a previous biopsy history – 62 respondents out of the total 116 (53%) – were very likely to be interested in having skin lesions evaluated without a biopsy (Figure 4).
Figure 4.
Likelihood of evaluating mole without biopsy – The majority of respondents (53%) selected “5 – Very Likely,” indicating strong intent, followed by 17% choosing 4 and 14% choosing 3. Lower likelihood ratings were less common, with 9% selecting “1 – Not Likely” and 6% selecting 2. This suggests that most participants expressed a high likelihood of engaging in the proposed action.
Most of the patients with a prior biopsy history – 94 out of a total of 114 respondents (82%) – were willing to pay out-of-pocket costs for alternative noninvasive tests if they were not covered by their medical insurance plan (Figure 5).
Figure 5.
Willingness to pay out-of-pocket for testing alternatives to biopsy. The vast majority (82%) were willing to pay out of pocket costs for alternatives for biopsy, demonstrating the desire for such solutions. 14% were willing to incur substantial costs at >$100.
Needle phobia and apprehension were identified as important factors influencing patients’ attitudes toward biopsies. These fears, coupled with concerns about pain and discomfort, may lead to delays in diagnosis or avoidance of medical care altogether.
4. Discussion
A skin biopsy is the first step in obtaining a histological diagnosis of dermatologic diseases. Once the biopsy is performed by a dermatologist or another clinical provider, the tissue must be fixed, processed, sectioned and histochemically stained. Afterward, a dermatopathologist or a trained professional must examine the sample under a microscope. This process can be time- and resource-intensive.
Understanding the decision-making process around skin biopsy is central to exploring patient perceptions and barriers to biopsy acceptance. The decision to perform a biopsy is made by a dermatology provider, yet limited access to board-certified dermatologists can delay or prevent accurate lesion assessment. In such cases, patients may be seen by advanced practice providers (APPs), such as physician assistants or nurse practitioners, whose diagnostic accuracy for skin cancer is lower than that of board-certified dermatologists. One study found APPs performed more biopsies than dermatologists to diagnose a single case of skin cancer, potentially increasing patient burden from unnecessary procedures. These provider-related factors directly influence patient experiences and highlight the need to better understand patient attitudes toward biopsies and their interest in less invasive diagnostic alternatives [6].
There are limited studies available on beliefs and attitudes toward skin biopsies. One study suggested that a biopsy might be linked to a more positive attitude toward the physician and increased treatment compliance by the patient [7]. This effect, linked to subliminal mortality salience triggered by the biopsy, suggests the procedure influences patient compliance, regardless of personality traits like trust in doctors or authoritarian tendencies.
Biopsies can also induce negative effects. A recent study identified several potential complications associated with punch biopsy, highlighting the importance of risk awareness and patient preparation [8]. The most common adverse effect was postoperative bleeding, occurring in 0.9% of cases, particularly when biopsies were performed outside the trunk or in patients with low platelet counts. Less frequent complications included postoperative infection and skin injury (each in 0.2% of patients), with the latter often resulting from sudden body movement during the procedure. A vagal reflex was reported in 0.1% of cases.
Negative psychological effects include anticipatory anxiety in patients, resulting in heightened post-procedure pain and discomfort [7]. Biopsy phobia or apprehension of undergoing a biopsy procedure may impede a patient’s decision to undergo a biopsy. This may originate from fear of pain, discomfort, needles, or a medical environment, uncertainty, a lack of control of what will happen during the procedure, or even a previous negative experience related to a negative health outcome. This may lead individuals to avoid delays in diagnosis or even treatment, which can impact their health. Individuals with biopsy apprehension may avoid seeking medical care altogether, leading to missed opportunities for early intervention and treatment.
A comprehensive informed consent process that outlines the risks and benefits of the procedure can contribute to reduced anxiety about the procedure and improved overall satisfaction. Moreover, providing information about a punch biopsy through video may help decrease pre-procedure anxiety levels both psychologically and physiologically.
Alongside the risks and concerns associated with skin biopsies, needle phobia is widely prevalent. One systematic review concluded that needle phobia may affect the majority of children, 20–50% of adolescents, and 20–30% of adults [9]. In another study of 1,325 adult participants, needle phobia was observed in 63.2% of adults, who rated their fear as 5.7 on a 10-point scale. The potential for pain was identified as a cause of needle phobia by 95.5% of respondents, yet only 44.4% reported this fear to their physician. Furthermore, 94.1% of respondents recognized the potential use of noninvasive alternatives as a way to reduce needle phobia [10].
Our results suggest that patients prefer a painless alternative to skin biopsy. Common attitudes associated with biopsy procedures included pain, prolonged recovery, risk of infection and risk of scarring.
Several technologies have emerged as alternatives to traditional skin biopsies, offering less invasive and more patient-friendly approaches for diagnosing and monitoring skin conditions. These alternatives aim to reduce discomfort, scarring, and the need for surgical procedures. Few are FDA-approved, while others are still in development.
