Evaluation and Biopsy of a Pigmented Skin Lesion in a 38-Year-Old Female — Village Dermatology, Katy & Houston, Texas
Patient Overview:
A 38-year-old established female patient presented to Village Dermatology in Katy, Texas for the evaluation of a new skin lesion on her left shoulder and right shoulder, as well as a mole under her left arm (axilla) that appeared three weeks prior. The patient reported that the lesion was not painful, bleeding, or changing in size or color, but wanted it evaluated for reassurance and appropriate care.
She also requested education and counseling regarding sun exposure and skin cancer prevention.
Clinical Examination
A comprehensive skin examination was performed, including the scalp, face, shoulders, and both axillae. The patient appeared well-developed, well-nourished, and in no acute distress.
Findings:
A darkly pigmented macule was identified in the left axillary vault.
No signs of ulceration, bleeding, or irritation were present.
A dermatoscopic evaluation revealed irregular pigmentation but no overtly malignant structures.
Differential Diagnosis
The primary considerations included:
Neoplasm of Unspecified Behavior
Dysplastic Nevus (Atypical Mole)
Lichenoid Keratosis
Because of the lesion’s new onset and pigmented appearance, a biopsy was recommended for definitive diagnosis.
Procedure: Shave Biopsy
After obtaining written informed consent, the area was prepped and anesthetized with 0.5% lidocaine with epinephrine.
A shave biopsy to the level of the dermis was performed using a Dermablade, and the specimen was sent for histopathologic evaluation (H&E staining).
Hemostasis was achieved with Drysol, and the site was dressed with petrolatum and a bandage.
The patient tolerated the procedure well without complications.
Post-Procedure Counseling
The patient was counseled on biopsy site care, including gentle cleansing and application of ointment to promote healing.
She was advised to contact the office if she does not receive biopsy results within two weeks.
In addition, sun protection education was provided, including:
Use of broad-spectrum SPF 30+ sunscreen daily
Avoidance of tanning beds
Regular self-skin checks and annual full-body skin exams
Clinical Insight
Pigmented lesions in sun-protected areas, such as the axilla, can represent a range of benign and atypical growths. While most are non-cancerous, early evaluation and biopsy are critical in distinguishing dysplastic nevi or melanoma from benign entities.
At Village Dermatology, we prioritize thorough skin cancer screening and patient education to promote early detection and lifelong skin health.
Follow-Up
The patient will be contacted once biopsy results are available. Depending on pathology, management may include simple observation, re-excision, or monitoring for recurrence.
Takeaway
This case highlights the importance of evaluating new or changing moles, even when they appear benign. Early dermatologic evaluation allows for accurate diagnosis and peace of mind.
At Village Dermatology in Katy and Houston, Texas, our board-certified dermatologists provide expert care for all skin lesions — from routine moles to complex skin cancers — with compassion and precision.
📞 Schedule your skin check today at Village Dermatology in Katy or Houston, TX, and take the first step toward proactive skin health.
