B e s t Wa y to P e r f o r m a P u n c h Bi o p s y Judith Domínguez-Cherit, MDa,*, Daniela Gutiérrez Mendoza, MDb KEYWORDS Nails Nail punch biopsy Punch biopsy Nail surgery Matrix Nail bed Nail plate Periungueal folds
KEY POINTS Punch biopsy is useful for the diagnosis and treatment of nail diseases. The goal of a punch biopsy is to obtain a 2- to 3-mm tissue sample for successful interpretation of nail diseases. All anatomic sites of the nail apparatus may be sampled with a punch biopsy. It is helpful to soften the nail before the procedure by soaking it in water for 5 minutes. Punch biopsy is a simple procedure with rapid healing time and few complications.
A video of nail punch biopsy accompanies this article at http://www.derm.theclinics.com/
Nail biopsy is used for the diagnosis and treatment of nail diseases. Punch biopsy is among the many techniques that may be used and, like all nail procedures, best results are possible when the surgeon is familiar with the anatomy and the physiology of the nail apparatus.
TREATMENT GOALS AND PLANNED OUTCOMES The goal of a punch biopsy is to obtain a 2- to 3-mm tissue sample for the diagnosis of nail diseases, to improve a medical condition, or to completely remove a nail tumor.
PREOPERATIVE PLANNING AND PREPARATION Before performing the procedure, the surgeon must plan the objective of the surgery. If the biopsy
is for diagnostic purposes, enough specimen for histologic analysis must be obtained. It must also be handled with care. Often, the tissue obtained from a punch biopsy is difficult to interpret because it is too small and fragile, and becomes damaged during handling.1 A second issue to consider is that an experienced surgeon who is familiar with the anatomy and the physiology of the nail apparatus is required to ensure the desired anatomic site is excised and to avoid damage of the area that will lead to postoperative complications. If the goal is to completely remove a lesion that is larger than 3 mm, it is better to consider using another method instead. It is always helpful to soak the nail in warm water for 5 to 10 minutes before the procedure to soften the nail especially in the case of thick toenails. The entire finger or toe should be cleaned with chlorhexidine or other surgical soap.2
No disclosures. a Department of Dermatology, Insituto Nacional de Ciencias Me´dicas y Nutricio´n “Salvador Zubiran”, Av. Vasco de Quiroga #15, Colonia Belisario Dominguez Seccio´n XVI, Delegacio´n Tlalpan, CP 14000, Me´xico Distrito Federal 14000, Mexico; b Department of Dermatology, Hospital General “Dr Manuel Gea Gonza´lez”, Av. Calzada de Tlalpan #4800, Tlalpan Seccion XVI, CP 14080, Me´xico Distrito Federal, Mexico * Corresponding author. E-mail addresses: [email protected]; [email protected] Dermatol Clin 33 (2015) 273–276 http://dx.doi.org/10.1016/j.det.2014.12.008 0733-8635/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
derm.theclinics.com
INTRODUCTION
Domı´nguez-Cherit & Gutie´rrez Mendoza
274
PATIENT POSITIONING The patient has to be in a comfortable sitting position. To achieve stability, it is best to use an armrest for fingernail procedures. In the case of toenails, a more stable position is attained with a bended knee.
THE BEST WAY TO PERFORM A PUNCH BIOPSY The following materials are necessary for a punch biopsy: 1. 2. 3. 4. 5.
A disposable punch no. 2 or 3; Iris scissors; Suture scissors when necessary; Nail holder; and Cyanoacrylate when necessary.
Fine instruments, like Castroviejo scissors, a nail holder, and forceps are recommended.
THE PROCEDURE This procedure needs to be done under local anesthesia (Video 1). The proximal nerve block is preferred. In the absence of nail plate, this is the best way to perform a punch biopsy. 1. The disposable punch is positioned vertically, at a 90 angle, or perpendicular to the finger. 2. The punch is rotated in 1 direction with continuous and mild pressure. 3. The tissue is then carefully extracted with the help of iris scissors, trying not to use forceps, to avoid crushing the specimen. 4. No suture is necessary.
Fig. 1. Technique for medial melanonychia (A). Cutting and elevating proximal nail plate (B). Performing a 3-mm punch biopsy (C). Removal of tissue (D). Circular defect (E). Reattachment and suture of nail plate and fold (F).
