Skin biopsy without anesthesia

Malea

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I need to get tested for a Small Fiber Neuropathie (SFN) via skin biopsy.

The problem is that I have severe MCAS and anesthesia for the biopsy would be a reeeeally bad idea because of extreme reactions. The last doctor I asked to do the biopsy without anesthesia didn‘t consent and strongly said that the pain could be so awful, that she can‘t agree to do it without anesthesia. I was convinced at that point and the biopsy wasn‘t done.

(Due to disability stuff and other procedures) It now would be really good to have this diagnosis so I‘m thinking again about doing the biopsy. (Without anesthesia)

I wanted to ask if anybody here has ever done a skin biopsy (the translation program says its called skin punches or cutaneous puncher) without anesthesia?
Was the pain manageable?

(Other diagnostic tests for SFN like QST or QSART are not an option due to my bad condition and the inability to drive longer distances in car.)
 
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ryan31337

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Hi @Malea,

I can't comment on the anaesthesia question but another alternative for SFN diagnosis is Sympathetic Microneurography. It is very, very specialised though so I imagine you'd probably have to drive even further to find someone capable - but you never know.

Ryan
 

kangaSue

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I've had a lot of skin punch biopsies for minor skin cancers and on a couple of occasions when the doctor has tried to rush the procedure when the local anaesthetic hasn't fully taken effect, the pain was significant so you would need to be able to be hypnotised or be very good at doing meditation in order to block out the pain I think.

Another alternative to QSART can be one of the skin conduction tests offered for sudomotor dysfunction from EZSCAN (Sudoscan) or VITALSCAN (QBioscan), not sure how widely available they are though.
https://www.frontiersin.org/articles/10.3389/fendo.2016.00018/full
http://www.vitalscan.com/dtr_bioscan_sudomotor.htm

I can't recall the details of another test off hand, but I read that a test to diagnose Small-Fiber Neuropathy was by doing a simple water immersion skin wrinkle test. I think the deal was that if your fingers didn't wrinkle after being immersed in body temperature water for something like 20 minutes, you had SFN. It wouldn't work if you only had SFN in the feet though.
 

Malea

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Hi @Malea,
I can't comment on the anaesthesia question but another alternative for SFN diagnosis is Sympathetic Microneurography. It is very, very specialised though so I imagine you'd probably have to drive even further to find someone capable - but you never know.
Another alternative to QSART can be one of the skin conduction tests offered for sudomotor dysfunction from EZSCAN (Sudoscan) or VITALSCAN (QBioscan), not sure how widely available they are though.
https://www.frontiersin.org/articles/10.3389/fendo.2016.00018/full
http://www.vitalscan.com/dtr_bioscan_sudomotor.htm
Thanks both of you for mentioning that there are even further diagnostic methods for SFN. I didn‘t know of them. Unfortunetely none of these methods is available in my area.

@kangaSue thanks for the honest opinion about the pain.

As pain is (for me) an immense mast cell trigger, too, I find it hard to decide which thing might be worse. But I had the idea today, if an anesthetic cream could be an option. I think my reaction would be not as bad as with the anesthetic syringe and it would solve the pain problem at least a little.
 

Gingergrrl

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The problem is that I have severe MCAS and anesthesia for the biopsy would be a reeeeally bad idea because of extreme reactions.
Hi Malea, do you know which anesthesias you might be allergic to or would it purely be guessing at this point?

There is a list from the Mastocytosis Society (part of their "emergency room protocol" packet) which lists all types of meds, including local anesthesias, and specifies which are to be avoided by people with MCAS versus which are generally tolerated by pwMCAS. Have you ever read that packet?

I once tested the dental anesthetic "Mepivocaine" (the version without Epi) and had absolutely no allergic reaction to it whatsoever (in case I need future dental work). I do not know, however, if this one is used outside of dental work or would be relevant for a skin biopsy. Also, can you pre-medicate before the procedure (IV Benadryl or something comparable) in case of a reaction?

(Other diagnostic tests for SFN like QST or QSART are not an option due to my bad condition and the inability to drive longer distances in car.)
This is pure ignorance on my part but is a QSART able to diagnose SFN? I am curious b/c I had a QSART in Feb 2016 (as part of autonomic testing at a clinic) but they did not interpret it for me and I was unable to obtain a copy of the results (long story, won't bore you with it).

BUT, they did tell me that my results were "abnormal" and showed "neuropathy of the long branch nerves to the feet". I rarely ever sweat and I assumed this was why. But nothing ever came of the results. My main doctor (who did not run the tests) later said that there was no point for me to do a skin biopsy b/c I had enough autoantibodies without one and we were able to get IVIG and the treatments that we wanted.

