Children can present with a wide range of skin anomalies. Some of these can prove to be relatively normal, whilst in the extreme, others can be life threatening, making timely assessment and accurate diagnosis crucial.
Many skin disorders can be diagnosed through direct observation and palpation but others may require referral to a dermatology specialist or expert. Children with a persistent skin problem or an unusual presentation may be referred to a dermatologist for further investigations in order to achieve differential diagnosis prior to initiating a clinically effective treatment regime. This may involve a microscopic or histo-pathological examination of the area of skin involved, or additional radiological imaging.
When a sample of the skin is required for the purpose of aiding an accurate diagnosis or further investigation, a minor surgical procedure is undertaken in order to obtain a biopsy sample. A biopsy can be performed by a punch biopsy, shave biopsy or surgical excision of part of a lesion (Godsell 1998).
When the full thickness of the skin (deeper dermis) needs to be assessed and analysed, a punch skin biopsy is performed. Pigmented and oily skins tend to have more scar formation than pale, dry skins (Rationale 1). Children with anaemia may have impaired healing due to reduced oxygen transportation in the blood (McClaren 1992).
Rare metabolic disorders and chromosomal abnormalities may sometimes be confirmed by examination of the fibroblasts and chondrocytes, which are cultured from skin (Rationale 2).
This procedure may be performed in a procedure room on the ward, outpatients or operating theatre.
Only a Health Care Professional (HPC) that has been trained in this skill should undertake the punch skin biopsy. Any training should acknowledge the physical act of the procedure, psychological aspects and the sequence of events (Rationale 3).
The HCP who undertakes this role should be responsible for ensuring that he/she works within their Code of professional Practice and competency. The newly trained HCP should continue to make him/herself aware of developments in practice, research and available products (NMCa 2008)(Rationale 4).
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A local anaesthetic is used when carrying out the procedure (Rationale 5).
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Oral sedation may also be required (Rationale 6).
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An aseptic non-touch technique should be employed throughout the procedure (Rationale 7).
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The site to be biopsied must be identified by the relevant multidisciplinary team member (Rationale 8).
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The site chosen for the purpose of investigating metabolic disorders is under the arm or axilla (Rationale 9).
Cytogenetics and chromosomes specimens are sent via Biochemistry to:
- N.E. Thames Regional Cytogenetics Unit
Fibroblast culture specimens are sent to:
- The Enzymology Laboratory, Level 5 Camila Botnar Laboratory, Great Ormond Street Hospital
Standard precautions and personal protective equipment (PPE) must be adopted according to hospital policy (Rationale 10).
Preparation of the child and family
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Obtain verbal and written consent from the child and family for the procedure (United Nations General Assembly 1989; Orr 1999; DH 2001a; DH 2010; NMCb 2008)(Rationale 11).
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Allow enough time between giving information to the family and child and performing the procedure (Rationale 12).
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The child and family should be given the relevant written information leaflet on skin biopsy obtainable from the GOSH website (Rationale 13 and Rationale 14).
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Inform the child and family of the following (Rationale 15, 16, and 17):
- that a punch skin biopsy is necessary
- the reason for the biopsy
- what it entails
- the potential risks of a punch skin biopsy
- are there any alternatives?
- the duration of the procedure
- the expected cosmetic outcome
- what happens afterwards?
- when to expect results
A play specialist and the child’s named nurse can help the child to be adequately prepared for the procedure (Heiney 1991)(Rationale 18).
Discuss with the family and child the appropriate method of distraction the child will use during the procedure itself. Attempt to discover what techniques are most likely to consume his attention eg. pop up books, musical books, and guided imagery where the child is encouraged to imagine something pleasant eg, a favourite holiday (Lanley 1999)(Rationale 19).
Preparation of equipment and environment
The child should be assessed for their sedation requirements. If required, the child needs to be nil orally for two hours pre-sedation (Rationale 20 and 21).
Avoid using the child’s own bed space or room. Use a clinical room (Rationale 22, 23 and 24).
The clinical area should be clean and an adjustable magnifying lamp available (Rationale 25).
