What is the diagnosis and treatment for a slightly raised lesion with a brown center, mild itch, and pain in an older adult?

Diagnosis: Seborrheic Keratosis (Most Likely)

The most likely diagnosis is seborrheic keratosis, a benign age-related growth that presents as a slightly raised, brown-centered lesion in older adults, and treatment is typically not required unless symptomatic, in which case cryotherapy or shave excision are appropriate options. 1, 2

Clinical Reasoning

Key Diagnostic Features

• Brown center with slight elevation in an older adult is classic for seborrheic keratosis, one of the most common benign skin lesions in elderly patients 1, 2
• Mild itch and surrounding pain can occur with seborrheic keratoses due to irritation or inflammation, though these symptoms warrant careful evaluation to exclude other diagnoses 3, 4
• The "stuck-on" appearance (slightly raised) is pathognomonic for seborrheic keratosis 1

Critical Differential Diagnoses to Exclude

Malignant melanoma must be ruled out given the brown pigmentation, particularly if there are any atypical features such as:

• Asymmetry, irregular borders, color variation, diameter >6mm, or evolution (ABCDE criteria) 1
• Any suspicious features mandate biopsy before assuming benign diagnosis 1

Basal cell carcinoma can present as a raised lesion with central pigmentation in older adults and would require excision 1, 2

Actinic keratosis presents as rough, scaly lesions and is a precursor to squamous cell carcinoma, requiring treatment 2

Recommended Management Approach

Initial Assessment

• Complete skin examination is essential - examining only the presenting lesion misses 0.6% of potentially lethal melanomas and 3.3% of basal cell carcinomas 1
• Document lesion characteristics: size, exact color pattern, border regularity, symmetry, and any changes over time 1, 5
• Assess for Nikolsky sign (negative in seborrheic keratosis) to exclude blistering disorders 3, 6

Symptomatic Treatment for Itch and Pain

First-line topical therapy:

• Apply 1% hydrocortisone cream to affected area 3-4 times daily for up to 2 weeks to address inflammation and pruritus 4, 7
• Use emollients with high lipid content to maintain skin barrier and reduce irritation 4

If symptoms persist after 2 weeks:

• Consider non-sedating antihistamines such as fexofenadine 180 mg or loratadine 10 mg daily 4
• Avoid sedating antihistamines in elderly patients due to increased dementia risk and excessive sedation 4

Diagnostic Workup for Persistent Symptoms

If itch and pain are disproportionate to the lesion appearance, investigate systemic causes:

• Full blood count and ferritin levels to exclude iron deficiency or overload, both of which cause skin pain and pruritus 3, 4, 8
• Liver and renal function tests if generalized symptoms suggest systemic disease 4
• Consider polycythemia vera if aquagenic pruritus (worsening with water contact) is present 3, 8

Definitive Management of the Lesion

Observation is appropriate if the lesion is clearly benign and asymptomatic 1, 2

Removal indications:

• Persistent symptoms despite topical treatment 4
• Cosmetic concerns 1
• Diagnostic uncertainty - biopsy is mandatory if any atypical features 1
• Repeated trauma or irritation 1

Removal methods:

• Cryotherapy (liquid nitrogen) for typical seborrheic keratoses 1
• Shave excision with histopathological confirmation if any diagnostic doubt 1

Critical Pitfalls to Avoid

• Never assume a pigmented lesion is benign without careful examination - melanoma can be missed in 0.6% of cases without complete skin assessment 1
• Do not use crotamiton cream - it is ineffective for pruritus in elderly patients 4
• Do not delay biopsy if there is any diagnostic uncertainty, as early melanoma detection is critical for survival 1
• Do not overlook medication review - drug-induced skin reactions can present with pain before visible changes 8
• Reassess if symptoms don't improve after initial treatment, as this may indicate an alternative diagnosis requiring different management 4