To biopsy or not to biopsy

presented by

David J Elpern MD

Williamstown, Massachusetts, USA

March 9, 2007

Abstract 44 yo man with progressive genital pigmentation
44-year-old man
1 year

The patient is a 44-year-old man who presents with a one year history of genital macules. New lesions continue to appear.

Physical Examination
Healthy man with Type III skin. There are irregular, uniformly tan macules on glans, corons and shaft of the penis. A few similar lesions are on the scrotum. The remainder of the cutaneous exam is unremarkable. No similar lesions on lips of oral mucous membranes.


Laboratory Data




Diagnosis For discussion
Reasons Presented

To biopsy or not to biopsy; that is the question.

Questions and Teaching Points

1. What is your diagnosis?
2. Do you recommend biopsy or observation

Keywords genital pigmentation
Comments from Faculty and Members

Julian Manzur M.D., Professor of Dermatology, Faculty of Medicine,Havana, Cuba on March 7, 2007

My impression:
1. Penile lentigines (macular penile melanosis)
2. Nevomelanocytic nevi acquired
3. Very atypical condylomata acuminata

I preferred to biopsy

Khaled El-hoshy M.D., Troy, Michigan, USA on March 7, 2007

Penile melanosis. No biopsy needed. Reassurance only.

Andy Affleck MRCP (UK), Clinical Fellow, Dundee, UK on March 7, 2007

Diagnosis = benign penile lentiginosis. I would not biopsy and I would not offer any treatment.

Robert Rudolph MD, FACP, Clinical Professor of Dermatology, University of Pennsylvania, Philadelphia, PA, USA on March 7, 2007

Looks like banal "penile melanosis". But, yes, I would biopsy one to confirm the diagnosis, and to reassure the patient about the benign nature of the lesions.

Shahbaz Janjua MD, Specialist Dermatologist, Ayza Skin and Research Centre, Lalamusa, Pakistan on March 7, 2007

Excellent images of benign genital melanotic macules. I would not biopsy these lesions unless I see something concerning.

Thamir Alkubaisi MD, Baghdad, Iraq, on March 7, 2006

A benign condition (penile melanosis), can also affect the labia. It needs only observation. The biopsy is not very helpful because atypical melanocytes occasionally can be present

Khalifa Shaquie MD, PhD, Professor of Dermatology, College of Medicine, University of Baghdad, Baghdad, Iraq on March 7, 2007

There is no clear cut diagnosis but it is not resolving lichen planus, not a drug rash and not lentigo maligna. The mind has the right to speculate about pigmented viral warts, early Kaposi sarcoma that might present as pigmented macules in a healthy man and other strange pigmented dermatoses. Shave biopsy will give the clue.

Henry Foong FRCP, Consultant Dermatologist, Ipoh, Malaysia on March 7, 2007

Clinically, this patient has benign penile melanosis. However, the decision to biopsy or not to biopsy depends on a number of other factors: the age of the patient, family history of skin cancer, past history of skin cancer, increasing number and size of lesions (?), atypical morphology of the lesions and the prevalence of the genital malignancy etc. Unless there are warning signs, I would not biopsy the lesion.

Ibrahim Mist MD, Amman, Jordan on March 8, 2007

My diagnosis is penile melanosis. It does not need biopsy. I would keep it under observation.

Abbas Naji Alshammari MD, Consultant Dermatologist, Qatar Armed Forces Clinic, Doha, Qatar on March 8, 2007

Exclusion of melanoma is a crucial element in suspected melanocytic lesion. The case presented here with multiple lightly pigmented macules unconfined to one area is very difficult to be suspected as malignancy even if a high index of obsession is applied! Simple lentigo or melanotic macules. How could a biopsy (increase in melanocytes number or activity) is helpful in managing this case?
Doing a biopsy is almost always a safe and simple procedure for the physician but not as such for the patient, physically or psychologically. Although, the case presented here is a simple one but carry an important message in dealing with a huge number of cases to decide honestly, when the biopsy is indicated? I have been in touch with some patients to whom certain unjustifiable investigations including biopsies were done. The result, a neurotic factor was added to be the major new complaint!

Azar Maluki MD, Assistant Professor of Dermatology, College of Medicine, University of Kufa, Najaf, Iraq on March 11, 2007

Sometimes, biopsy may be so important both to the doctor and the patient when a spot diagnosis can not be made easily, as in this case. At least, the result of biopsy may determine further follow up and the mode of managment.

Bushan Kumar MD, Former Professor of Dermatology, Chandigarh, India on March 13, 2007

Benign penile lentiginosis. No Biopsy required. Reassure. Chances of malignancy are remote.

Bernardo Gaia MD, Dermatology Resident, Rio de Janeiro, Brazil on March 27, 2007

Before considering biopsy, I´d have a dermoscopic examination.

Please Click Here To Comment and Evaluate

Back to January 21, 2007 Case