Mole Check & Shave Biopsy Case Report: Evaluating a New Neck Lesion in a 31-Year-Old Male
Routine skin checks play a critical role in identifying new or changing lesions early. At Village Dermatology, we emphasize thorough skin evaluations and patient education to ensure timely diagnosis and peace of mind. This case highlights the evaluation and management of a new growth discovered during a routine mole check in Katy and Houston, Texas.
Patient Presentation
A 31-year-old male presented as a new patient for a mole check after his barber noticed a new growth on the back of his neck. The patient denied any personal or family history of melanoma or non-melanoma skin cancer and had no prior history of skin cancer.
He requested evaluation to determine whether the lesion was benign or required further treatment.
Clinical Examination
A focused examination was performed of the scalp, face, head, and neck, with dermoscopy used to further evaluate the lesion. The patient appeared well-developed, well-nourished, alert, and in no acute distress.
On exam, a papule on the left inferior posterior neck was identified. Based on its appearance, the lesion was considered indeterminate.
Assessment
Neoplasm of Uncertain Behavior
Location: left inferior posterior neck
Differential diagnosis included:
Nevus
Acrochordon (skin tag)
Treatment Plan: Shave Biopsy
The risks, benefits, and alternatives were discussed, and the patient elected to proceed with a shave removal biopsy for definitive diagnosis.
Procedure Details
Written consent obtained
Area prepped with alcohol
Local anesthesia achieved using 0.3 cc of 1% lidocaine with epinephrine
Shave biopsy performed to the level of the dermis using a Dermablade
Specimen sent for histopathologic evaluation (H&E)
Hemostasis achieved with Drysol
Petrolatum and bandage applied
The patient was instructed on wound care and advised to contact the office if biopsy results were not communicated within two weeks.
Additional Findings: Skin Tags
Multiple skin tags (acrochordons) were also noted around the neck. These were discussed as benign growths commonly found in friction areas.
Quoted removal of 10 lesions for $150
Counseling provided regarding treatment options, including surgical removal or cryotherapy
Patient Counseling & Education
The patient was counseled on:
Skin cancer awareness and monitoring for new or changing lesions
The benign nature of most nevi and skin tags
When to seek evaluation for concerning changes such as rapid growth, bleeding, or color change
Preventive health screenings were also completed, including tobacco and alcohol use screening.
Follow-Up
Follow up as needed (PRN)
Await pathology results from the shave biopsy
Comprehensive Mole Checks in Katy & Houston
This case underscores the importance of professional skin exams—even for young adults without a personal or family history of skin cancer. At Village Dermatology, we offer thorough mole checks, in-office biopsies, and personalized counseling to help patients stay proactive about their skin health.
