Full Body Skin Exam in a 56-Year-Old Male: Benign Findings, Actinic Keratosis, and Lipoma
by: Ashley Baldree
At Village Dermatology in Katy and Houston, Texas, annual full body skin exams are a cornerstone of preventive care. These visits allow for the monitoring of existing lesions and early detection of skin cancer or precancerous growths. This case highlights a 56-year-old male with multiple skin findings, including benign nevi, actinic keratosis, lentigines, cherry angiomas, and a lipoma.
Patient Presentation
A 56-year-old male presented for a full body skin examination as a new patient. He reported longstanding lesions on the right upper back and chest, which had been present for years and remained asymptomatic. His primary concern was preventive screening and reassurance.
The patient declined genital examination but agreed to a full inspection of all other body areas.
Dermatologic Examination
A comprehensive skin exam was performed, including dermatoscope evaluation. Findings included:
Benign Nevi: Symmetrical, evenly pigmented macules and papules with no concerning features.
Actinic Keratosis (AK): One precancerous lesion located on the left forehead.
Lentigines (Sun Spots): Light tan macules in sun-exposed areas.
Cherry Angiomas: Bright red vascular papules scattered on the trunk and extremities.
Lipoma: A soft, 6 cm mass on the left posterior shoulder, consistent with a benign fatty tumor.
Impression and Plan
Benign Nevi
Plan: Observation only.
Counseling: Monthly self-skin checks recommended. Patient educated on the ABCDEs of melanoma (Asymmetry, Border, Color, Diameter, Evolution).
Actinic Keratosis
Treatment: One lesion treated with liquid nitrogen cryotherapy.
Risks explained: Crusting, blistering, pigment changes, incomplete removal, recurrence, and infection.
Counseling: AKs are precancerous and should be treated promptly to prevent progression to squamous cell carcinoma.
Lentigines
Plan: Sun protection counseling.
Recommendations: Daily broad spectrum SPF 30+ sunscreen, reapplied every 2 hours during sun exposure. Suggested options included mineral sunscreens and lip balm with SPF.
Optional treatments discussed: bleaching creams, retinoids, chemical peels, and laser.
Cherry Angiomas
Plan: Observation only.
Counseling: Removal with laser or electrodesiccation is optional if desired for cosmetic reasons.
Lipoma
Findings: 6 cm soft tissue mass on left posterior shoulder.
Plan: Referral to plastic surgeon Dr. Rodger Brown for surgical excision due to size and location.
Counseling: Lipomas are benign and often stable, but removal can be considered for comfort or cosmetic reasons.
Key Takeaway
This case demonstrates the value of comprehensive annual skin exams. Even when lesions appear stable or benign, dermatology visits provide reassurance, allow for the treatment of precancerous conditions like actinic keratoses, and guide patients on cosmetic or surgical options for benign growths.
At Village Dermatology in Katy and Houston, TX, we provide expert full body skin checks, mole monitoring, cryotherapy, and referrals for surgical removal of large benign growths.
