Management of Benign-Appearing Seborrheic Keratosis Lesions
For clinically benign-appearing seborrheic keratosis lesions without concerning features, biopsy is not necessary, and annual skin surveillance is appropriate. 1
Clinical Decision-Making for These Lesions
When Biopsy is NOT Required
Your clinical assessment appears sound. Lesions that are clinically consistent with seborrheic keratosis and lack warning signs do not require biopsy. 2 The key is ensuring none of the following concerning features are present:
Major warning signs to exclude (the "7-point checklist"): 2
- Change in size
- Change in shape
- Change in color
- Diameter ≥ 7 mm
- Inflammation
- Sensory change (itching, tenderness)
- Crusting or bleeding
When Biopsy IS Required
Complete excision with a 2 mm margin of normal skin should be performed if: 1, 3, 2
- Any of the above warning signs are present
- The lesion has irregular borders, asymmetry, or heterogeneous pigmentation (ABCDE criteria) 1
- Clinical uncertainty exists about the diagnosis
- The lesion fails to respond to treatment (if treatment were attempted) 1
Critical pitfall: Melanoma can mimic seborrheic keratosis, as can pigmented basal cell carcinoma. 1, 3 Visual assessment alone has documented cases of misdiagnosis. 2 However, when lesions are clinically typical for seborrheic keratosis without concerning features, observation is appropriate.
Recommended Follow-Up Strategy
Annual skin surveillance is appropriate for patients with multiple seborrheic keratoses. 1 This recommendation is based on:
- Seborrheic keratoses themselves are benign and do not transform into malignancy 1
- However, their presence indicates chronic sun exposure, which is a risk factor for skin cancer 1
- Patients with multiple benign lesions benefit from periodic surveillance to detect any new or changing lesions that may represent actual malignancy 1
Patient Education Components
Educate the patient to monitor for and report: 1
- New lesions developing
- Any existing lesion showing change in size, shape, or color
- Development of irregular borders or pigmentation
- Symptoms such as itching, bleeding, or crusting
- Any lesion that "looks different" from the others
Sun protection counseling is essential given that multiple seborrheic keratoses indicate significant cumulative sun exposure, which increases melanoma and non-melanoma skin cancer risk. 1
Documentation Recommendations
Your documentation should include: 1
- Location of lesions (you've done this appropriately)
- Clinical appearance consistent with seborrheic keratosis
- Absence of concerning features
- Patient education provided regarding warning signs
- Plan for annual surveillance
This approach balances avoiding unnecessary biopsies of benign lesions (which carry cost and morbidity) while maintaining appropriate vigilance for malignancy. 1