Full Body Skin Exam for a Patient with Family History of Melanoma
A Dermatology Case Report from Village Dermatology in Katy & Houston, Texas
Case Overview
A 46-year-old male presented to Village Dermatology as a new patient for a full body skin examination (FBSE) due to a family history of malignant melanoma. The patient denied any personal history of skin cancer or melanoma but sought proactive screening given his increased risk.
Family history is a critical risk factor for melanoma, making routine skin checks an essential part of preventive dermatologic care—especially in sun-exposed regions like Katy, Texas and Houston, Texas.
Comprehensive Skin Examination
A complete FBSE was performed, including evaluation of the scalp, face, neck, chest, abdomen, back, upper and lower extremities, genitalia, buttocks, and nails. The patient had Fitzpatrick Skin Type III and was in overall good health.
Dermatoscopic examination revealed several common benign lesions as well as one pigmented lesion requiring biopsy.
Key Findings and Diagnoses
1. Benign Nevi (Moles)
The patient had multiple benign nevi distributed across the body, including a 10 mm lesion on the inferior thoracic spine. These moles were symmetrical, evenly pigmented, and clinically benign.
Management:
Counseling on the benign nature of nevi
Monthly self–skin examinations
Clinical photography for future comparison
Routine observation
2. Lentigines (Sun Spots)
Scattered light tan macules consistent with lentigines were noted in sun-exposed areas.
Management:
Education on sun protection
Recommendation for broad-spectrum SPF 30+ sunscreen
Discussion of topical retinoids and cosmetic treatment options if desired
3. Seborrheic Keratosis
A classic “stuck-on” brown papule was identified on the epigastric skin.
Management:
Reassurance of benign nature
No treatment required
4. Actinic Damage
Evidence of sun-related skin damage was observed on the left medial superior chest.
Management:
Counseling on photoaging
Sun avoidance and daily sunscreen use
Consideration of topical retinoids to improve skin texture and tone
5. Cherry Angiomas
Multiple benign vascular growths were present throughout the body.
Management:
Education and reassurance
Cosmetic treatment options discussed, though not medically necessary
6. Pigmented Lesion of Uncertain Behavior
A darkly pigmented macule on the left buttock raised concern for a dysplastic nevus versus neoplasm of uncertain behavior.
Procedure Performed:
Shave biopsy to the level of the dermis
Local anesthesia with lidocaine and epinephrine
Specimen sent for histopathologic evaluation
Patient counseled on wound care and follow-up
Importance of Skin Checks with a Family History of Melanoma
Patients with a first-degree relative with melanoma have a significantly higher lifetime risk of developing melanoma themselves. Early detection through routine FBSEs can be lifesaving.
Recommendations Included:
Monthly self–skin exams
Daily use of broad-spectrum sunscreen
Sun-protective clothing
Annual professional skin examinations
Follow-Up Plan
The patient will return in one year for a routine full body skin exam, with earlier follow-up as needed depending on biopsy results.
Why Choose Village Dermatology in Katy & Houston, Texas?
At Village Dermatology, we specialize in skin cancer screening, mole evaluation, and preventive dermatology. Our board-certified dermatology team provides thorough, compassionate care tailored to patients with increased melanoma risk.
If you have a family history of melanoma or notice new or changing moles, schedule a full body skin exam with our expert dermatologists serving Katy and Houston, TX.
