Biopsy, Global Period, Infection, Postsurgical Wound Care, Teledermatology



  1. de Golian, Emily
  2. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term to describe the provision of dermatologic medical services through telecommunication technology. This is a teledermatology case of a shallow erosion on the lower back.


Article Content

The store-and-forward feature of teledermatology allows patient medical information (including history and visual data) obtained from one provider's location to be electronically transferred to a provider in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.



Chief complaint: biopsy site infection.


History of Present Illness

A 32-year-old woman presents with an erythematous yellow-based erosion on her lower back 9 days after a biopsy. The patient presented to clinic concerned about a secondary infection. Prior treatment: topical petroleum ointment and daily bandage change. Primary symptom: The lesion is asymptomatic. She has no personal or family history of skin cancer or melanoma. Other significant laboratory/study findings: none.



Fully satisfactory.



One image was provided that shows a well-circumscribed, oval, shallow erosion with a confluent pink rolled border and central depression marked by yellow viscous exudate and scattered erythematous patches of granulation tissue on the left lower back. There is no evidence of purulence, induration, or erythema. The lesion is surrounded by several geometric patches in what appears to correspond to the distribution of the adhesive component of bandages.



Lesion A


The presented lesion and history are most consistent with the diagnosis a noninfected healing shave biopsy site on the lower left back. The absence of rubor (erythema), calor (inflammatory heat), dolor (pain), and bloody or purulent drainage along with the appearance of red granulation tissue throughout the lesion are reassuring. The surrounding geometric erythema is suggestive of contact dermatitis.



Skin Care and Treatment Recommendations

We recommend reassurance as the shave biopsy site continues to heal and encourage the patient to continue with the occlusive dressings. A shave biopsy site may take up to 4-6 weeks to heal. Contact dermatitis to adhesive bandages is common. We recommend the patient to rotate the sites of application (which she appears to be doing) and consider an alternate brand of plasters. The adhesive in bandages is proprietary and often brand specific (see Figure 1).

Figure 1 - Click to enlarge in new windowFIGURE 1. A well-circumscribed, oval, shallow erosion with a confluent pink rolled border, central depression, yellow viscous exudate, and scattered erythematous patches of granulation tissue.


Type of Visit

This biopsy site is healing as expected; we recommend reassurance at this time and follow-up as outlined by the service provider.



Wound care after a biopsy site may be a concern to patients, who may mistakenly assume that the early phases of regenerative tissue proliferation represent an infectious process. Proper wound healing begins with an acute inflammatory phase, consisting of coagulation, vascular changes, and release of proinflammatory cytokines signaling the extravasation of polymorphic neutrophils and macrophages (Bolognia, Jorizzo, & Schaffer, 2012). This initial response with accumulating cellular debris may create the healthy yellow viscous exudate seen on the surface of this patient's biopsy, which may often be confused for purulent drainage secondary to infection. Within 2-3 days, the inflammatory phase transitions to the proliferative phase, where fibroblasts enter the wound site and reconstruct the damaged tissue through production of collagen and an extracellular matrix. This fresh pink/red tissue is called granulation tissue, and although granular and uneven in texture, it is a strong indicator of proper wound healing, as seen in the patient's biopsy site above.


Despite proper wound healing and the formation of granular tissue, biopsy site infections do occur. According to Wahie and Lawrence (2007), a retrospective analysis of 100 postdiagnostic skin biopsy found that 27% of all biopsy sites, including shave, punch, excisional, and curettage biopsies, incurred postprocedural infection. Factors associated with higher risk of infection included location below the waist, inpatient status, smoking, and concurrent immunosuppression. If fever greater than 24 hours, chills, focal swelling, warmth, redness, or purulent and/or foul smelling discharge are present, providers should be prepared to perform local wound cultures with the initiation of oral antibiotics.


Regarding billing for biopsy wound evaluations, the global period for procedures is important to understand. Although diagnosis codes have now transitioned from International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, to International Statistical Classification of Diseases, 10th Revision codes, for dermatology, the Current Procedural Terminology codes remain the same. A single or first biopsy is billed with Code 11100. This code bears a global billing period of 0 days, meaning additional visits related to the procedure, regardless of time frame, may incur separate billing. The code is inclusive of same-day preoperative work, intraoperative work, and postoperative work (Bracy, 2013). Destruction of premalignant or malignant lesions, in contrast, bears a global period of 10 days, so that follow-up visits related to the originally billed treatment may not be billed within the stated global period. The global period for flap and graft repairs extends to a full 90 days (Kirckik, 2009). In revisiting the wound check case described above, because Biopsy code 11100 has a global period of 0 days, charges for a teledermatology visit or clinic visit can and should be billed by the service provider for appropriate reimbursement. Teledermatology represents a useful option for remote clinical evaluation in such cases.


Nursing Education of the Patient

The patient may remove the initial dressing after 24-48 hours and begin cleansing the wound two to three times per day using only mild soap and water followed by generous application of petroleum-based ointment (Smack et al., 1996). The site should be covered with an occlusive bandage to ensure the wound is always moist and to avoid scab formation (Katz, Alvarez, Kirsner, Eaglstein, & Falanga, 1991). Acetaminophen or over-the-counter ibuprofen may be recommended if initial pain is present after local anesthesia recedes.




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Katz M. H., Alvarez A. F., Kirsner R. S., Eaglstein W. H., & Falanga V. (1991). Human wound fluid from acute wounds stimulates fibroblast and endothelial cell growth. Journal of the American Academy of Dermatology, 25(6, Pt. 1), 1054-1058. [Context Link]


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Smack D. P., Harrington A. C., Dunn C., Howard R. S., Szkutnik A. J., Krivda S. J., [horizontal ellipsis] James W. D. (1996). Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. Journal of the American Academy of Dermatology, 276(12), 972-977. [Context Link]


Wahie S., & Lawrence C. M. (2007). Wound complications following diagnostic skin biopsies in dermatology inpatients. Archives of Dermatology, 143(10), 1267-1271. [Context Link]


1The standardized teledermatology reader report format is available for authors on the journal's Web site ( [Context Link]