Comprehensive Skin Exam and Biopsy for a 44-Year-Old Male in Katy, Texas
by: Dr. Ashley Baldrey
Case Overview
A 44-year-old male presented to Village Dermatology in Katy, Texas, for a full-body skin examination. As a new patient, he sought a comprehensive evaluation for new lesions that had developed over the past several months. The patient noted stable, moderately pigmented spots on his left cheek and superior forehead, prompting professional assessment and preventive care.
Clinical Findings
A full skin exam was performed, including inspection of the scalp, face, neck, trunk, extremities, and nails. The patient appeared well-developed and well-nourished, alert and oriented, with no acute distress. A dermatoscope was used to closely examine all lesions.
Key Dermatologic Findings and Management
1. Neoplasm of Unspecified Behavior – Left Posterior Neck
A darkly pigmented macule on the left posterior neck raised concern for a neoplasm of uncertain behavior, with differential diagnosis including lentigo versus lentigo maligna.
A shave biopsy was performed under local anesthesia (lidocaine with epinephrine) using a dermablade. Hemostasis was achieved with Drysol, and the site was dressed with Petrolatum and a sterile bandage.
The biopsy specimen was sent for histopathologic evaluation to rule out malignancy. The patient was instructed to follow up if biopsy results were not communicated within two weeks.
2. Benign Nevi
Multiple symmetrical, evenly pigmented nevi were observed across the body. The patient was counseled that these are benign and do not require treatment.
He was advised to perform monthly self-skin checks and to contact the office if any moles change in size, shape, color, or develop symptoms such as itching or bleeding.
3. Actinic Keratosis (AK)
The patient reported a history of actinic keratoses previously treated with Efudex (5-fluorouracil), with temporary clearance. Since he has undergone topical treatment in the past, photodynamic therapy (PDT) was discussed as a future treatment option for improved clearance of sun-damaged skin.
The importance of sun protection using broad-spectrum sunscreen SPF 30+, sun-protective clothing, and regular skin checks was reinforced.
4. Seborrheic Keratoses
Benign stuck-on, warty, brown papules were identified on the left clavicular neck and anterior shoulder. These are harmless growths associated with aging. The patient was reassured that treatment is unnecessary unless for cosmetic reasons.
5. Lentigines and Ephelides (Freckles)
Reticulated tan macules in sun-exposed areas were consistent with lentigines and ephelides. These are benign sun-induced pigment changes. The patient was counseled that improvement is possible with sun protection, topical brightening agents, chemical peels, or laser treatments.
6. Cherry Angiomas
Bright red vascular papules were noted and diagnosed as cherry angiomas. The patient was informed that these are benign blood vessel growths, treatable with laser or electrodessication if desired for cosmetic reasons.
7. Lichenoid Keratosis
A pink scaly papule on the left upper back was consistent with lichenoid keratosis, a benign inflammatory lesion. The lesion was pared and treated with liquid nitrogen cryotherapy (two freeze-thaw cycles). The patient was informed of expected healing and potential temporary changes in pigmentation.
Sunscreen and Skincare Recommendations
To prevent recurrence of sun-induced skin lesions, the following broad-spectrum SPF 50+ sunscreens were recommended:
Face:
Neutrogena Sheer Zinc Face SPF 50
EltaMD UV Clear
La Roche-Posay Toleriane UV
Supergoop Unseen Sunscreen
Body:
La Roche-Posay Melt-In Milk
Supergoop Play Everyday Lotion
EltaMD UV Sport
HEB Mineral Sunscreen
Discussion
This case highlights the importance of annual full-body skin examinations, especially for patients in sunny climates like Katy and Houston, Texas. Chronic UV exposure contributes to the development of actinic keratoses, lentigines, and other precancerous lesions.
Through early detection and preventive counseling, dermatologists can effectively manage benign and potentially malignant skin changes while emphasizing long-term sun protection and self-surveillance.
Conclusion
Routine skin evaluations play a vital role in maintaining skin health and detecting early signs of skin cancer. Patients in the Katy and Houston areas are encouraged to schedule regular dermatology visits with Village Dermatology for personalized care, preventive guidance, and treatment of sun-induced skin conditions.
