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letter
. 2009 Jan;55(1):24.

Punch biopsy of pigmented lesions is potentially hazardous

Brett D Montgomery 1, Genevieve Marie Sadler 1
PMCID: PMC2628830  PMID: 19155361

We are concerned about the recently published video by Czarnowski et al, which teaches the procedure of punch biopsy on a pigmented lesion.1 Although punch biopsy is a useful skill in primary care dermatology in some circumstances, it is generally inappropriate for the diagnosis of pigmented lesions.

Guidelines from around the world recommend excisional (rather than incisional) biopsy of suspicious pigmented lesions.2,3 Incisional biopsies, such as punch biopsies, risk sampling error. For example, areas of invasive melanoma might be present in an excisional specimen but missed in a smaller biopsy.4 Also, different but contiguous pigmented lesions commonly exist5; sampling only the benign lesion can lead to missed or delayed diagnosis of a malignancy, with potentially hazardous consequences.

Possible indications for incisional biopsy of pigmented lesions include very large lesions for which excisional biopsy would be difficult, such as large macular pigmented facial lesions.3 Even in these cases, the use of punch biopsy in diagnosing melanocytic lesions is potentially perilous, and according to British guidelines, “there is no place for incisional biopsy in primary care.”2 We recommend that incisional biopsy in primary care be limited to nonpigmented lesions and rashes.

References

  • 1.Czarnowski C, Ponka D, Rughani R, Geoffrion P. Punch biopsy. Minor surgery video series. Can Fam Physician. 2008;54:1021. [PMC free article] [PubMed] [Google Scholar]
  • 2.Roberts DL, Anstey AV, Barlow RJ, Cox NH, Newton Bishop JA, Corrie PG, et al. UK guidelines for the management of cutaneous melanoma. Br J Dermatol. 2002;46(1):7–17. doi: 10.1046/j.1365-2133.2001.04614.x. [DOI] [PubMed] [Google Scholar]
  • 3.Australian Cancer Network . The management of cutaneous melanoma. Clinical practice guidelines. Canberra, Australia: National Health and Medical Research Council; 1999. [Accessed 2008 Dec 11]. Available from: www.nhmrc.gov.au/publications/synopses/cp68syn.htm. [Google Scholar]
  • 4.Somach SC, Taira JW, Pitha JV, Everett MA. Pigmented lesions in actinically damaged skin. Histopathologic comparison of biopsy and excisional specimens. Arch Dermatol. 1996;132(11):1297–302. [PubMed] [Google Scholar]
  • 5.Dalton SR, Gardner TL, Libow LF, Elston DM. Contiguous lesions in lentigo maligna. J Am Acad Dermatol. 2005;52(5):859–62. doi: 10.1016/j.jaad.2004.11.063. [DOI] [PubMed] [Google Scholar]

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