The medium for a skin biopsy should be obtained from the appropriate laboratory (Rationale 26 and 27).
Special arrangements to be made for specific media:
- Formalin is used for routine histology and is obtainable from Histology.
- Liquid nitrogen is used for immunofluoresent investigations (Harper 1990). Special guidelines for the handling of liquid nitrogen may be obtained from the bone marrow laboratory (Rationale 28).
- A ‘special fixative’ for electron microscopy investigation (Harper 1990) is obtained from the Virology department.
The media cannot be sent by the pneumatic tube and should be collected by porters or delivered to the appropriate ward/clinical area or Outpatients department (Rationale 29).
The following equipment should be prepared:
- clean dressing trolley/tray or appropriate clean surface
- sterile dressing pack containing sterile non-woven swabs and a sterile towel (Rationale 30)
- disposable scalpel/sterile scissors
- sterile gloves
- disposable plastic apron
- 2 per cent chlorhexidine gluconate/70 per cent isopropyl alcohol solution applicator eg, Chloraprep® (Rationale 31 and 32)
- electronic prescription or prescription chart
- local anaesthetic, eg Lidocaine 1 per cent. Lidocaine with Adrenaline (Epinephrine) is a powerful vasoconstrictor, therefore decreasing bleeding in wounds. However this may be contraindicated in areas of end artery flow, ie. fingers and toes. This can cause palpitations and tremors, so is therefore used with caution.
- 2ml syringe
- blue needle Fg 23
- orange needle Fg 25
- correctly labeled specimen pot containing the appropriate medium. This is decided by the type of investigation required (see above).
- a sterile occlusive latex free dressing, e.g. Cutiplast® size 7.2cmx5cm or Opsite® size 6.5cmx5cm (Rationale 33, 34 and 35)
- conforming bandage
- wound closure strips, eg Steri-strips®
- tape
- disposable punch biopsy needle size 0.3 mm or 0.4 mm
- hypoallergenic dressing, eg Mepitel® (Rationale 36)
Parental role
Identify with the parent/carer their role throughout the procedure, adopting the appropriate method of distraction with the child to use during the procedure itself. The child’s parent/carer may remain with their child if they wish to do so (Rationale 37).
Explain the procedure to the family and negotiate with the them if they would like to apply the topical local anaesthetic cream to the biopsy area (Rationale 38).
Performing the procedure
Application of local anaesthetic cream
A topical local anaesthetic should be applied to the biopsy site prior to the procedure. Consult the child and family on the use of Ametop® cream. Check for previous allergic reactions to the cream and use Emla® if necessary. If Emla® is used, ensure that it remains in situ for the appropriate time (Rationale 39).
Special precautions may need to be taken with known atopic children, eg. with eczema.
The local anaesthetic used should be prescribed and checked according to the Administration of Medicines Policy (Rationale 40).
Positioning the child
Whilst maintaining the dignity of the child, place the child in a comfortable position with the potential biopsy area exposed. Positioning of the child will depend on the site of the skin biopsy. The position should be the most comfortable and reassuring for the child. Small children/infants can lie or sit on an adult’s lap. Ensure a young child has his/her favourite cuddly toy or comforter with him/her throughout (Robinson 1997; Royal College of Nursing 2010)(Rationale 41 and 42).
Consider moving and handling risks.
Preparation of the skin biopsy site
Perform a hygenic handwash (Your 5 moments of hand hygiene http://www.gosh.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=100485)
Put on the appropriate protective clothing.
Remove the local anaesthetic cream and wipe dry with a tissue or gauze. Confirm with the child, if appropriate, that the cream has caused numbness of the skin effectively.
The biopsy area should be cleaned for 30 seconds with an alcohol based cleansing solution eg Chloraprep® and allowed to dry for another 30 seconds (Niffeneger 1997; Franklin 1998; DH 2003).
Check the child’s name, date of birth, hospital number and allergies against the prescription charts (Rationale 43).
The local anaesthetic should be prepared using an aseptic non-touch technique. Draw up in a 2ml syringe with a blue needle and change to an orange needle (Rationale 44).
