From the Guidelines
In the UK, keratoacanthoma is typically managed by complete surgical excision, which serves both diagnostic and therapeutic purposes, as recommended by the British Association of Dermatologists' guidelines for the care of patients with actinic keratosis 2017 1. The preferred approach is excisional biopsy with 2-3mm margins, as this allows for histological examination to rule out squamous cell carcinoma, which can be difficult to distinguish clinically. For smaller lesions (<1cm) or those in cosmetically sensitive areas, curettage and electrodesiccation may be considered. In cases where surgery is contraindicated or for multiple lesions, intralesional treatments such as 5-fluorouracil (50mg/ml, 0.1-0.5ml per lesion) or methotrexate (25mg/ml, 0.1ml per cm of lesion diameter) can be effective alternatives. Oral retinoids like acitretin (25-50mg daily for 2-3 months) may be used for multiple lesions. While some keratoacanthomas may spontaneously regress within 4-6 months, treatment is generally recommended due to potential for local tissue destruction and the difficulty in distinguishing them from squamous cell carcinoma, as noted in the guidelines for the management of actinic keratoses 1. Follow-up is typically arranged for 3-6 months after treatment to ensure complete resolution and detect any recurrence, which occurs in approximately 5% of cases. It's worth noting that the management of keratoacanthoma should be individualized, taking into account patient-specific factors, such as general fitness, coexisting serious medical conditions, and the use of antiplatelet or anticoagulant medication, as highlighted in the guidelines for the management of basal cell carcinoma 1. However, the most recent and highest quality study, the British Association of Dermatologists' guidelines for the care of patients with actinic keratosis 2017 1, prioritizes surgical excision as the primary management approach for keratoacanthoma. Key considerations in the management of keratoacanthoma include:
- Complete surgical excision for diagnostic and therapeutic purposes
- Excisional biopsy with 2-3mm margins for histological examination
- Alternative treatments, such as curettage and electrodesiccation, intralesional treatments, and oral retinoids, for specific cases
- Individualized management, taking into account patient-specific factors
- Follow-up for 3-6 months after treatment to ensure complete resolution and detect any recurrence.
From the Research
UK Management of Keratoacanthoma
- The management of keratoacanthoma in the UK is primarily focused on distinguishing it from squamous cell carcinoma (SCC) due to their similar clinical and histopathological characteristics 2.
- Surgical excision is often recommended to ensure that a potentially malignant SCC is not left untreated, although this approach can lead to unnecessary surgical morbidity and financial strain for patients, especially the elderly population 2.
- Alternative treatment modalities, such as intralesional methotrexate, have been explored, with studies showing promising results in resolving keratoacanthomas without the need for surgical excision 3.
- A review of therapeutic management options for keratoacanthomas highlights the variability in treatment choices and the need for a more standardized approach, considering the uncertain behavior of these neoplasms 4.
- In some cases, keratoacanthomas may develop as a postoperative complication of skin cancer excision, emphasizing the importance of considering keratoacanthoma in the differential diagnosis of rapidly growing nodules within or around surgical sites 5.
Treatment Options
- Surgical excision with or without Mohs micrographic surgery remains a standard treatment option for keratoacanthoma 4, 3.
- Intralesional methotrexate has been shown to be an effective treatment for solitary and multiple keratoacanthomas, with high cure rates and minimal complications 3.
- Other treatment modalities, such as curettage and electrodesiccation, and oral isotretinoin, may also be considered in certain cases 5.