What is the recommended treatment for seborrhic keratosis?

Treatment of Seborrheic Keratosis

The most effective treatments for seborrheic keratosis are cryosurgery, shave excision, curettage, or electrodessication, with cryosurgery being the most commonly used method for removal. 1

Understanding Seborrheic Keratosis

Seborrheic keratosis (SK) is the most common benign epidermal tumor encountered in dermatological practice. These lesions:

• Present with a well-demarcated, "stuck-on" appearance with a waxy or keratotic surface 2
• Affect approximately 83 million Americans, particularly those over 50 years old 1
• Can occur on all body areas except palms and soles, with face and upper trunk being most common 3
• Are biologically benign and do not require removal for medical reasons unless histologic confirmation is needed or lesions become symptomatic 1

Treatment Options

First-line Treatments:

1. Cryosurgery

   • Most commonly used removal method 1
   • Advantages: Quick, office-based procedure
   • Disadvantages: Potential for pigmentation changes, especially in darker skin types

2. Shave Excision

   • Second most common removal method 1
   • Advantages: Provides tissue for histological confirmation
   • Disadvantages: Risk of scarring, requires local anesthesia

3. Electrodessication

   • Effective for smaller lesions
   • Advantages: Precise control of depth
   • Disadvantages: Risk of scarring and hypopigmentation

4. Curettage

   • Often combined with other methods
   • Advantages: Effective for thicker lesions
   • Disadvantages: May leave depressed scars

Emerging Treatments:

1. Hydrogen Peroxide Topical Solution 40% (HP40; Eskata™)

   • Applied directly to SK lesions up to four times with 20-second applications
   • Moderate success with minimal adverse effects 2
   • Advantages: Non-invasive option

2. Laser Therapy

   • Various lasers can be used including CO2, Er:YAG, and Q-switched lasers 4
   • Advantages: Precision, potentially better cosmetic outcomes
   • Disadvantages: Higher cost, specialized equipment needed

Treatment Algorithm

1. For isolated, small lesions:

   • First choice: Cryosurgery with liquid nitrogen
   • Alternative: Electrodessication for very small lesions

2. For larger or thicker lesions:

   • First choice: Shave excision or curettage
   • Consider sending specimen for histopathological examination if any atypical features

3. For multiple lesions:

   • Consider staged treatment sessions
   • Cryosurgery for multiple lesions in one session
   • Consider topical treatments like HP40 for suitable candidates

4. For facial lesions or cosmetically sensitive areas:

   • Consider shave excision for better cosmetic outcome
   • Laser therapy may be beneficial but more costly

Important Considerations

• Diagnostic confirmation: While diagnosis is usually clinical, dermoscopy can help differentiate SK from melanoma or other malignancies 3

• Patient selection: Careful patient selection is required to optimize cosmetic results, particularly in skin of color patients and patients with thick or numerous lesions 1

• Patient preference: Many patients seek removal for cosmetic concerns rather than medical necessity - 61% of women report trying to conceal SKs with hairstyles, makeup, and clothes 2

• Potential complications: All removal methods carry risks of pigmentation changes, scarring, and discomfort before and after the procedure 2

• Treatment gaps: While there is great interest from both patients and providers in topical non-invasive treatments for SK, effective options remain limited, representing an area of unmet need 1

When to Consider Biopsy

• Lesions with atypical features (rapid growth, bleeding, irregular borders)
• Lesions that fail to respond to standard treatments
• When clinical diagnosis is uncertain

By selecting the appropriate treatment modality based on lesion characteristics, patient preferences, and anatomical location, optimal outcomes can be achieved for patients with seborrheic keratosis.