Can you remind me (even though I know you have probably told me a million times :bang-head:), is the skin biopsy to get a SFN diagnosis for potential IVIG or for other reasons/treatments?
 
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Sushi

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I wanted to ask if anybody here has ever done a skin biopsy (the translation program says its called skin punches or cutaneous puncher) without anesthesia?
Was the pain manageable?
I have had a skin biopsy for skin cancer with only saline injected as an anesthetic. It wasn't perfect, but the pain was mild. The dermatologist said that when saline is used this way it only has anesthetic properties for a couple of minutes.
Hi Malea, do you know which anesthesias you might be allergic to or would it purely be guessing at this point?
When I need a local anesthesia I get lidocaine without epinephrine. You might try to find out if it is the epi that would bother you or the lidocaine itself.
 

Diwi9

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Would your doctor agree to do it if you could tolerate an anxiolytic like Xanax or Valium? It doesn't sound like you need it, but would maybe make your doctor feel better... In someways, it's actually good to hear that your doctor has compassion.
 

5150

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Skin biopsy punch hole is deeper than one might imagine. / Reaction to pain is an individual thing. Some can take it better than others.
 

Diwi9

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@5150 - What would you estimate the diameter of one of these punch biopsies to be? Where on the body is it performed for SFN?
 

kangaSue

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This is pure ignorance on my part but is a QSART able to diagnose SFN? I am curious b/c I had a QSART in Feb 2016 (as part of autonomic testing at a clinic) but they did not interpret it for me and I was unable to obtain a copy of the results (long story, won't bore you with it).

BUT, they did tell me that my results were "abnormal" and showed "neuropathy of the long branch nerves to the feet". I rarely ever sweat and I assumed this was why. But nothing ever came of the results.
Cleveland Clinic has a good article about SFN.
https://www.mdedge.com/ccjm/article/95083/diabetes/small-fiber-neuropathy-burning-problem

Symptoms typically start with burning feet and numb toes. Results of routine nerve conduction studies and electromyography are typically normal in this disease but sweat abnormalities (sudomotor dysfunction) occurs in about 75% of cases of SFN.

SFN is a disorder of the peripheral nerves that primarily or exclusively affects small somatic fibers, autonomic fibers, or both, resulting in sensory changes and autonomic dysfunction when both types are involved so then is often more commonly referred to as Autonomic Neuropathy.
 

Gingergrrl

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Symptoms typically start with burning feet and numb toes. Results of routine nerve conduction studies and electromyography are typically normal in this disease but sweat abnormalities (sudomotor dysfunction) occurs in about 75% of cases of SFN.
Thank you for that link @kangaSue and I just glanced through it and I have never had burning/numb feet or toes (that I remember)! But I did have sudomotor/sweat dysfunction on the QSART in 2016.

SFN is a disorder of the peripheral nerves that primarily or exclusively affects small somatic fibers, autonomic fibers, or both, resulting in sensory changes and autonomic dysfunction when both types are involved so then is often more commonly referred to as Autonomic Neuropathy.
And I definitely had all sorts of autonomic dysfunction :eek:. It is so hard to know what was due to what any more!
 
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Dechi

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I don’t know if this is the same type of biopsy, but gynecologists routinely do cervix biopsies on women without anesthesia. I had one done. I can’t say it was pleasant but there was little pain.

I also had a gastric biopsy done without local anesthesia but with some meds that knocked me for a few minutes and this one hurt like hell for about a week. And it wasn’t supposed to be painful. So go figure...
 

Butydoc

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I need to get tested for a Small Fiber Neuropathie (SFN) via skin biopsy.

The problem is that I have severe MCAS and anesthesia for the biopsy would be a reeeeally bad idea because of extreme reactions. The last doctor I asked to do the biopsy without anesthesia didn‘t consent and strongly said that the pain could be so awful, that she can‘t agree to do it without anesthesia. I was convinced at that point and the biopsy wasn‘t done.

(Due to disability stuff and other procedures) It now would be really good to have this diagnosis so I‘m thinking again about doing the biopsy. (Without anesthesia)

I wanted to ask if anybody here has ever done a skin biopsy (the translation program says its called skin punches or cutaneous puncher) without anesthesia?
Was the pain manageable?

(Other diagnostic tests for SFN like QST or QSART are not an option due to my bad condition and the inability to drive longer distances in car.)
I have personally performed many skin biopsies using normal saline as a local anesthetic. If performed properly, there is usually minimal pain.
 

