What is the first step in caring for this woman’s pigmented lesion?

A 41-year-old female presented with concerns about an enlarging irregular pigmented macule on the left temple that has changed over the last year in both size and color. It currently measures 2 cm x 1.8 cm. She is otherwise healthy. There is no adenopathy appreciated.

How would you treat this pigmented lesion?

A. Shave biopsy 
B. 4 mm punch biopsy of the most darkly pigmented area
C. Wide excision with 5 mm margins 
D. Wide excision with 1 cm margin
E. Follow conservatively and re-evaluate in 3 to 6 months 

(Answer and discussion on next page)

Answer: Shave biopsy

A shave biopsy revealed the entire lesion to be a benign lentigo. Pathologists much prefer being able to see the entire epidermis of these lesions as a 4 mm punch biopsy may miss important areas due to sampling error. Wide excision is indicated by histology and not appearance. It would be unfortunate to have the patient suffer unnecessary surgery and disfigurement for a benign lesion. 

Given the variegation of pigment and size of lesion, a biopsy was warranted rather than conservative management or attempting a bleaching agent. It should be noted that hydroquinone has fallen out of favor in Europe as a treatment option due to safety concerns of carcinogenicity in animals; it has already been removed from the US market.