Continuing Education Activity

Nail biopsies are performed in order to diagnose and treat a big assortment of pathologies, some of which are potentially fatal. The breeze through biopsy is not just one proficiency but a variety of techniques, each of which plays a specific character in diagnoses. This activity outlines proper indications, contraindications, preparations, and techniques for nail biopsies and highlights the healthcare team ‘s function in evaluating and treating nail pathologies. Objectives:

  • Describe the relevant anatomy of the smash unit pertinent to nail biopsies .
  • Identify pathologies that require a smash biopsy.

    Reading: Nail Biopsy

  • Outline the steps in performing each of the smash biopsy techniques .
  • Review how interprofessional team collaboration can improve affected role consequence when the subject warrants a nail biopsy .

Access free multiple choice questions on this topic.


The nail biopsy is an essential operation utilized by dermatologists to establish the diagnosis of a variety show of bark and complete pathologies. The nail biopsy encompasses respective biopsy techniques that include but are not limited to the collar denture, pinpoint sleep together, complete pen up, and nail matrix. [ 1 ] [ 2 ] The favor fundamental diagnosis frequently determines the site of the biopsy and the techniques employed. The nail matrix is very finespun and carries its own biopsy risks and side effects. even then, the majority of pinpoint biopsies carry minimal to no risk of permanent nail muscular dystrophy. [ 3 ]

Anatomy and Physiology

The nail matrix is a crescent structure at the base of the complete, which produces the nail down plate. damage to the matrix may lead to scarring and muscular dystrophy of the complete. The matrix is divided into proximal and distal ; the proximal matrix is responsible for producing the superficial complete plate, while the distal matrix is responsible for the inferior pinpoint plate. Biopsy of the distal matrix is less likely to produce scarring. The hypodermic tissue deficient to the nail home plate is quite thin, making it easily to reach the cram of the distal phalange. The extensor muscle tendon of each digit is estimated to be approximately 12 mm proximal from the breeze through carapace and, consequently, unlikely to be damaged during a act biopsy. [ 2 ] The collar unit of measurement receives its arterial issue from the proper digital arteries that run along with the digits on the median and lateral aspects. The venous system predominately mirrors the course of the arterial supply. The 2nd, 3rd, and 4th breeze through digits are innervated by the palmar proper digital nerves, while the 1st and 5th smash digits are innervated by the dorsal proper digital nerves. [ 4 ] [ 5 ]


A pinpoint biopsy is indicated in respective pathologies, including infectious, incendiary, autoimmune, traumatic, and oncological. This is generally performed when the pathology is isolated to the nail unit of measurement. [ 1 ] common diseased entities diagnosed via nail down biopsy includes onychomycosis, psoriasis, lichen planus, twenty pinpoint muscular dystrophy, melanonychia, melanoma, and benign tumors of the smash unit .


relative contraindications to nail biopsy include peripheral vascular disease and arterial compromise. As in any operation, proper consent should be taken before the procedure being performed. [ 3 ]


Antiseptic Agents

  • frequently alcohol or chlorhexidine, a variety of other antiseptics are suitable for nail down biopsy .

Local Anesthetic

  • The most normally used local anesthetic is a 1 % lidocaine solution .
  • To decrease pain during the anesthetic application, 1 milliliter of sodium bicarbonate 8.5 % solution may be added to 10 milliliter of 1 % lidocaine. [ 6 ]
    • While data is insufficient to suggest increased risk, caution should be used when using epinephrine in patients with peripheral arterial disease .
    • The use of epinephrine for digital blocks can be performed but is less often utilize. [ 7 ]

    To decrease excess bleeding during the procedure, epinephrine diluted to 1:100,000 – 200,000 is generally considered safe to use in healthy patients .

Biopsy Instruments

  • compression bandage
  • punch or shave creature
  • pinpoint clippers
  • scalpel
  • tissue scissors
  • Needle driver
  • Nail elevator [ 2 ]

 Hemostatic Agents

  • Aluminum chloride is the most normally used styptic agent .
  • Hyfrecators can be used but carry an increased risk of muscular dystrophy near the nail down matrix .

Sterile Gauze Non-absorbable Suture Non-stick Wound Dressing and Sterile Petroleum Ointment

  • Data suggests that petroleum gelatin is merely vitamin a effective in preventing scent contagion and promoting hoist heal as antibiotic ointments while limiting allergic reactions [ 8 ]


Nail biopsies are much performed entirely by the practitioner. however, some practitioners find that being accompanied by a nurse or medical adjunct may increase the efficiency of the routine by cutting sutures, providing any extra materials that may be needed intraprocedurally, providing hemostasis and setting up the biopsy tray .


Before any biopsy or anesthetic application, the biopsy locate and the surrounding peel must be cleansed with an antiseptic. local anesthetic anesthesia is applied as a steel obstruct, which can either be a digital blocking or wing blockage. After anesthesia lotion, a 10-15 minute waiting period is sufficient for the wide anesthetic effect. During the waiting period, the digit may be placed in a basin of water to soften the collar plate allowing for an easier biopsy. Once ready, a compression bandage is applied to the finger to decrease intraprocedural bleed. The compression bandage should merely be applied for a maximal of 15 minutes to reduce the risk of neurovascular compromise. [ 9 ] many dermatologists err on the side of caution and undertake to apply and remove the compression bandage in under 5 minutes to far reduce risk. For certain biopsy techniques, the pinpoint must be avulsed before biopsy of the wound in question. A common technique to avulse the nail is with the use of a nail elevator. The nail elevator is first inserted under the proximal nail down flock to lightly loosen the nail plate from the overlying pinpoint fold. The elevator is then inserted under the distal nail plate and pushed proximally to detach the smash denture from the nail bed and nail matrix. [ 9 ]