BeautifulDay

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I don't tolerate anesthesia well. 8 months ago I had an operation to fix my thumb. A year before, I fell down the steps taking out the recycling and onto the glass. Darn intermittent foot drop.

My doctor did the entire operation with me awake -- two nerve graphs using lidocaine. I didn't feel a thing. The doctor knew if he could distract me, I'd be a much better patient. On my side of the blue cloth divider, they put the Harry Potter movie on the screen and gave me ear phones. An hour later, I was telling my husband we had to go home and rent Harry Potter so I could finish it.

Of course, in those of us with memory issues, lidocaine did cause a bump in that fog for a few weeks. I had that happen.

Someone mentioned Valium above. I get sleep paralysis on Valium where I can hear what's going on around me (and can later repeat the conversation or TV show I heard), but I can't move a muscle. It's not something I suggest trying for an operation, if it's not something you already have had experience with.
 

Malea

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Thanks everyone for answering!

Hi Malea, do you know which anesthesias you might be allergic to or would it purely be guessing at this point?

There is a list from the Mastocytosis Society (part of their "emergency room protocol" packet) which lists all types of meds, including local anesthesias, and specifies which are to be avoided by people with MCAS versus which are generally tolerated by pwMCAS. Have you ever read that packet?
(...)

This is pure ignorance on my part but is a QSART able to diagnose SFN? I am curious b/c I had a QSART in Feb 2016 (as part of autonomic testing at a clinic) but they did not interpret it for me and I was unable to obtain a copy of the results (long story, won't bore you with it).
Thanks for mentioning the mastocytosis list! I will have a look at it!
It‘s purely guessing at this point... since I‘m reacting to everything right now. But since reactions to everything (creams, smells, supplements, medications, food... really everything) are so bad, I‘m sure the reaction to the injection would be extremely bad, too.
And I still like my life! So, I‘m better not going to try it.

The diagnosis would help with administrative procedures (like disability) and would be the only chance to get Ivig paid for me. But as I‘m having no doctor who would support Ivig in my case (in front of insurance) and fight for it right now, that is unfortunately more of a future thing.

I would think that a positive QSART result could indicate a SFN. But I have absolutely no knowledge about this whole thing.
And I know from some people who got the SFN-diagnosis who have no pain/ burning sensation, just the autonomic dysfunction. Doesn‘t seem to be too unusual.


I have had a skin biopsy for skin cancer with only saline injected as an anesthetic. It wasn't perfect, but the pain was mild. The dermatologist said that when saline is used this way it only has anesthetic properties for a couple of minutes.
I have personally performed many skin biopsies using normal saline as a local anesthetic. If performed properly, there is usually minimal pain.
This is so interesting and good to know! Thanks. I havn‘t heard of that before.

Is there a lidocaine spray-on or paint-on solution? It would only have to be on a small area I am guessing.
Yes, we have a cream here, that contains lidocain and prolicain. I‘ve found on google that it‘s used for children for this kind of biopsy.
I would be hopeful that the reaction would be milder to the cream than to the injection.

Where on the body is it performed for SFN?
The biopsy has to be taken above the right (?) ankle. Often there is also a second biopsy taken at the thigh which can tell you something more about the SFN...which I can’t remember. :/
 
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Gingergrrl

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Thanks for mentioning the mastocytosis list! I will have a look at it!
No problem and let me know if you can't find it and I will try to find the link. It is a really good resource.

It‘s purely guessing at this point... since I‘m reacting to everything right now. But since reactions to everything (creams, smells, supplements, medications, food... really everything) are so bad, I‘m sure the reaction to the injection would be extremely bad, too. And I still like my life! So, I‘m better not going to try it.
I agree and it is better to be safe. Even though I am no longer reactive to things, I would still be very afraid of an injection of anesthesia unless I knew for sure that I was not allergic to it.

The diagnosis would help with administrative procedures (like disability) and would be the only chance to get Ivig paid for me. But as I‘m having no doctor who would support Ivig in my case (in front of insurance) and fight for it right now, that is unfortunately more of a future thing.
This makes sense both for disability and in case you find a doctor in the future who supports you trying IVIG.

I would think that a positive QSART result could indicate a SFN. But I have absolutely no knowledge about this whole thing. And I know from some people who got the SFN-diagnosis who have no pain/ burning sensation, just the autonomic dysfunction. Doesn‘t seem to be too unusual.
I actually have wondered, based on my abnormal QSART, abnormal lack of sweating, and my entire arsenal of dysautonomia if I had some kind of SFN but I will never know for sure.