Dermatological Consultation for Pigmented Lesion in Young Adult Male

Case at a Glance

A 26-year-old male presents with concerns about a pigmented lesion that has been present for approximately 2+ years. The patient reports anxiety about the lesion's appearance, specifically noting its irregular shape and darker coloration.

Patient's Story

The patient, a 26-year-old male with a history of health anxiety, sought dermatological consultation regarding a mole on his skin. He reported that the lesion had been present for at least two years, though he was uncertain of the exact duration. The patient expressed significant concern about the lesion's appearance, particularly its asymmetrical shape and darker pigmentation, which had been causing him considerable distress.

Initial Assessment

Upon initial evaluation, the patient presented with a pigmented lesion of concern. The patient's anxiety about the lesion was evident, and he specifically mentioned worrying about the lesion's irregular borders and color variation. Initial photographic documentation was obtained, though image quality was suboptimal for detailed analysis.

The Diagnostic Journey

The initial clinical impression suggested a benign-appearing pigmented lesion. However, given the patient's concerns about asymmetry and color variation, further evaluation was considered. The consulting dermatologist noted that while the lesion did not immediately appear concerning, the patient's specific observations about irregularity warranted closer examination with higher-quality imaging.

Final Diagnosis

Clinically benign-appearing melanocytic nevus with patient-reported irregular features requiring monitoring and possible dermoscopic evaluation.

Treatment Plan

1. Obtain high-resolution dermoscopic images for detailed analysis 2. Patient education regarding normal vs. concerning mole characteristics 3. Routine skin surveillance with follow-up in 6-12 months 4. Patient counseling regarding health anxiety management 5. Instructions for self-monitoring using ABCDE criteria

Outcome and Follow-up

The patient was reassured about the likely benign nature of the lesion based on initial assessment. Plans were made for enhanced imaging and regular dermatological surveillance. The patient was educated about warning signs that would warrant immediate re-evaluation and was provided with resources for managing health-related anxiety. Follow-up appointment scheduled for comprehensive skin examination and reassessment of the lesion in question.