Managing SKs: Case Vignettes
Case 1. A Woman With Multiple Lesions on the Face and Neck
Danielle Y., a 57-year-old African American woman, presented to an aesthetic dermatologist with five small, darkly pigmented papule-like lesions on her face and neck. She denied experiencing pain or itching in those areas and recalled no trauma, infection, or other circumstance that would account for them. Her primary care provider (PCP) diagnosed the lesions as dermatosis papulosa nigra, then referred her to the aesthetic dermatologist to discuss potential options for treatment. The PCP informed her that the lesions are benign with no malignant potential.
Danielle works as a buyer for a major retail clothing company. She said that her job includes frequent in-person customer interactions and presentations. Her mother and aunt have many more lesions similar to hers, and she is concerned about the negative effect on her professional appearance if additional lesions develop. Having had other aesthetic dermatologic interventions, she understands that she will have to pay for lesion removal out of her own pocket.
The aesthetic dermatologist explains the options of cryosurgery, curettage and electrocautery, laser therapy, and topical therapy. He notes the risk of postinflammatory pigmentary disorders in patients with skin of color after any of these interventions. He explains that the topical therapy is associated with mostly mild levels of hyperpigmentation and hypopigmentation in, respectively, 8% and 3% of patients roughly 3 months after the first treatment, in a population of mostly light-skinned individuals.1
Danielle is very concerned about the possibility of destructive interventions worsening her appearance. She suggests trying the topical on one or two lesions to assess the response. The dermatologist agrees to this plan.
Case 2. A Man With a Pigmented Lesion on the Neck
Alan W., a 79-year-old white man, presented to his dermatologist for a quarterly skin examination. As a light-skinned individual (Fitzpatrick type II) with a history of severe sunburn while on surface ship duty in the Navy, he is at risk for dermatologic malignancies. He has had multiple precancerous lesions removed in the last 5 years or so.
The dermatologist noticed that a thick (~4 mm) pigmented lesion on the back of the neck near the hairline had enlarged and appears to have darkened since the last examination. The lesion was first noted many years ago and had remained unchanged, until today. The dermatologist had previously diagnosed it as a seborrheic keratosis (SK), for which Alan declined treatment. Dermoscopic examination does not clarify the diagnosis. Given the patient’s history, the dermatologist biopsies the lesion.
The biopsy indicates that the lesion is an SK. The patient has had cryosurgery in the past and found the procedure very painful. He expresses a desire to avoid it. The dermatologist recommends electrocautery and curretage, for which the patient will receive anesthesia with 1% lidocaine and after which some wound care will be required. The patient agrees.
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 [email protected] 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.
- 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 two identical, randomized, double-blind, placebo-controlled, phase 3 studies (A-101-SEBK-301/302). J Am Acad Dermatol. 2018;79(5):869-877.