Nail plate biopsy : This biopsy technique is relatively limited in diagnostic information and is chiefly used for fungal culture. It is considered the simplest form of a nail biopsy. A share of the collar plate is removed with a scissor or complete clipper. In most cases, this biopsy technique does not require anesthesia or styptic efforts. however, when a more proximal assign of the nail is required, the nail may be partially avulsed before the biopsy, which requires a digital parry and hemostasis. Scarring is rare. Nail bed biopsy : This is performed to diagnose hide lesions and rashes isolated under the nail plate. To perform a nail bed biopsy, the complete is normally avulsed. alternatively, a punch biopsy may be taken directly through the pinpoint plate. After avulsion, the specimen is removed with an excisional biopsy taken lengthways or via a punch biopsy instrument. Biopsies larger than 3 millimeter in size often require a suture. onycholysis may occur after the pinpoint has regrown. Nail fold biopsy : This is performed on the lateral nail folds to diagnose periungual lesions or rashes. The lesion is removed via a shave/punch creature or is excised with a scalpel. A breeze through elevator joyride may be inserted below the surrounding smash fold to assist in easier removal of the wound while besides decreasing the pinpoint matrix ‘s risk of damage. Scarring is rare, and the biopsy locate can be left to heal via secondary purpose. Nail matrix biopsy : The pinpoint matrix biopsy is frequently employed to diagnose or rule out melanoma in patients with longitudinal melanonychia originating from the matrix. The smash may be partially or wholly avulsed, and the wound is either biopsied via a punch tool or excised with a scalpel. It is important to note that it is best to excise the lesion horizontally quite than lengthways, unlike nail go to bed biopsies. The biopsy site is often sutured for better cosmesis and regrowth of the nail. The site may be scarred, and the nail may regrow with a disconnected nail disfigurement. stain of the biopsy specimen before send-out can be helpful for orientation and histological interpretation by the diagnostician. [ 2 ] [ 3 ] longitudinal pinpoint biopsy : The longitudinal nail down biopsy is frequently used for large and laterally located lesions or when a sample of the stallion nail whole may be required to diagnose the underlie pathology. One such model is longitudinal melanonychia, which may be a sign of melanoma. With this technique, the nail matrix, bed, fold, and hyponychium are all sampled simultaneously and give the most diagnostic data. To perform the biopsy, an incision is made in-line with the lateral nail fold starting halfway between the cuticle and distal interphalangeal joint fold and followed distally to the nail point. Another incision is placed up to 3 mm median or lateral to the initial incision within the complete plate to connect each incision ‘s proximal and distal apices. The weave is then lifted with a bark crochet or forceps and removed with tissue scissors to bone depth. The biopsy web site is then sutured for optimum heal and cosmesis. This technique is the most encroaching smash biopsy technique and has the highest risk for scarring and complete muscular dystrophy. [ 2 ] [ 10 ] hemostasis can be obtained via chemical curdling with aluminum chloride, Monsel ’ sulfur solution, or less park hyfrecation. A popular technique is holding blackmail over the biopsy web site. alternatively, pressure can be applied over the digital arteries after the biopsy is arrant. After waiting at least 5 minutes and ensuring there is hemostasis, cleaning and dressing lotion can commence. [ 2 ] The site can be cleaned with alcohol or normal saline solution and covered in sterile petroleum. The non-stick snip should be applied. [ 9 ]


Complications may include :

  • Bleeding
  • postoperative trouble
  • infection
  • Nail regrowth defects ( split smash disfigurement, erythronychia, dystrophic complete plates )
  • Hypersensitivity reaction to lidocaine
  • Vasovagal answer ( due to anesthetic injection )

Clinical Significance

Nail biopsies are used in conjunction with clinical findings to confirm the diagnosis. The biopsy specimen is processed and histologically evaluated, providing extra data that allows the clinician to make a clinicopathologic diagnosis. With a proper diagnosis, planning and treatment can commence .

Enhancing Healthcare Team Outcomes

The importance of consent, both orally and written, is imperative before any dermatologic routine. Nail biopsies are of special consideration given the potential complications arising from the break of the breeze through matrix. coordination and cooking between healthcare team members provide the opportunity for an optimum operation result. The practicing doctor who performs the nail biopsy, the dermatopathologist, processes, and examines the specimen. All of the aesculapian staff who assist are all of bang-up importance to ensure the ultimate finish of the biopsy : diagnosis, treat, and helping patients. [ Level V ]

Nursing, Allied Health, and Interprofessional Team Interventions

The role of the nurse or aesculapian assistant may vary depending on how the practitioner performs the biopsy. They may help with suture, provide the doctor with extra biopsy materials, set up the biopsy tray or they may help with hemostasis .

Nursing, Allied Health, and Interprofessional Team Monitoring

In summation to monitoring the digit for signs of ischemia, the affected role ’ second comfort should be monitored throughout the procedure. Nail biopsies are accurate procedures and even little movements from an uncomfortable affected role can decrease the practitioners ability to biopsy the mean sphere and repair the site for best aesthetic outcomes .


Nail biopsy, complete plate, longitudinal, collar bed, nail matrix, breeze through fold, punch, shave, excommunication, cross egg-shaped extirpation, distal matrix. Photo illustration by Katherine Humphreys

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Category : Nail Technique

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