Best Way to Perform a Punch Biopsy If the nail plate is present, it has to be removed before biopsy. This is the best way it can be done: 1. The nail plate can be removed with a bigger punch (4 mm). 2. The nail plate is removed and the underlying nail bed is exposed. 3. A smaller punch (2–3 mm) is used to for a biopsy of the nail bed. 4. The nail plate is reinserted and may be fixed with cyanoacrylate glue or by suturing the nail plate to the nail fold (Fig. 1).3 Another way to remove the nail plate is to cut the desired shape of the nail plate with a scalpel. The submarine technique can also be used.4 This technique consists of removing a strip of nail plate or total avulsion. The submarine technique is used when the site for the tissue sampling has been explored previously. A punch biopsy can be used in every anatomic site of the nail apparatus (Fig. 2). It is helpful in
diagnosing nail disorders, but can also be useful for treating subungual abscess or hematoma (Fig. 3). A modified nail punch biopsy technique consists in using a 2-mm punch for trepanation of the nail plate (Table 1).5
POTENTIAL COMPLICATIONS AND THEIR MANAGEMENT Some complications can be expected, including edema and pain. These complications can be prevented by elevating the extremities. The hand may be elevated using a sling. Infection, although rare, is an unexpected complication that should be treated immediately after it is suspected with oral broad spectrum antibiotics.
POSTPROCEDURAL CARE A thick dressing is secured and kept in place for 48 hours to prevent excessive bleeding and to protect the area from trauma and pain. The patient should be careful to rest for at least 1 week to avoid swelling, pain, and other potential complications. After 2 days the patient will need to clean the surgical site with peroxide on a daily basis and apply a petrolatum gauze to prevent objects from sticking to the wound.2
OUTCOMES If any, permanent nail dystrophy or hemorrhage may occur.
EVIDENCE: CLINICAL RESULTS IN THE LITERATURE A proximal nail fold–lunula double punch technique has been recently published and it seems to have
Fig. 2. Punch biopsy of the nail apparatus. Punch biopsy may be performed on the nail bed (a). On the nail bed when the nail plate is present, a bigger punch must first be used to expose the nail bed (b). On the nail bed with the submarine technique, which exposes the distal end of the nail bed by clipping the nail plate (c), on the proximal (d) or lateral nail fold (e).
Fig. 3. Punch biopsy to treat a complete subungual hematoma. A punch is positioned perpendicular to the nail plate to evacuate a hematoma.
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Table 1 Indications for punch biopsy according to anatomic site Uses Anatomic Site
Diagnosis
Treatment
Nail plate
Onicomicosis Hematomas Tumors Inflammatory conditions
—
Inflammatory conditions Longitudinal melanonychia Tumors Inflammatory conditions Eritronychia
Tumors Longitudinal melanonychia
Periungual folds Hyponychium Eponychium Lateral folds Matrix
Nail bed
good results for tissue sampling. It avoids having to cut the proximal nail fold to expose the matrix. According to the authors, it is less painful, has faster cure rates, and fewer possibilities for dystrophy.1
SUMMARY A punch biopsy can be used for the diagnosis and treatment of nail conditions in all areas of the nail apparatus. When the procedure is performed with a careful handling of the anatomic site and specimen, a successful diagnosis can be achieved in most cases.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.det. 2014.12.008.
Tumors Warts
Subungual hematoma Acute paronychia
REFERENCES 1. Kim JE, Ahn HS, Cheon MS, et al. Proximal nail fold-lunula double punch technique: a less invasive method for sampling nail matrix without nail avulsion. Indian J Dermatol Venereol Leprol 2011; 77(3):346–8. 2. Haneke E. Nail surgery indications and outcomes. Expert Rev Dermatol 2006;1(1):1–11. 3. Domı´nguez Cherit J, Fonte Avalos V, Gutie´rrez Mendoza D. Principios Ba´sicos en cirugı´a de un˜as. ˜ AS. Mexico City (Me´xico): Elsevier; 2011. p. En UN 42–58. 4. Zaiac M, Norton ES, Tosti A. The “submarine hatch” nail bed biopsy. J Am Acad Dermatol 2014; 70:E128. 5. Khan A, Wes E, Tyler M. Two-millimeter biopsy punch. A painless instrument for evacuation of subungueal haematomas in adults and children. J Hand Surg Eur 2011;36:615.
