🩺 Case Report: Melasma & New Skin Lesion Evaluation in a 56-Year-Old Female — Village Dermatology, Katy & Houston, Texas
Patient Overview
A 56-year-old female presented to Village Dermatology as a new patient with two primary concerns:
Chronic facial discoloration on the cheeks, present for years
A new red lesion on the left forearm that appeared approximately six weeks ago
She sought expert evaluation and updated management for both concerns.
Clinical Examination
A focused dermatologic exam was performed, including the scalp, face, cheeks, and left forearm.
The patient appeared well-developed, well-nourished, and in no distress. A dermatoscope was used to closely examine both the hyperpigmented facial patches and the left forearm lesion.
Findings:
Melasma: Ill-defined hyperpigmented patches across the periorbital and malar (cheek) regions
Left forearm lesion: A red plaque on the ventral proximal forearm, suspicious for a neoplasm requiring biopsy
Diagnosis
1. Melasma (L81.1)
A chronic, hormonally and UV-triggered pigmentation disorder characterized by blotchy hyperpigmented facial patches.
2. Neoplasm of Unspecified Behavior (D49.2)
A new red plaque on the left forearm with differential diagnosis including:
Lichenoid keratosis
Actinic keratosis
Squamous cell carcinoma in situ
Benign neoplasm of uncertain behavior
Given clinical uncertainty, biopsy was recommended for definitive diagnosis.
Treatment Plan
1. Melasma Management
The patient received extensive education on sun protection and pigmentation triggers.
Although previously using hydroquinone, she declined restarting it and elected to begin tretinoin 0.025% cream, which was prescribed.
Key Counseling Points:
Apply a pea-sized amount of tretinoin at bedtime
Wait 30 minutes after washing the face before applying
Use a moisturizer if dryness occurs
Strict sun protection is essential
Reapply SPF 30+ sunscreen every 2 hours when outdoors
Avoid harsh bleaching agents, mercury-containing creams, resorcinol, or phenol-based products
Additional Treatment Options Reviewed:
Topical vitamin C
Glycolic acid
Tranexamic acid
Superficial chemical peels
Non-ablative Fraxel laser
Photographs were taken to monitor progress at the next visit.
2. Forearm Lesion: Shave Biopsy
Given the concerning appearance and differential, the patient proceeded with a shave biopsy.
Procedure Summary:
Location: Left ventral proximal forearm
Anesthesia: 0.5 cc lidocaine with epinephrine
Technique: Dermablade shave biopsy to the dermis
Hemostasis: Achieved with Drysol
Dressing: Petrolatum and bandage applied
Pathology: Specimen sent for H&E staining
Follow-up: Patient to be notified of results; instructed to call if not contacted within 2 weeks
The patient tolerated the procedure well.
Follow-Up
A follow-up appointment was scheduled in 3 months to:
✔ Reassess melasma with updated photos
✔ Review biopsy results and determine next steps
✔ Evaluate progress with tretinoin and sun protection routines
Patient Counseling & Education
The patient was advised to contact the office if:
Melasma worsens
She develops irritation from tretinoin
The biopsy site fails to heal or new lesions develop
She notices ulceration, bleeding, or rapid growth of any skin lesion
At Village Dermatology in Katy and Houston, Texas, we focus on early detection, personalized skin rejuvenation, and evidence-based treatment for all pigment and lesion concerns.
