After 40 hard-fought years, a 60-year-old man has finally gotten tired of everyone—family, friends, and even his health care provider—hounding him to get the lesion on his face checked. For decades, there were no significant changes to its appearance; recently, however, parts of the lesion have begun to darken and become more raised. This prompts him to seek evaluation.

The patient spends a great deal of time outdoors. He can easily gain and keep a tan for the entire summer, rarely burning. However, family history is positive for skin cancer—although only in fairer-skinned relatives.

Physical examination reveals a 4×3.5-cm lesion, located on his left lateral cheek, that is roughly round and dark brown. Although largely uniform in color, it has focal areas of much darker skin and 2 raised dark nodules consistent with possible seborrheic keratosis.

The patient’s skin shows modest evidence of sun damage. No nodes are felt in the adjacent head or neck nodal drainage areas.