influenced by physicians, patients, administrators, consultants, and health insurance providers. Although the physician executes the biopsy, the other parties may affect how skin biopsies are performed. Our society is becoming increasingly conscious about aesthetics, and, in recent years, dermatology has mirrored the increased emphasis on cosmetics. The overall number of surgical and nonsurgical cosmetic procedures increased 228% from 1997 to 2002.5 The growing concern of patients regarding their appearance may sway physicians toward obtaining smaller biopsies in an attempt to minimize scarring. Choosing to perform a shave biopsy rather than a punch biopsy also may be cosmetically driven. When introducing the shave biopsy for clinical use in 1974, Kopf and Popkin3 advocated that this method yielded “good to excellent cosmetic results” and obliterated the potential for “stitch marks” that may be left by sutured punch biopsy sites. Pressure from administrators and health insurance providers also may be influencing dermatologists to choose the shave technique. The need to see more patients in less time may cause dermatologists to prefer faster and more efficient procedures; the shave biopsy can be performed quickly and requires less equipment than the punch method.3 Larger punch biopsy specimens may require sutures that necessitate follow-up care for suture removal. Because of the speed with which the shave biopsy can be performed and the minimal equipment required, this method allows dermatologists to practice with the efficiency that the market demands. In general, punch biopsies should be performed when it is suspected that the pathology lies in the dermis or subcutaneous fat. A shave biopsy is adequate for diagnosis when the epidermis or superficial dermis is the locale of the disease process. Exophytic growths also may be aptly sampled by a shave biopsy.6 The trend toward small shave biopsy specimens may be beneficial because it provides improved cosmetic outcomes and saves time. However, does diagnostic acumen decrease as biopsy specimen sizes shrink? A 1996 study by Todd et al7 compared the diagnostic accuracy of a 2-mm punch biopsy with a standard elliptical excision. In 79 of the 84 cases studied, the 2-mm punch biopsy and the excision both reached the same histopathologic diagnosis. However, in 5 cases (ie, 1 squamous cell carcinoma, 1 seborrheic keratosis, 1 erythema multiforme, 2 hemangiomas), only the ellipse biopsy was diagnostic.7 A study by Russell et al8 compared the accuracy of the punch versus the shave biopsy technique in diagnosing basal cell carcinoma subtypes. The analysis of basal cell carcinoma specimens from both punch and shave biopsies had equivalent accuracy of diagnosis.8 Somach et al9 found that accurate diagnosis of melanoma on sun-damaged skin frequently was not possible with small biopsy specimens. Swanson et al10 argued that punch biopsies are not adequate in diagnosing melanoma and proposed that excisional biopsies are preferable to ensure that the base of the tumor is included. Therapeutics for the Clinician 338 CUTIS® Therapeutics for the Clinician Shave or Punch Biopsies, % 1988 1993 1998 2003 0 10 20 30 40 50 60 70 80 90 100 Year Academic dermatologists—shave biopsies Private practice dermatologists—shave biopsies Academic dermatologists—punch biopsies Private practice dermatologists—punch biopsies Figure 1. Percentage of punch and shave biopsies performed during the 16-year study period among dermatologists in academic and private practices. VOLUME 76, NOVEMBER 2005 339 In conclusion, as dermatologists attempt to optimize the quality of patient care, the trend of decreasing biopsy specimen size should be monitored. To our knowledge, there are no published studies regarding sampling error rates in skin biopsy results. However, we suspect that definitive diagnosis may become increasingly difficult as the size of biopsy specimens continues to get smaller. REFERENCES 1. Keyes EL. The cutaneous punch. J Cutan Genitourin Dis. 1887;5:98-101. 2. Buhmann A. Atmung und glykolyse in normaler und pathologish veranderte Haut, insbesondere mit Hinblick auf Psoriasis. Biochem Ztschr.