Abstract We present a 66-year-old man who presented to dermatology with an unusual lesion. An outdoor worker with prior history of melanoma, the patient was referred with a new pigmented lesion adjacent to his melanoma scar. This was identified as a seborrhoeic keratosis and the patient was reassured. Following a full body examination, an incidental lesion was identified on the left anterior shoulder. The lesion measured 9 × 7 mm, was dermal-based, dome-shaped, soft to palpation and skin coloured with light peripheral pigmentation. The lesion was featureless upon dermoscopic examination. The clinical differential diagnosis included neurofibroma and an intradermal naevus. The lesion was narrowly excised. Histological examination revealed an ill-defined, wedge-shaped dermal lesion with tumour fascicles with a vaguely plexiform arrangement. The widely separated fascicles comprised loosely arranged spindle cells, mature adipocytes and scant collagen fibres with a myxoid stroma. The spindle cells were stained diffusely with CD34 immunohistochemistry. The adipocytes and a proportion of spindle cells (around 20–30%) were stained with S100. The features were in keeping with a dermal plexiform spindle cell lipoma. Spindle cell lipoma is an uncommon benign, histologically distinct tumour, accounting for 1.5% of all adipocytic neoplasms. More common within the subcutis, it is rare for these lesions to present with a purely intradermal location. Dermal spindle cell lipomas tend to be less cellular than their subcutaneous counterpart. This coupled with the variable representation of the three constituent lesion components (spindle cells, mature adipocytes and fibromucinous stroma) results in a wide range of possible differential diagnoses. The plexiform variant of spindle cell lipoma (PSCL) is a poorly recognized form with even greater potential for misdiagnosis, particularly with plexiform neurofibroma—leading to an erroneous diagnosis of neurofibromatosis. Dermal PSCL is an exceptionally rare diagnosis with only eight cases reported in the literature thus far. Here, we report a further case of dermal plexiform spindle cell lipoma, with, for the first-time, corresponding clinical images. In our summary, we discuss in detail the potential diagnostic pitfalls of this rare tumour and how to best employ immunohistochemical staining to avoid them.