What is the diagnosis and treatment for hyperkeratotic seborrheic keratosis?

From the Guidelines

Hyperkeratotic seborrheic keratosis should be treated with caution, prioritizing methods that allow for histological examination to rule out skin cancer, such as deep shave or formal excision with histological examination, as recommended by the British Association of Dermatologists' guidelines for the care of patients with actinic keratosis 2017 1. When considering treatment options for hyperkeratotic seborrheic keratosis, it is essential to prioritize methods that allow for histological examination to rule out skin cancer. The British Association of Dermatologists' guidelines for the care of patients with actinic keratosis 2017 suggest that surgery, including deep shave or formal excision with histological examination, may be preferred in some instances, especially where there is diagnostic uncertainty or a differential diagnosis of squamous cell carcinoma (SCC) 1.

Some key points to consider when treating hyperkeratotic seborrheic keratosis include:

• The importance of histological examination to rule out skin cancer
• The potential for curettage to be used, but with caution and potentially multiple cycles of therapy if SCC is a differential diagnosis
• The need to prioritize treatment methods that allow for thorough examination of the lesion
• The importance of protecting the skin from sun exposure to prevent new lesions from forming

In terms of specific treatment options, the following may be considered:

• Deep shave or formal excision with histological examination, as recommended by the British Association of Dermatologists' guidelines for the care of patients with actinic keratosis 2017 1
• Curettage, potentially with multiple cycles of therapy if SCC is a differential diagnosis
• Other removal options, such as cryotherapy, electrocautery, or shave excision, but with caution and careful consideration of the potential risks and benefits.

From the FDA Drug Label

Indications and Usage For debridement and promotion of normal healing of hyperkeratotic surface lesions, particularly where healing is retarded by local infection, necrotic tissue, fibrinous or purulent debris or eschar. Urea is useful for the treatment of hyperkeratotic conditions such as dry, rough skin, dermatitis, psoriasis, xerosis, ichthyosis, eczema, keratosis pilaris, keratosis palmaris, keratoderma, corns and calluses, as well as damaged, ingrown and devitalized nails. Clinical Pharmacology Urea gently dissolves the intracellular matrix which results in loosening of the horny layer of the skin and shedding of scaly skin at regular intervals, thereby softening hyperkeratotic areas of the skin. INDICATIONS AND USAGE For Dermatologic Use: Salicylic Acid 6% is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders including verrucae, and the various ichthyoses (vulgaris, sex-linked and lamellar), keratosis palmaris and plantaris keratosis pilaris, pityriasis rubra pilaris, and psoriasis (including body, scalp, palms and soles).

Hyperkeratotic seborrheic keratosis treatment options include:

• Urea (TOP) 2, which can help soften hyperkeratotic areas of the skin
• Salicylic acid (TOP) 3, which can aid in the removal of excessive keratin in hyperkeratotic skin disorders Key points:
• Urea gently dissolves the intracellular matrix, loosening the horny layer of the skin and shedding scaly skin 2
• Salicylic acid is a topical aid in the removal of excessive keratin in hyperkeratotic skin disorders, including various ichthyoses and psoriasis 3

From the Research

Hyperkeratotic Seborrheic Keratosis

• Hyperkeratotic seborrheic keratosis is a common benign skin tumor that can be managed with various treatment options 4.
• The use of a keratolytic agent with occlusion has been shown to be effective in treating hyperkeratotic seborrheic keratoses, with patients expressing satisfaction with this topical therapeutic technique 4.
• Other treatment options for seborrheic keratosis include cryosurgery, shave excision, electrodessication, curettage, and laser application, which can be used to remove lesions effectively, but may have potential drawbacks and require careful patient selection 5, 6, 7, 8.
• Topical agents, such as a 40% hydrogen peroxide formulation, have been approved for the treatment of seborrheic keratosis, and non-invasive topical treatments can optimize cosmetic outcomes of lesion removal 8.
• The pathophysiology of seborrheic keratosis is still not fully understood, but ultra-violet exposure, human papillomavirus infection, and Merkel cell polyomavirus nucleic acid have been identified as potential predisposing factors 7.

Treatment Options

• Cryosurgery is the most common method of removal for seborrheic keratosis, but other options such as shave excision, electrodessication, and curettage can also be employed 5, 6.
• Laser application is another treatment option for seborrheic keratosis, which can be used to remove lesions effectively, but may have potential drawbacks such as post-procedure depigmentation and scarring 7.
• Nanosecond-pulsed electric field technology is a promising new technique for the treatment of seborrheic keratosis, with fewer side-effects compared to other methods 7.

Patient Satisfaction and Cosmetic Outcomes

• Patient satisfaction is an important consideration in the treatment of seborrheic keratosis, with many patients electing to have asymptomatic lesions removed for cosmetic purposes 5, 8.
• The cosmetic outcomes of seborrheic keratosis treatment modalities are of keen interest to dermatologists, particularly in patients with darker Fitzpatrick skin types 8.