Advances in Seborrheic Keratosis
Seborrheic keratosis (SK) has been called the “Rodney Dangerfield of skin lesions”— it earns little respect (as a clinical concern)
because of its benignity, commonality, usual ease of diagnosis, and simplicity of treatment.1 But these humble lesions are deceiving: They can mimic or camouflage cutaneous malignancy, signal internal malignancy, and cause substantial distress for patients.2-5 Understanding why they remain benign despite the presence of mutations also found in cancer cells may lead to new therapies for cancer—and for SKs.1,6
Recently, the US Food and Drug Administration (FDA) approved the first topical therapy—hydrogen peroxide topical solution, 40% (HP40)—for use on raised SKs, offering clinicians an effective and nondestructive option for removing these lesions. Unlike some topical dermatology products, HP40 is distributed only through dermatology practices and must be applied by a clinician.7 This article offers an update about the management of SKs and the use of this new therapy.
SKs—commonly called age spots—represent the most common benign tumor in humans and are among the most frequent reasons for a visit to a dermatologist.1,8 The lesions of SK typically appear as round or oval, sharply demarcated verrucous plaques with a waxy, stuck-on appearance and with variable thickness and color. As their vernacular name implies, they become more prevalent with advancing age. One author estimated that 80% to 100% of individuals older than 50 years will develop at least one SK.9 Although characteristically observed in middle-aged to older adults, they also occur in teens and young adults.10 SKs rarely travel alone; most individuals with SKs have more than one such lesion. In one study (N=406), the average number of nonsymptomatic SKs per patient was 26.11
SKs result from the accumulation of normal keratinocytes between the basal layer and the keratinizing surface.12 They can develop virtually anywhere except for the palms, soles, and mucous membranes9, but are most commonly observed on the trunk and face.6,13 The tendency to develop SKs can run in families; some genetic links have been identified.14,15
SKs are associated with an extremely low risk of malignancy. They can expand and thicken with time,6 however, and may be mistaken for melanoma and other skin cancers.4 Patients may regard the lesions as unsightly, annoying, or irritating, especially if the lesions are visible or rub against clothing.
Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail or you may print it out at that time.
The online post-test and evaluation can be accessed at http://tinyurl.com/SebK2018.
Inquiries about continuing medical education (CME) accreditation may be directed to the University of Louisville Office of Continuing Medical Education & Professional Development (CME & PD) at firstname.lastname@example.org or (502) 852-5329.
Joseph F. Fowler Jr, MD
Michael S. Kaminer, MD
The University of Louisville School of Medicine designates this Enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Joint Provider Accreditation Statement
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Louisville School of Medicine and Global Academy for Medical Education. The University of Louisville School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and Global Academy for Medical Education.
Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Continuing Nursing Education: The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours. Designated for 0.1 contact hours of pharmacotherapy credit for Advanced Practice Registered Nurses.
Seborrheic keratoses (SKs) represent the most common benign tumor in humans and are among the most frequent reasons for visiting a dermatologist. SKs can mimic or mask cutaneous malignancy. Clinicians should be able to diagnose SKs efficiently and accurately to avoid missing melanoma or other cancers. Medical intervention is not required unless the diagnosis is uncertain or the SKs are symptomatic (eg, bleeding, irritation, or itching). Patients with benign lesions often express interest in treatment due to the emotional and social impact of SKs. Current destructive options can be associated with pain, scarring, and pigmentary abnormalities. The first topical therapy approved for use on SKs—hydrogen peroxide topical solution, 40% (HP40)—received US Food and Drug Administration approval about 1 year ago. Clinicians need to be aware of and sympathetic to patient concerns about SKs and treatments. They also benefit from being informed about the latest therapeutic options for removing SKs.
At the conclusion of this activity, participants should be better able to:
- Differentiate between benign seborrheic keratosis (SK) and other common skin lesions
- Recognize the potential emotional and social impact of SK lesions on patients
- Designatherapeuticapproachforindividual patients with SK lesions that maximizes outcomes while minimizing adverse events.
Individuals in a position to control the content of this educational activity are required to disclose: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of non-profit or government organizations and non-health-care-related companies, within the past 12-months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.
Joseph F. Fowler Jr, MD, Speakers Bureau: Smart Practice, Regeneron; Grant/Contracted Research Support: Aclaris Therapeutics, Galderma Laboratories, Pfizer, Novartis, Lilly, Accuitis, Dermira, Ralexar, and Regeneron. He will discuss the investigational/unlabeled uses of A-101 40% solution; 5% potassium dobesilate cream; aqueous trichloroacetic acid (TCA) and formic acid combination; tazarotene 0.1% cream; A-443654; GSK690693.
