Shave biopsy is recommended for raised or pedunculated lesions. Non-melanotic malignant tumors such as basal cell carcinomas may be removed by combining scalpel or shave excision with electrodesiccation of the base. ^{3, 4} It may be performed using a scalpel, curette, scissors or electrosurgery. It is a rapid method of removal of growths on protruding or convex surfaces (such as the pinna and the nose) and allows easy removal of superficial lesions. Cosemetic results are usually good and the wound heals by secondary intention, thus requiring no sutures. Most shave biopsies should be performed at the level of the deep dermis. The goal is to remove all cells of the lesion without penetrating too deeply since this will promote scarring. If penetration occurs to the level of fatty tissue, convert the area to a fusiform excision and close with sutures. Do not use the shave biopsy to remove lesions suspected to be melanoma since this precludes adequate measure of depth of invasion and interferes with prognostic determination and, therefore, therapeutic intervention.

This procedure involves forming an incision over a subdermal lesion and using sharp and blunt dissection techniques to remove the lesion intact, if possible. This method is commonly used for such lesions as epidermal inclusion cysts (sebaceous cysts), fibromas, and lipomas. A simple ellipse may be used instead of an incision over large lesions where redundancy of skin is a problem.

This technique is most commonly used for evacuation of pockets of liquid material. Examples where this may be useful are abscesses, hematomas, and seromas.

Cryosurgery is the rapid removal of heat from tissue to produce a controlled destruction of benign and pre-malignant epithelial lesions. Mechanisms of cellular destruction may include physical destruction by formation of intracellular ice, change in intracellular ionic milieu, or denaturation of cell membrane components. ⁵ Lateral spread of ice formation is approximately 1.3 times that of depth. The average spread of the lateral ice rim beyond the lesion should extend 2 to 3 mm. This usually correlates to approximately 20 to 40 seconds of freeze for skin lesions. The most destruction of abnormal tissue is accomplished by the freeze-thaw-refreeze technique.

• Holding tip of nozzle 8-10 cm from the skin, spray lesion in short bursts to achieve a lateral spread of freeze to 2-4 mm and thawing times of approximately 30 seconds.
• Repeat freeze-thaw cycle once.

• Place desired amount of liquid nitrogen in a vacuum container and loosely secure opening.
• Using a cotton-tipped applicator, dip into liquid nitrogen and place on the lesion. Since liquid nitrogen evaporates quickly, it will probably be necessary to repeat this several times to obtain adequate freeze.
• Create a freeze zone extending 2-4 mm around the lesion. It should require about 30 seconds thaw time.
• Repeat the freeze-thaw cycle once for smaller lesions and twice for larger or deeper lesions.

• Make sure there is adequate pressure in the tank (usually in the green zone on most tanks).
• Choose a tip that covers the lesion but does not cover surrounding healthy tissue.
• Place water-soluble gel on the tip to act as a thermocouple.
• Place tip in contact with lesion and activate the cryoprobe. Do not apply excessive pressure to the cryotip as this will increase the depth of freeze.
• Apply freeze until a 2-3 mm iceball is formed beyond the outer edge of the lesion.
• When the desired depth is reached, deactivate the unit but do not remove the cryoprobe until the frost has disappeared (usually about 5 seconds).
• Repeat freeze-thaw cycle once.

Punch biopsy is a useful adjunct to clinical differential diagnosis in managing inflammatory dermatoses and suspected malignancies. It allows sampling of a full-thickness skin plug and thus is useful in appropriately identifying disease processes that affect the deeper dermis. The area to be sampled and duration of presence of lesion are key factors in determining proper selection of biopsy. For example, vesicobullous lesions should be biopsied early in the course of the disease while chronic lesions may not develop their histologically typical features for weeks. When there are several areas to choose from, select an early lesion or one that is well-advanced. Larger lesions should be sampled near the edge of an advancing border. Do not choose areas that have secondary changes such as crusting, excoriation, secondary infection, fissuring, erosion, or ulceration. Healing characteristics of the involved area and potential for harm to underlying structures should also be considered when choosing the site to be sampled.

Biopsy of a suspected skin cancer requires special consideration. If a lesion appears to be a basal cell carcinoma, samples may be taken throughout since most sections will yield representative tissue. It is best to completely excise lesions thought to be squamous cell carcinoma. If this is not possible or if cosmesis is a concern, a wedge of tissue taken from the edge inward may be performed. Punch biopsy samples taken from the central, edge, and deep portions of the lesion will suffice when the index of suspicion is low. ⁶ If a melanoma is strongly suspected, it is best to remove the entire lesion. Incisional or punch biopsy is indicated when the lesion is too large for simple excision or when complete removal would result in substantial disfigurement. ³ Punch biopsy may be used when the lesion is thought to be benign but histological confirmation is desired. ^{6, 7} The biopsy should include the most clinically suspicious area (the most raised or darkly pigmented). ³ If pigmented tissue is encountered at the base of the punch biopsy specimen, the depth of the punch should be continued well into the subcutaneous fat. It is very important to extend the biopsy to the entire depth of the lesion since depth in millimeters is the major prognostic feature of Stage I and II melanoma. ^{3, 7} There is no evidence that incisional biopsy increases the risk of disease progression. ³

Electrosurgery is the use of electrical energy to incise, excise, or destroy normal or diseased tissue or to control bleeding. Both benign and malignant tumors may be treated via this method. It is useful since it provides rapid surgical results and is affordable. Electrosurgery is often mistakenly referred to as electrocautery. While electrocautery involves destruction of tissue by heat application, electrosurgery refers to the use of a high-frequency electrical apparatus which transfers current into the tissue via a cold-tipped electrode. It is in the tissue that the electrical energy is converted to heat energy. When a high-frequency alternating current is applied to tissue, molecular heat generates a to-and-fro motion of electrons. ⁸ Altering the delivery characteristics of the electrical current allows one to fulgurate, desiccate or incise.

Electrosection is comparable to scalpel incision except for a small amount of heat-induced tissue damage. This technique may be used when excision with preservation of the tissue is desired for pathological interpretation. ^{4, 9} If melanoma is suspected, scalpel excision should be used since electrosurgery thermal damage may interfere with interpretation of margin involvement. Indications for this procedure include nevi, basal cell carcinomas, keratocanthomas, and fibromas. ⁴

Unlike electrodesiccation, electrofulgaration does not involve contact with the tissues. It refers to the use of very high-voltage, low-amperage, high-frequency electrical energy capable of sparking from the electrode to the tissue without actually touching the tissue. There is less heat production in the deeper tissues since superficial charring and carbonization forms an insulating barrier. Cutaneous lesions treated by this method usually heal rapidly since there is minimal dermal damage.

Cautery refers to the application of heat to tissue. This can be accomplished by both physical and electrical means. Electrocautery involves development of resistance to the passage of electrical current through a wire filament thus creating heat. The disadvantage of cautery is that this heat can cause third degree burns with excessive scarring and prolonged healing. ⁸

Verrucous lesions

Cystic acne