Case Report: Evaluation of Skin Lesions in a 23-Year-Old Female with Dysplastic Nevus and Benign Moles | Village Dermatology Katy & Houston, TX

by: Caroline Vaughn

Introduction

Skin cancer prevention and mole monitoring are an important part of dermatology care, especially for patients with a history of dysplastic nevi. At Village Dermatology in Katy and Houston, Texas, we provide comprehensive skin exams, patient education, and treatment when concerning lesions are identified. This case highlights a 23-year-old female who presented for evaluation of multiple skin lesions and counseling regarding sun protection and mole monitoring.

Patient Presentation

The patient is a 23-year-old female who presented with multiple skin lesions on the body, present for several years. The lesions were asymptomatic and had not been previously treated. She also requested education regarding sun exposure, mole checks, and surveillance for suspicious growths. Her history is significant for dysplastic nevi biopsied at an outside dermatologist in Louisiana. She has no family history of melanoma.

Examination

A full-body skin examination was performed, including:

• Scalp, head, face, and neck

• Chest, abdomen, back

• Upper and lower extremities

• Digits and nails

• Groin and buttocks (underwear not removed at patient’s request)

A dermatoscope was used for detailed mole evaluation.

Findings included:

• Dysplastic Nevus with Severe Atypia (left upper back, previously biopsied)

• Benign Nevi: regular, symmetric, evenly-colored macules and papules on the back, left 5th toe, and left dorsal great toe

• Lentigines: pigmented sun-induced lesions

Impression & Plan

1. Dysplastic Nevus with Severe Atypia (D22.5)

• Previously biopsied, severe atypia confirmed

• Excision recommended for complete removal

• Patient counseled on self-skin checks and importance of monitoring for new or changing lesions

2. Benign Nevi (D22.5, D22.72)

• Multiple stable, non-concerning moles identified

• No treatment necessary

• Patient counseled to perform monthly self-skin checks and return if changes occur

3. Lentigines (L81.4)

• Related to sun exposure and sun damage

• Benign, but can be treated with sunscreen, bleaching creams, retinoids, chemical peels, or laser therapy

• Patient counseled on strict sun protection

Sun Protection Counseling

The patient received detailed sunscreen and sun safety education:

• Broad Spectrum SPF 30+ sunscreen recommended, applied 15 minutes before sun exposure

• Reapply every 2 hours, or every 45–60 minutes if swimming/sweating

• Use of sun protective clothing and hats encouraged

• Lip balm with SPF for lip protection

Conclusion

This case underscores the importance of regular dermatology skin checks for patients with a history of atypical moles. At Village Dermatology in Katy and Houston, TX, our team provides comprehensive care, including mole mapping, biopsy, excision, and ongoing patient education to prevent skin cancer and maintain healthy skin.