KEY POINTS Punch biopsy is useful for the diagnosis and treatment of nail diseases. The goal of a punch biopsy is to obtain a 2- to 3-mm tissue sample for successful interpretation of nail diseases. All anatomic sites of the nail apparatus may be sampled with a punch biopsy. It is helpful to soften the nail before the procedure by soaking it in water for 5 minutes. Punch biopsy is a simple procedure with rapid healing time and few complications.
A video of nail punch biopsy accompanies this article at http://www.derm.theclinics.com/
Nail biopsy is used for the diagnosis and treatment of nail diseases. Punch biopsy is among the many techniques that may be used and, like all nail procedures, best results are possible when the surgeon is familiar with the anatomy and the physiology of the nail apparatus.
TREATMENT GOALS AND PLANNED OUTCOMES The goal of a punch biopsy is to obtain a 2- to 3-mm tissue sample for the diagnosis of nail diseases, to improve a medical condition, or to completely remove a nail tumor.
PREOPERATIVE PLANNING AND PREPARATION Before performing the procedure, the surgeon must plan the objective of the surgery. If the biopsy
is for diagnostic purposes, enough specimen for histologic analysis must be obtained. It must also be handled with care. Often, the tissue obtained from a punch biopsy is difficult to interpret because it is too small and fragile, and becomes damaged during handling.1 A second issue to consider is that an experienced surgeon who is familiar with the anatomy and the physiology of the nail apparatus is required to ensure the desired anatomic site is excised and to avoid damage of the area that will lead to postoperative complications. If the goal is to completely remove a lesion that is larger than 3 mm, it is better to consider using another method instead. It is always helpful to soak the nail in warm water for 5 to 10 minutes before the procedure to soften the nail especially in the case of thick toenails. The entire finger or toe should be cleaned with chlorhexidine or other surgical soap.2
No disclosures. a Department of Dermatology, Insituto Nacional de Ciencias Me´dicas y Nutricio´n “Salvador Zubiran”, Av. Vasco de Quiroga #15, Colonia Belisario Dominguez Seccio´n XVI, Delegacio´n Tlalpan, CP 14000, Me´xico Distrito Federal 14000, Mexico; b Department of Dermatology, Hospital General “Dr Manuel Gea Gonza´lez”, Av. Calzada de Tlalpan #4800, Tlalpan Seccion XVI, CP 14080, Me´xico Distrito Federal, Mexico * Corresponding author. E-mail addresses: [email protected]; [email protected] Dermatol Clin 33 (2015) 273–276 http://dx.doi.org/10.1016/j.det.2014.12.008 0733-8635/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
derm.theclinics.com
INTRODUCTION
Domı´nguez-Cherit & Gutie´rrez Mendoza
274
PATIENT POSITIONING The patient has to be in a comfortable sitting position. To achieve stability, it is best to use an armrest for fingernail procedures. In the case of toenails, a more stable position is attained with a bended knee.
THE BEST WAY TO PERFORM A PUNCH BIOPSY The following materials are necessary for a punch biopsy: 1. 2. 3. 4. 5.
A disposable punch no. 2 or 3; Iris scissors; Suture scissors when necessary; Nail holder; and Cyanoacrylate when necessary.
Fine instruments, like Castroviejo scissors, a nail holder, and forceps are recommended.
THE PROCEDURE This procedure needs to be done under local anesthesia (Video 1). The proximal nerve block is preferred. In the absence of nail plate, this is the best way to perform a punch biopsy. 1. The disposable punch is positioned vertically, at a 90 angle, or perpendicular to the finger. 2. The punch is rotated in 1 direction with continuous and mild pressure. 3. The tissue is then carefully extracted with the help of iris scissors, trying not to use forceps, to avoid crushing the specimen. 4. No suture is necessary.
Fig. 1. Technique for medial melanonychia (A). Cutting and elevating proximal nail plate (B). Performing a 3-mm punch biopsy (C). Removal of tissue (D). Circular defect (E). Reattachment and suture of nail plate and fold (F).