Michael S. Kaminer, MD, Consultant: Cytrellis Biosystems, Zeltiq, Soliton, Exploramed, L’Oreal, Endo, Arctic Fox LLC.
CME/CE Reviewers: Courtney Schadt, MD, Assistant Professor, Division of Dermatology, University of Louisville School of Medicine, has no relevant financial relationships to disclose. Staff and Advisory Board Disclosures: The University of Louisville CME & PD Advisory Board and office staff have nothing to disclose with the following Board Member exceptions: Sathya Krishnasamy, MD-Kowa Pharmaceuticals; Ashlee Bergin, MD-Merck Pharmaceuticals; Michael Sowell, MD-Amgen, Impax Pharmaceuticals.
The PIM planners and managers have nothing to disclose.
Global Academy for Medical Education Staff:
Eileen McCaffrey; Sylvia H. Reitman, MBA, DipEd; and Ron Schaumburg have no relevant financial relationships to disclose.
This CME/CE supplement was developed from interviews with the faculty. Dr Fowler and Dr Kaminer acknowledge the editorial assistance of Global Academy for Medical Education and Eileen McCaffrey, medical writer, in the development of this supplement. Neither the editors of Dermatology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The ideas and opinions expressed in this supplement are those of the faculty and do not necessarily reflect the views of the supporter, Global Academy for Medical Education, the University of Louisville, Postgraduate Institute for Medicine, or the Publisher.
Copyright © 2018 Global Academy for Medical Education, LLC, and Frontline Medical Communications. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher.
Global Academy for Medical Education, LLC, Frontline Medical Communications, The University of Louisville, and Postgraduate Institute for Medicine will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including claims related to the products, drugs, or services mentioned herein.
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- Carrera C, Segura S, Aguilera P, et al. Dermoscopic clues for diagnosing melanomas that resemble seborrheic keratosis. JAMA Dermatol. 2017;153(6):544-551.
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- Silva JA, Mesquita Kde C, Igreja AC, et al. Paraneoplastic cutaneous manifestations: concepts and updates. An Bras Dermatol. 2013;88(1):9-22.
- Neel VA, Todorova K, Wang J, et al. Sustained Akt activity is required to maintain cell viability in seborrheic keratosis, a benign epithelial tumor. J Invest Dermatol. 2016;136(3):696-705.
- Eskata [package insert]. Malvern, PA: Aclaris Therapeutics, Inc; 2017.
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- Lin J, Han S, Cui L, et al. Evaluation of dermoscopic algorithm for seborrhoeic keratosis: a prospective study in 412 patients. J Eur Acad Dermatol Venereol. 2014;28(7):957-962.
- Yagerman S, Marghoob AA. The ink test: identifying 3-dimensional features of seborrheic keratoses under dermoscopy. JAMA Dermatol. 2013;149(4):497-498.
- Eastman KL, Knezevich SR, Raugi GJ. Eruptive seborrheic keratoses associated with adalimumab use. J Dermatol Case Rep. 2013;7(2):60-63.
- Jackson JM, Alexis A, Berman B, Berson DS, Taylor S, Weiss JS. Current understanding of seborrheic keratosis: prevalence, etiology, clinical presentation, diagnosis, and management. J Drugs Dermatol. 2015;14(10):1119-1125.
- Draelos ZD, Rizer RL, Trookman NS. A comparison of postprocedural wound care treatments: do antibiotic-based ointments improve outcomes? J Am Acad Dermatol. 2011;64(3 suppl):S23-S29.
- Kaufman BP, Aman T, Alexis AF. Postinflammatory hyperpigmentation: epidemiology, clinical presentation, pathogenesis and treatment. Am J Clin Dermatol. 2018;19(4):489-503.
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- Kim YK, Kim DY, Lee SJ, Chung WS, Cho SB. Therapeutic efficacy of long-pulsed 755-nm alexandrite laser for seborrheic keratoses. J Eur Acad Dermatol Venereol. 2014;28(8):1007-1011.
- Baumann LS, Blauvelt A, Draelos ZD, et al. Safety and efficacy of hydrogen peroxide topical solution, 40% (w/w), in patients with seborrheic keratoses: results from 2 identical, randomized, double-blind, placebo-controlled, phase 3 studies (A-101-SEBK-301/302). J Am Acad Dermatol. 2018;79(5):869-877.
- Kao S, Kiss A, Efimova T, Friedman A. Ex vivo evaluation of cytotoxicity and melanocyte viability after A-101 hydrogen peroxide topical solution 40% or cryosurgery treatment in seborrheic keratosis lesions. J Am Acad Dermatol. 2018;79(4):767-768.