What are the treatment options for seborrheic keratosis?

Treatment Options for Seborrheic Keratosis

Cryosurgery is the first-line treatment for seborrheic keratosis, with other effective options including shave excision, electrodessication, and curettage depending on lesion characteristics and patient preferences. 1, 2

Understanding Seborrheic Keratosis

Seborrheic keratosis (SK) is the most common benign epidermal tumor, affecting approximately 83 million Americans. These lesions:

• Can occur anywhere on the body except palms and soles
• Most commonly appear on the face and upper trunk
• Tend to increase in size, thickness, and pigmentation over time
• Are typically removed for cosmetic reasons rather than medical necessity

Treatment Options

Procedural Treatments

1. Cryosurgery

   • Most commonly used method 1
   • Particularly effective for thinner lesions
   • Advantages: Quick, office-based procedure
   • Disadvantages: Risk of hypopigmentation, especially in darker skin types

2. Shave Excision

   • Effective for raised lesions
   • Provides tissue for histologic confirmation when needed
   • Advantages: Complete removal with minimal scarring when performed correctly
   • Disadvantages: Risk of scarring if too deep

3. Electrodessication

   • Useful for multiple small lesions
   • Advantages: Precise control of depth
   • Disadvantages: Risk of scarring and pigmentary changes

4. Curettage

   • Often combined with electrodessication
   • Advantages: Complete removal of thicker lesions
   • Disadvantages: Potential for scarring

5. Laser Therapy

   • Options include CO2 and erbium:YAG lasers
   • Advantages: Precise depth control, good for multiple lesions
   • Disadvantages: Cost, specialized equipment required

Topical Treatments

1. 40% Hydrogen Peroxide Solution

   • Recently approved topical treatment 3, 4
   • Applied in-office
   • Advantages: Non-invasive option
   • Disadvantages: May require multiple treatments

2. Salicylic Acid

   • FDA-approved for hyperkeratotic disorders 5
   • 6% concentration can be used for SK
   • Advantages: Over-the-counter availability
   • Disadvantages: Less effective than procedural methods, requires repeated applications

Treatment Selection Algorithm

1. For few, discrete lesions:

   • First choice: Cryosurgery
   • Alternative: Shave excision (especially if histologic confirmation needed)

2. For multiple lesions:

   • First choice: Cryosurgery for fewer lesions
   • Alternative: Laser therapy or 40% hydrogen peroxide for numerous lesions

3. For thick, hyperkeratotic lesions:

   • First choice: Curettage with or without electrodessication
   • Alternative: Shave excision

4. For facial lesions (cosmetically sensitive areas):

   • First choice: Shave excision or light cryotherapy
   • Alternative: Laser therapy

5. For patients with darker skin types:

   • First choice: Shave excision or electrodessication
   • Avoid: Aggressive cryotherapy (risk of hypopigmentation)

Special Considerations

• Diagnostic uncertainty: If there is any concern for malignancy (rapid growth, bleeding, ulceration, irregular borders), perform shave biopsy for histopathologic examination
• Eruptive seborrheic keratoses (Sign of Leser-Trélat): Consider evaluation for underlying malignancy
• Post-treatment care: Advise patients about potential temporary erythema, crusting, and pigmentary changes

Treatment Outcomes

• Complete removal rates vary by modality:
  • Cryosurgery: 65-75% clearance with single treatment
  • Shave excision: 90-95% clearance
  • Electrodessication and curettage: 85-90% clearance
  • Topical treatments: Variable and often require multiple applications

Despite the benign nature of seborrheic keratoses, treatment is often sought for cosmetic concerns or discomfort. The choice of treatment should be based on lesion characteristics, location, and patient preferences, with special attention to minimizing adverse effects like scarring and pigmentary changes, particularly in patients with darker skin types.