Treatment Options for Seborrheic Keratosis
Cryotherapy, shave excision, and electrodesiccation/curettage are the primary treatment options for seborrheic keratosis, with selection based on lesion characteristics and patient preference. 1, 2
Understanding Seborrheic Keratosis
Seborrheic keratosis (SK) is the most common benign epidermal tumor encountered in dermatology practice. These lesions:
- Typically appear as well-demarcated, "stuck-on" growths with a waxy or keratotic surface
- Can occur on all body areas except palms and soles, most commonly on the face and upper trunk
- Are more prevalent in individuals over age 50
- Are benign and do not require removal for medical reasons unless symptomatic or diagnosis confirmation is needed
Treatment Indications
Treatment is primarily pursued for:
- Cosmetic concerns (most common reason)
- Lesions that become irritated or symptomatic
- Diagnostic uncertainty requiring histologic confirmation
Treatment Options
1. Destructive Therapies
Cryotherapy (Liquid Nitrogen)
- Most commonly used method 2
- Advantages: Quick, office-based procedure; no anesthesia required
- Disadvantages: Risk of hypopigmentation, especially in darker skin types; potential for blistering
Electrodesiccation and Curettage
- Advantages: Effective for thicker lesions; provides tissue for histologic examination
- Disadvantages: Requires local anesthesia; potential for scarring
Shave Excision
- Advantages: Provides tissue for histopathologic examination; good cosmetic results
- Disadvantages: Requires local anesthesia; potential for scarring
2. Advanced Therapies
- Laser Therapy
- CO2 or erbium:YAG lasers
- Advantages: Precise control; good for multiple lesions
- Disadvantages: Expensive; requires specialized equipment
3. Topical Therapies
- Hydrogen Peroxide 40% Solution (Eskata™)
- Applied directly to SK lesions
- Moderate success with minimal adverse effects 3
- May require multiple applications
Treatment Selection Algorithm
For thin, small lesions or multiple lesions:
- First-line: Cryotherapy with liquid nitrogen
- Apply for 5-10 seconds depending on thickness
For thicker lesions:
- First-line: Shave excision or electrodesiccation and curettage
- Consider sending tissue for histopathologic examination if any diagnostic uncertainty
For facial lesions or in patients concerned about pigmentation:
- First-line: Shave excision with light electrodesiccation of the base
- Alternative: Gentle cryotherapy (shorter freeze time)
For numerous lesions:
- Consider combination approach with cryotherapy for smaller lesions and excision for larger ones
- May require multiple sessions
Important Considerations
- Diagnostic uncertainty: If melanoma or squamous cell carcinoma is in the differential diagnosis, perform shave excision or biopsy rather than destructive therapy
- Skin type: In darker skin types, cryotherapy carries higher risk of post-inflammatory hypopigmentation
- Location: Facial lesions may benefit from more conservative approaches to minimize scarring
- Patient expectations: Discuss potential for scarring, pigmentation changes, and possibility of recurrence
Follow-up Recommendations
- Evaluate treated areas 4-6 weeks after procedure
- Educate patients about sun protection to prevent new lesions
- Inform patients that new lesions may develop over time as SK is related to aging and sun exposure
Pitfalls to Avoid
- Avoid aggressive cryotherapy on facial lesions or in darker skin types
- Do not assume all pigmented lesions are seborrheic keratoses; biopsy when uncertain
- Consider the "sign of Leser-Trélat" (sudden appearance of multiple SKs) as a potential paraneoplastic syndrome requiring further evaluation
Remember that while seborrheic keratoses are benign, treatment should be performed by qualified healthcare providers to ensure proper diagnosis and minimize complications.