FDA-approved technologies include reflective confocal microscopy (RCM), a type of confocal microscopy that uses reflective optics to capture black-and-white images of samples. While RCM allows for high-resolution images, the process is time-consuming and requires extensive training to interpret images, and the image depth is limited to 300 μm, making it unsuitable for assessing tumor invasion or deep margins [11]. Tape stripping refers to the collection of genetic material from the superficial layers of skin cells via tape and the analysis of the extracted RNA. While it is minimally invasive, it is limited in its ability to analyze the deeper layers of the skin, which makes it ineffective in assessing changes deeper within the dermis [12]. Additionally, compared with biopsy, mRNA extraction is labor-intensive [12]. Electrical impedance spectroscopy involves applying an electric current via specialized microneedle probes. Changes in impedance caused by the presence of melanoma cells were assessed by measuring the differential electrical impedance in normal and melanoma skin [13].
There are few studies available supporting anxiety-reducing measures for skin biopsy. Some studies suggest that skin biopsy can also cause changes in the physician-patient relationship [7]. A study performed by Kim et al. revealed that performing a skin biopsy improved patients’ outlook toward their dermatologist through “terror management theory” [7]. The procedure, which can subliminally remind patients of the possibility of cancer, triggers a sense of mortality. This psychological response, as described by the theory, increases patient compliance with a doctor’s recommendations. Anticipatory emotional distress can occur with patients undergoing breast biopsy, leading to increased levels of biopsy-related pain and discomfort [14]. Music therapy has been proposed as an effective way to reduce both the psychological and physical status of patients undergoing biopsy [15]. Additionally, patients experience less anxiety before breast biopsies if they favorably perceive their communication with their radiologist [16]. These studies suggest that there may be some effective coping strategies to reduce biopsy-related anxiety and that biopsy may be a tool to improve the physician-patient relationship. However, good communication on the risks and benefits places additional time burdens on the clinic visit. Additional studies must explore patient preference for noninvasive alternatives to skin biopsy as options to mitigate anticipatory anxiety.
Our results show there is substantial interest in noninvasive testing options instead of a biopsy. Biopsies are perceived as painful, and scarring remains a concern for many patients. Needle phobia likely adds an extra level of fear around the skin biopsy and would be worth exploring in more detail in future studies. Interestingly, patients are open to paying out of pocket for an alternative assessment approach even when it is not covered by insurance. Future surveys should ask about income levels and insurance types to assess how socioeconomic status and accessibility to healthcare affect a patient’s openness to alternative testing approaches to skin biopsies.
The present study offers new insights, though important limitations remain. Survey data was only collected from patients who were willing to take it prior to their dermatology clinic visit, which could have filtered out patients who were nervous or have baseline anxiety about interactions at the dermatology office. Additionally, it was a single-site study which surveyed literate and English-speaking patients. Therefore, it did not explore or assess for cultural or linguistic factors that can affect biopsy beliefs. Furthermore, there was no free response section to gauge more nuanced perceptions around biopsy beliefs. Further studies that elaborate on biopsy beliefs and provide more robust responses will add to the current limited literature around this topic.
5. Conclusion
Given the level of discomfort, recovery time and pain perception associated with skin biopsy, many patients express strong interest in evaluating moles without undergoing a biopsy. Noninvasive diagnostic options offer an appealing alternative, especially for those concerned about procedural risks and post-procedural recovery. Notably, even when these technologies are not covered by insurance, patients show a clear willingness to pay out of pocket for noninvasive assessments. Our findings underscore the need for continued research into and development of accessible, noninvasive modalities for lesion evaluation.
Acknowledgments
We thank Dr. Yoav Litvin, Shamika Majmudar and Anne Callahan in editing the manuscript and reviewing the data.
Funding Statement
Orlucent Inc. funded the study.
Author contributions statement
Conceptualization: Sivamani, Shachaf. Data curation – Sivamani, Subramanyam, Gahoonia. Formal analysis – Sivamani, Subramanyam. Funding acquisition – Sivamani, Shachaf. Investigation – Subramanyam, Gahoonia. Methodology – Sivamani. Project administration – Shachaf, Sivamani. Resources – Subramanyam, Sivamani. Supervision – Sivamani, Shachaf. Validation – Sivamani, Shachaf. Visualization – Subramanyam, Sivamani, Gahoonia. Writing – original draft Writing – review & editing. Original draft writing: Subramanyam, Gahoonia. Review and editing: Shachaf, Sivamani.
Ethical disclosure
The Allendale IRB approved this study. The study was exempt from requiring informed consent documentation as no personally identifying information was captured from the participants. The data was collected anonymously, and patients were provided study information with an opt-out option. A single survey of participants was distributed between June 2022 and November 2022.
Disclosure statement
Raja Sivamani received research support from Orlucent. Catherine Shachaf receives salary from Orlucent. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Data availability statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.