What is the diagnosis for a 25-year-old female presenting with 5 smooth papules, 1-2mm in size, flat, and located on the face, treated with cryotherapy, suspected to be Seborrheic Keratoses (SKs)?

Diagnosis: Flat Facial Papules in a Young Female

This clinical presentation is NOT consistent with seborrheic keratoses (SKs), and cryotherapy was likely inappropriate treatment. SKs in a 25-year-old female presenting as 5 smooth, flat, 1-2mm papules on the face represents an atypical presentation that warrants reconsideration of the diagnosis.

Why This is Unlikely to be Seborrheic Keratoses

Classic SKs present as verrucous "stuck-on" papules or plaques, not smooth flat lesions. 1, 2 The key diagnostic features that are missing include:

• Age discordance: SKs predominantly occur in adult patients with increasing incidence with age, making them uncommon in a 25-year-old 1, 2
• Morphology mismatch: SKs are characteristically described as verrucous, hyperkeratotic lesions with a "stuck-on" appearance, not smooth and flat 1, 2, 3
• Size consideration: While 1-2mm lesions can occur, the combination of small size, smooth texture, and flat morphology is atypical 2

More Likely Differential Diagnoses

The smooth, flat, small papular presentation on the face of a young female suggests alternative diagnoses:

• Flat warts (verruca plana): Smooth, flat-topped papules 1-4mm in size, commonly on the face in young adults
• Syringomas: Small, smooth, skin-colored to yellowish papules, typically periorbital
• Milia: Small, white, smooth papules commonly on the face
• Lichen planus: Can present as flat-topped papules, though typically larger and violaceous
• Early actinic keratoses: Though extremely rare at age 25 unless significant sun exposure or immunosuppression 4

Documentation for Physical Examination

When documenting facial papules in the medical record, include these specific details:

• Number and distribution: Document exact count and anatomic location (e.g., "5 papules distributed over bilateral malar regions")
• Size: Measure in millimeters (documented as 1-2mm here)
• Color: Specify if skin-colored, hyperpigmented, hypopigmented, erythematous, or other
• Surface texture: Smooth vs. rough/verrucous/hyperkeratotic (documented as smooth here)
• Elevation: Flat vs. raised vs. pedunculated (documented as flat here)
• Dermoscopic findings: If available, document specific patterns (e.g., for true SKs: comedo-like openings, milia-like cysts, fissures and ridges) 1, 2
• Symptoms: Presence or absence of pruritus, tenderness, or bleeding

Appropriate Management Approach

Given the diagnostic uncertainty, the following steps should be taken:

• Dermoscopy evaluation: Essential to differentiate between SK and other pigmented or non-pigmented lesions before treatment 1, 2
• Consider biopsy: For atypical presentations in young patients, histological confirmation may be warranted before destructive therapy 4
• Reassess post-cryotherapy: Monitor healing time (typically 3-6 weeks for cryotherapy-treated lesions) and watch for complications 5
• Document response: If lesions recur or fail to respond, this strongly suggests misdiagnosis and warrants biopsy 4

Cryotherapy Considerations for True SKs

If these were confirmed SKs, cryotherapy parameters would include:

• Freeze time: 15-20 seconds until 1-2mm of surrounding skin appears frozen 5
• Expected healing: Crusted eschar forms within days, complete healing typically by 3-6 weeks 5
• Complications: Hypo- or hyperpigmentation (especially in darker skin types), with pigmentary changes typically improving by 6-12 months 5
• Facial precautions: Avoid eyelids, lips, nose, and ears due to potential complications 5

Critical Pitfall to Avoid

The most significant error here is treating without definitive diagnosis. The atypical presentation (young age, smooth flat morphology) should have prompted dermoscopy or biopsy before destructive therapy 1, 2. If lesions recur or fail to clear completely, obtain histological diagnosis before retreatment 4.