[4 min read] How to biopsy pigmented skin lesions

A recent article published in Australian Doctor warned against shave biopsies for pigmented skin lesions suspicious for melanoma. Below, Professor David Wilkinson offers guidance for the best-practice approach to biopsying these lesions in general practice.

General practitioners can, and should, follow the national guidelines for the diagnosis and treatment of skin cancer. The most up to date version for melanoma is found here.

Regarding the biopsy of pigmented skin lesions, actually the situation is simple and straightforward. If our suspicion is that we are looking at a melanoma, and we want to confirm that. To do so, we must remove the whole lesion for diagnostic purposes, if at all possible. A 2mm excision biopsy of a suspicious pigmented skin lesion will always yield the most accurate result. This is what we should always aim to do.

Partial biopsy of a suspicious pigmented skin lesion is to be avoided wherever possible. However, in some settings this is impossible to do (such as in large facial lesions) and so a shave or punch biopsy (or a combination of these or multiple biopsies) is appropriate.

This is not about cutting corners – it is about doing the best we can under tricky circumstances.

An experienced clinician will, at times, do a shave biopsy on suspicious pigmented skin lesions, but he / she will only do this if the lesion is small and flat. He / she will go deep enough and ensure that the entire lesion is removed for the biopsy.

As always, we should use national guidelines to support our practice. And, as always, we should apply the guidelines to the patient and situation in front of us.

Professor David Wilkinson


Read more from Professor David Wilkinson on recent research:


Interested in skin cancer medicine?

The HealthCert Professional Diploma programs offer foundation to advanced training in skin cancer medicine, skin cancer surgery or dermoscopy and provide an essential step towards subspecialisation. All programs are university quality-assured, CPD-accredited and count towards multiple Master degree pathways and clinical attachment programs in Australia and overseas. The programs are delivered online and/or face-to-face across most major cities of Australia.

Courses in Skin Cancer Medicine:
Melbourne | Adelaide | Gold Coast | Brisbane | Perth | Sydney | Online

Courses in Skin Cancer Surgery:
Melbourne | Adelaide | Gold Coast | Brisbane | Perth | Sydney

Online courses in Dermoscopy:
Trimester 1: Jan Trimester 2: May | Trimester 3: Sep

One comment on “[4 min read] How to biopsy pigmented skin lesions

  1. re How to biopsy pigmented skin lesions (David Wilkinson)
    I strongly agree with Professor Wilkinson where he states “A 2mm excision biopsy of a suspicious pigmented skin lesion will always yield the most accurate result. This is what we should always aim to do.”
    There are several reasons an excision biopsy is preferable to a shave:
    1. Regardless of “experience”, shave biopsies are more likely to have positive margins [1]. That is a fact. That can impact staging but also it is known that 10% of true melanomas are erroneously diagnosed as benign [2]. In such a situation an excision is added security.
    2. Histological assessment is more accurate with an orientated elliptical excision.
    3. It has been shown that the scar is potentially shorter after re-excision following an ellipse compared to a shave3
    4. Re-excision margins are measured from a precise line after an excision compared to an uncertain location after a shave.
    I strongly agree with the statement “General practitioners can, and should, follow the national guidelines for the diagnosis and treatment of skin cancer” and I also agree that a shave biopsy of large facial lesions may be appropriate.
    When considering a shave biopsy of a “small and flat” lesion I would consider it unlikely to be able to justify a deviation from guidelines. I suggest that in such a circumstance, if considering a shave biopsy, we could ask ourselves whether that is being considered for the benefit of the practitioner rather than the patient.

    1. Mills JK, White I, Diggs B, Fortino J, Vetto JT. Effect of biopsy type on outcomes in the treatment of primary cutaneous melanoma.(Report). American Journal of Surgery. 2013 May 1;205(5):585–90.
    2. Farmer ER, Gonin R, Hanna MP. Discordance in the histopathologic diagnosis of melanoma and melanocytic nevi between expert pathologists. Hum Pathol. 1996 Jun;27(6):528–31.
    3. Rosendahl C, Hishon M, Akay BN. Shave Versus Elliptical Biopsy for Melanoma Substantially
    Increases Re-excision Area and Length. Dermatologic surgery : official publication for American
    Society for Dermatologic Surgery [et al]. 2017 Sep 4;

Leave a Reply

Your email address will not be published. Required fields are marked *