Changing Pigmented Lesion in a 42-Year-Old

Clinical History

‍42-year-old male, no personal or family history of melanoma, frequent sun exposure. His partner noticed a lesion on his upper back that has changed over three months. On exam: approximately 8mm, asymmetric, irregular borders, color varies from brown to dark brown.

Clinical Question

I’m not sure whether to refer urgently for biopsy or follow with serial photography. It doesn’t look great, but there’s no family history and he’s only 42.

Specialist Guidance 

‍Based on the submitted image, I would recommend removal.

This lesion meets multiple ABCDE criteria: asymmetry, border irregularity, color variation, diameter over 6mm, and it’s evolving. Refer for excisional biopsy, not shave.

If this is melanoma, you need Breslow depth for staging, and a shave can compromise that. If derm wait times are beyond two weeks, go directly to a surgeon who does excisional biopsies. Don’t let the lack of family history reassure you. The majority of melanomas occur in patients with no family history. Any pigmented lesion hitting two or more ABCDE criteria warrants biopsy regardless of age or family history.

Outcome

Referred urgently. Excisional biopsy within 10 days. Pathology: melanoma in situ. Wide local excision, margins clear. No further treatment needed. Referral was targeted and timely based on specialist guidance.

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