The HCP should warn the child that subcutaneous infiltration of the local anaesthetic will sting or cause a burning sensation. It should be injected subcutaneously using the ‘spider technique’, lifting a skin fold to ensure that the subcutaneous injection is achieved. This forms a ‘bleb’ or small bump (Winslow 1997; King 2003)(Rationale 45).
Time must be allowed for the anaesthetic to take effect. Wait 2-3 minutes before proceeding (Rationale 46).
Taking the skin biopsy sample
Pull the skin around the biopsy area tight (Rationale 47).
Introduce an appropriate sized disposable punch biopsy firmly at a perpendicular angle to the anaesthetised area of the skin surface (Rationale 48).
The needle punch biopsy should be rotated 360 degrees with the cutting edge carrying the punch down onto the tissue (Rationale 49).
The guard on the sterile punch biopsy will prevent too deep a penetration (Rationale 50).
Withdraw the needle whilst applying pressure on the puncture site with a non-woven swab. This should release the skin specimen.
Remove the specimen using the plastic disposable forceps and disposable scalpel or sterile scissors (Rationale 51).
Specimens taken for rare metabolic disorders should be removed using a disposable scalpel blade (Rationale 52).
Place the specimen in the appropriate biopsy medium and ensure container is correctly labelled (Rationale 53).
Apply continuous pressure to biopsy site for three to five minutes or until bleeding stops (Rationale 54).
For immunocompromised children, once bleeding has stopped apply some Bactroban® ointment to the site.
Apply wound closure strips, eg Steri-strips® in a ‘star’ pattern (Rationale 55).
Once haemostasis has been achieved apply (Harper 1990)(Rationale 56) either:
- a dry dressing, eg Cutiplast® or Op-site® or
- a low-adherent dressing, eg Mepitel®, if the surrounding skin is fragile
Cover the dressing with a pressure dressing. When tape cannot be applied due to fragile skin use a bandage to secure the dressing (Rationale 57).
Dispose of used equipment and sharps according to the Trust Waste Policy. Remove protective clothing and perform a social hand wash (Rationale 58).
Document the type of specimen, the time, date and site where the biopsy was taken (Rationale 59).
Place the sample in a protected polythene specimen bag and send it to the appropriate laboratory as quickly as possible by a porter or clinicians assistant (Rationale 60 and 61).
Record the procedure in the child’s health care records (NMC 2007)(Rationale 62).
Time should be taken to give positive feedback to the child for tolerating the invasive procedure and to the parent/carer for their valuable contribution (Rationale 63 and 64).
Post procedural care
Once the procedure has been completed the child may return to their bed or the playroom or they may go straight home (Rationale 65).
If sedation has been given, their level of consciousness and their vital signs must be assessed according to their Child Early Warning Score (CEWS) pre discharge (Rationale 66).
Assess the child’s need for analgesia. Oral analgesia may be required if the child experiences pain or discomfort (Rationale 67).
The analgesia must be prescribed and administered according to the Administration of Medicines Policy. Advise the family to give further analgesia when at home if the child continues to experience discomfort.
The dressing should be observed intermittently within the first 24 hours for any bleeding. The pressure dressing should be removed after this time (Rationale 68).
The child’s doctor should be informed if bleeding is observed. The family/child’s carer should be given clear instructions to contact their GP or health care professional if a problem occurs.
A clean wound should be left untouched, leaving the exudates to nourish the natural healing process (Brigg 1996; Dealey 1994)(Rationale 69, 70 and 71).
The site should be kept dry and left untouched for 48 hours (Rationale 72).
The dressing may be removed after 48 hours.
The Steri-strips® may begin to fall off. Allow this to happen. If still intact they may be removed after the 3rd day. Many children prefer to remove their own dressings by soaking them off in the bath or shower (Bale 1996)(Rationale 73).
Once skin edges have sealed, bathing or showering is not likely to cause any further risk. (Briggs 1997)(Rationale 74).
Healing in immune-compromised children may be delayed because of reduced efficiency of the immune system. Secondary to this is a decreased resistance to infection, which in turn will delay healing (Trott 1997; Morrison 1992).
