Case Report: Excision of a Compound Nevus with Severe Atypia in a 53-Year-Old Male | Village Dermatology Katy & Houston, TX
by: Caroline Vaughn
Introduction
Skin cancer prevention and early detection are central to dermatologic care. At Village Dermatology in Katy and Houston, Texas, we regularly evaluate and treat patients with atypical moles and skin lesions. This case highlights a 53-year-old male who presented with a concerning mole on his upper back, ultimately diagnosed as a compound nevus with severe atypia.
Patient Presentation
The patient was initially seen on August 14, 2025 for a neoplasm of uncertain behavior located on the left superior lateral upper back. At that visit, a shave biopsy was performed.
Pathology Results
The biopsy specimen was reviewed and returned with a diagnosis of:
Compound Nevus with Severe Atypia
Given this result, surgical excision was recommended to ensure complete removal and reduce the risk of progression.
Follow-Up and Surgical Excision
The patient presented for definitive treatment via surgical excision.
Clinical Exam
Healing biopsy site on the left mid-upper back
No acute distress; patient well developed and nourished
Surgical Details
Location: Left mid-upper back
Pre-op size: 0.5 cm x 0.7 cm
Margins: 0.5 cm
Total excised diameter: 1.5 x 1.7 cm
Final wound length: 5.4 cm
Repair type: Intermediate layered closure
Anesthesia: Local infiltration with 1% lidocaine with epinephrine
Estimated blood loss: Minimal
Complications: None
The procedure involved a fusiform excision down to the adipose tissue, removal of the lesion, and layered closure to optimize healing and minimize scarring. The specimen was sent for histopathologic evaluation.
Post-Procedure Counseling
The patient was counseled on wound care and recovery:
No heavy lifting, swimming, or exercise for 14 days
Suture removal and wound check scheduled in 14 days
Contact the office if experiencing fever, chills, bleeding, or severe pain
Conclusion
This case demonstrates the importance of timely biopsy and surgical management of atypical moles. At Village Dermatology in Katy and Houston, TX, our dermatologists carefully evaluate skin lesions, perform biopsies when necessary, and provide expert excision techniques to optimize both medical safety and cosmetic outcomes.