Best Way to Perform a Punch Biopsy If the nail plate is present, it has to be removed before biopsy. This is the best way it can be done: 1. The nail plate can be removed with a bigger punch (4 mm). 2. The nail plate is removed and the underlying nail bed is exposed. 3. A smaller punch (2–3 mm) is used to for a biopsy of the nail bed. 4. The nail plate is reinserted and may be fixed with cyanoacrylate glue or by suturing the nail plate to the nail fold (Fig. 1).3 Another way to remove the nail plate is to cut the desired shape of the nail plate with a scalpel. The submarine technique can also be used.4 This technique consists of removing a strip of nail plate or total avulsion. The submarine technique is used when the site for the tissue sampling has been explored previously. A punch biopsy can be used in every anatomic site of the nail apparatus (Fig. 2). It is helpful in
diagnosing nail disorders, but can also be useful for treating subungual abscess or hematoma (Fig. 3). A modified nail punch biopsy technique consists in using a 2-mm punch for trepanation of the nail plate (Table 1).5
POTENTIAL COMPLICATIONS AND THEIR MANAGEMENT Some complications can be expected, including edema and pain. These complications can be prevented by elevating the extremities. The hand may be elevated using a sling. Infection, although rare, is an unexpected complication that should be treated immediately after it is suspected with oral broad spectrum antibiotics.
POSTPROCEDURAL CARE A thick dressing is secured and kept in place for 48 hours to prevent excessive bleeding and to protect the area from trauma and pain. The patient should be careful to rest for at least 1 week to avoid swelling, pain, and other potential complications. After 2 days the patient will need to clean the surgical site with peroxide on a daily basis and apply a petrolatum gauze to prevent objects from sticking to the wound.2
OUTCOMES If any, permanent nail dystrophy or hemorrhage may occur.
EVIDENCE: CLINICAL RESULTS IN THE LITERATURE A proximal nail fold–lunula double punch technique has been recently published and it seems to have
Fig. 2. Punch biopsy of the nail apparatus. Punch biopsy may be performed on the nail bed (a). On the nail bed when the nail plate is present, a bigger punch must first be used to expose the nail bed (b). On the nail bed with the submarine technique, which exposes the distal end of the nail bed by clipping the nail plate (c), on the proximal (d) or lateral nail fold (e).
Fig. 3. Punch biopsy to treat a complete subungual hematoma. A punch is positioned perpendicular to the nail plate to evacuate a hematoma.
275
276
Domı´nguez-Cherit & Gutie´rrez Mendoza
Table 1 Indications for punch biopsy according to anatomic site Uses Anatomic Site
Diagnosis
Treatment
Nail plate
Onicomicosis Hematomas Tumors Inflammatory conditions
—
Inflammatory conditions Longitudinal melanonychia Tumors Inflammatory conditions Eritronychia
Tumors Longitudinal melanonychia
Periungual folds Hyponychium Eponychium Lateral folds Matrix
Nail bed
good results for tissue sampling. It avoids having to cut the proximal nail fold to expose the matrix. According to the authors, it is less painful, has faster cure rates, and fewer possibilities for dystrophy.1
SUMMARY A punch biopsy can be used for the diagnosis and treatment of nail conditions in all areas of the nail apparatus. When the procedure is performed with a careful handling of the anatomic site and specimen, a successful diagnosis can be achieved in most cases.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.det. 2014.12.008.
Tumors Warts
Subungual hematoma Acute paronychia
REFERENCES 1. Kim JE, Ahn HS, Cheon MS, et al. Proximal nail fold-lunula double punch technique: a less invasive method for sampling nail matrix without nail avulsion. Indian J Dermatol Venereol Leprol 2011; 77(3):346–8. 2. Haneke E. Nail surgery indications and outcomes. Expert Rev Dermatol 2006;1(1):1–11. 3. Domı´nguez Cherit J, Fonte Avalos V, Gutie´rrez Mendoza D. Principios Ba´sicos en cirugı´a de un˜as. ˜ AS. Mexico City (Me´xico): Elsevier; 2011. p. En UN 42–58. 4. Zaiac M, Norton ES, Tosti A. The “submarine hatch” nail bed biopsy. J Am Acad Dermatol 2014; 70:E128. 5. Khan A, Wes E, Tyler M. Two-millimeter biopsy punch. A painless instrument for evacuation of subungueal haematomas in adults and children. J Hand Surg Eur 2011;36:615.