Immune-compromised children may be prescribed a prophylactic topical antibiotic. Patients with an uncomplicated laceration do not usually develop an infection. The first application is applied after haemostasis has occurred (Rationale 75).
The second application should be made 48 hours after the procedure when the dressing is removed.
The topical antibiotics must be prescribed and administered according to the Administration of Medicines Policy (Rationale 76).
A written instruction sheet on the care of the biopsy site must be given and explained to the main parent/caregiver on discharge. It should also include parent education about the wound healing process, which should include a discussion of when the child can return to their normal activities (Rationale 77).
An outpatient’s appointment must be given to family (Rationale 78).
The child and family must be informed of the results of the procedure as soon as possible, although they should be advised it can take six to eight weeks to grow the skin cells and a further six to eight weeks for the biopsy results to be available dependant on the nature of analysis of the biopsy (Rationale 79 and 80).
This discussion must be recorded in the child’s health care records (NMC 2007)(Rationale 81).
Rationale 1: To identify disease processes in the deeper dermis and to confirm diagnosis (Godsell 1998).
Rationale 2: To aid diagnosis and identify potential treatment.
Rationale 3: To ensure consistent and safe practice.
Rationale 4: To ensure that his/her knowledge remains valid, up to date and his/her practice safe and efficient.
Rationale 5: To minimise pain, stress and anxiety.
Rationale 6: In receiving sedation, the patient is better able to tolerate the overall procedure.
Rationale 7: To minimise the risk of infection.
Rationale 8: To aid diagnosis.
Rationale 9: To minimise visible scarring and provide a good cosmetic outcome.
Rationale 10: To prevent contamination and to safeguard the HCP performing the procedure.
Rationale 11: To ensure that informed consent is obtained and to allow the family to develop coping strategies.
Rationale 12: If too much or too little time is allowed, the child will become anxious. The better informed the child the better able he/she will be able to develop coping strategies.
Rationale 13: To address any information requirements.
Rationale 14: To empower the child and family and alleviate any worries or concerns
Rationale 15: To obtain informed written consent according to Hospital Policy.
Rationale 16: To minimise anxiety.
Rationale 17: To empower the family.
Rationale 18: To prepare the child according to their age and cognitive development in language that they can understand avoiding jargon.
Rationale 19: To prevent the child’s whole attention being centred on the invasive procedure. These techniques can help to distract and relax the child (Heiney 1991; Langley 1999).
Rationale 20: To facilitate compliance and minimise anxiety.
Rationale 21: To minimise risk of vomitting and potential aspiration.
Rationale 22: All equipment is close at hand.
Rationale 23: To ensure the child’s own bed space remains a safe haven.
Rationale 24: Greater privacy for the child and family.
Rationale 25: To allow good visualisation of the biopsy area.
Rationale 26: Discuss with the laboratory what medium is required for the different types of biopsies.
Rationale 27: Ensure the laboratory request form has the correct information.
Rationale 28: To meet the Control of Substances Hazardous to Health Regulations (COSHH) and Health & Safety Regulations (Health and Safety Executive 2002).
Rationale 29: To prevent leakage and contamination, which may prevent the skin cells from growing.
Rationale 30: Some literature suggests that fibres shed from cotton wool swabs can become entwined in tissue and create foci for infection (Brigg 1996).
Rationale 31: Active against a wide range of gram-positive and negative organisms.
Rationale 32: Routine use of Providone-iodine solution should be avoided in small babies and children. Iodine absorption may cause hypothyroidism during a critical period of neurological development and stains the skin cells (Smerdely 1989).
Rationale 33: A wound dressing serves several functions. They protect the wound from further insult, keep the wound clean, and provide a moist environment that promotes healing (Autio 2002).
Rationale 34: To minimise increased risk of scarring.
Rationale 35: Choosing an appropriate dressing is difficult especially with the wide and confusing range that is available for use today. For children, dressings must be easy to apply, remove and be able to withstand the rigors of children’s activities and secure enough to prevent the child from interfering with the wound (Teare 1997).
Rationale 36: To prevent further breakdown of fragile skin.
Rationale 37: To minimise anxiety to the child and to empower the family/carer.
Rationale 38: Parents are better able to gain their child’s co-operation.
Rationale 39: The minimal time for Ametop® is 30 minutes. The optimal application time for Emla® to achieve 95% anaesthesia to the area is 90 minutes. This is due to the nerve fibre size and is particularly relevant in the age group 1-5 years. Application of local anaesthetic will reduce the pain of the procedure (Lawson 1995; Clark 1986; Smith 2003).
Rationale 40: To meet hospital policy requirements.
Rationale 41: To minimise the risk of infection.
Rationale 42: To reassure the child and help reduce the pain.
Rationale 43: To identify the patient and prevent a medication error.
Rationale 44: To minimise the risk of infection.
Rationale 45: Less adipose tissue the greater risk of intramuscular injection (Rationale 26 and 27).
Rationale 46: To gain maximum benefit from the anaesthesia and to ensure that it is effective.
Rationale 47: To immobilise the skin.
Rationale 48: To facilitate effective biopsy taking.
Rationale 49: To ensure that the full thickness of the deeper dermis is obtained.
Rationale 50: To avoid damage to underlying tissue and to minimise pain and bleeding.
Rationale 51: To obtain sample and prevent damage to the fibroblasts and skin tissue.
Rationale 52: To ensure that the fibroblasts on the skin are not damaged.
Rationale 53: To prepare for laboratory analysis to enable correct analysis and correctly identify the patient.
Rationale 54: To achieve haemostasis.
Rationale 55: To ensure the edges of the wound are drawn carefully together so as to promote effective healing and improve cosmetic outcome. Steri-strips® work best in superficial low-tension wounds. It is inexpensive, easy and painless to apply (Rationale 15).
Rationale 56: To protect the site and minimise infection, in order to maintain comfort and prevent further irritation and provide a moist environment that promotes healing (Rationale 15).
Rationale 57: To maintain skin integrity and comfort.
Rationale 58: To meet hospital policy and to prevent an inoculation injury reducing the risk of cross infection.
Rationale 59: To enable analysis to take place.
Rationale 60: Depending upon the medium used, there is a risk of chemical injury to those handling the sample.
Rationale 61: To meet the Control of Substances Hazardous to Health Regulations (COSHH) and Health and Safety Regulations (Health and Safety Executive 2002).
Rationale 62: To maintain an accurate record.
Rationale 63: To conclude the procedure with a positive outcome.
Rationale 64: To acknowledge the value of the involvement of the parent/carer.
Rationale 65: To facilitate safety and comfort.
Rationale 66: To ensure the child is awake and orientated prior to discharge.
Rationale 67: To relieve pain and to promote comfort.
Rationale 68: To detect early signs of biopsy site complications.
Rationale 69: To minimise the risk of infection.
Rationale 70: Children in good health have a vigorous healing reaction.
Rationale 71: Increased metabolism and good circulation contribute to increased rates of healing (Dealey 1994).
Rationale 72: Consider wound healing within the context of the child’s childhood disorder.
Rationale 73: To minimise the risk of scarring.
Rationale 74: To allow normal hygiene practices to resume.
Rationale 75: To prevent infection. Use of adhesive tapes is also associated with decreased infection rates (Trott 1997).
Rationale 76: To meet Hospital Policy.
Rationale 77: To ensure that the child doesn’t pick at the tape and remove the dressing delaying healing.
Rationale 78: To inform parents of results and to recommend future action/treatment
Rationale 79: To keep the child and family informed.
Rationale 80: This may be due to time taken for the growing of skin cells.
Rationale 81: To provide an accurate record.
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Document control information
Lead author(s) Zoe Wilks, Head of Nursing/Operational Manager, Outpatient Department
Document owner
Zoe Wilks, Head of Nursing/Operational Manager, Outpatient Department
Approved byClinical Practice Committee
First introduced: September 1 2000
Date approved: 26 March 2012
Review schedule: Two years
Next review: 26 March 2014
Document version: 2.0
Replaces version: 1.0
