By recollection, my first encounter with a seborrheic keratosis (SK) was as a senior medical student in 1956. I was on a dermatology rotation when my father came to visit me. He was worried about a recently developed 1-cm–in–diameter, irregular, raised, scaly, darkly-pigmented cutaneous growth on his chest. I brought him to my dermatology professor who diagnosed SK, said it was benign, and removed it successfully with shave surgery. There was no Medicare back then, and my self-employed father was uninsured. Many physicians used to give "professional courtesy," but not this dermatologist. The bill arrived in the mail.
SKs run in families. My first SK appeared when I was 57 and grew rapidly on my cheek, under my left eye, visible to all. I did not like the way it looked; my dermatologist called it an SK and removed it with shave surgery. It healed under a big black scab and left a scar that gradually waned. Blue Cross paid the bill. So continued my SK odyssey.
Long-term readers of my Medscape column will recall that I first wrote about my personal use of fingernail surgery as a safe and effective treatment of SKs in 2006, with outcome follow-ups in 2016 and 2021.
How do you manage your own SKs? You don't have any? Look again if you are curious and older than 35.
Many of us have a multidecade personal experience with SKs. Because they are deemed cosmetic, removal is not medically necessary nor typically covered by health insurance. However, Americans are believed to spend as much as $90 billion each year to the cosmetics industry, of which, $18 billion is for aesthetic plastic surgery.
Here's what I've found out about SK removal:
Yale Medicine: Treatments for SKs include cryotherapy, electrosurgery, curettage, laser treatment, and dermabrasion. (Imagine the fees generated for these in-office procedures.)
Google generative artificial intelligence: Charges for SK removal range from $50-650, more than one patient visit is often required, and because SK removal is a cosmetic procedure, insurance often does not pay or reimburse.
Bing: Shave excision costs $100-$500 per lesion plus pathology fees if sent for microscopic study. Cryotherapy is at least $400, and topical therapy runs $300 or more.
Veterans Affairs Health: Does not offer surgical removal of SKs unless they are bleeding, irritated, or hamper daily activities, in other words, if removal is medical necessary.
ChatGPT: States that "many millions" of Americans have SKs removed each year.
Accurate data are difficult to come by. SKs are not malignant, so there seems to be no registries. Because insurance generally does not pay for SK removal, no claims data are available to search. Without much American research being done on SKs, the scientific literature has little to report.
Still, despite fuzzy data, extrapolating 80 million affected, the 30%-50% of people who seek removal yields 24-40 million therapeutic encounters for SK removal yearly. Charges ranging from $50 to $650 per removal would translate to a low of $1,200,000,000 and a high of $26,000,000,000,000 annually — absurd, I know, especially because these hefty sums represent out-of-pocket costs.
According to Medscape survey data, the average US dermatologist income was $443,000 in 2023. There are approximately 11,000 dermatologists in the United States. Taking the low end ($1,200,000,000) and dividing by 11,000 results in $109,090 per year per dermatologist. Pretty good money for primarily cosmetic SK eradications. Of course, plastic surgeons, general surgeons, family physicians, and other specialists also treat SKs.
Is it time to disrupt this one lucrative element of the American medical industrial complex (AMIC)? Might there be another path for patients to take?
Experience With DIY Eradication
Of course, there is "fingernail surgery." There is no way to know how many SKs are simply scraped off by patients. Judging from earlier reader comments, however, probably a lot.
Several years ago, Aclaris Pharmaceuticals developed a 40% hydrogen peroxide product called Eskata for topical eradication of SKs and obtained FDA approval for marketing and sales in 2017. After 2 years the company, ceased to sell the product. Eskata was intended for physicians to prescribe and apparently not enough did so to sustain the business. When Aclaris considered direct-to consumer (DTC) advertising, it was warned by the FDA for misleading and incomplete disclosure of potential adverse effects.
It seems obvious that physicians are quite happy with the methods they already practice and for which they earn a pretty penny. The market may simply have been too crowded with treatment options, so the economics did not work for the introduction of yet another new therapeutic modality for physicians. I have not discovered any serious effort to change the marketing strategy of Eskata to DTC. Of course, the ingredients are already available and very inexpensive, so no large pharmaceutical company would likely touch it. There is very little money to be made by manufacturing and pushing this treatment for the SK market.
Published research supports the topical use of 40% hydrogen peroxide as one treatment for SKs.
A company in Massachusetts named DermBiont recently announced promising results in late-stage clinical trials of an investigational drug named SM-020 gel, an AKT inhibitor intended for home use DIY chemical ablation of SKs.
DermBiont uses the physician lesion assessment (PLA) score to gauge progress toward eradication:
PLA 3: thick; a visible elevated SK lesion with a thickness > 1 mm
PLA 2: thin; a visible elevated SK lesion with a thickness ≤ 1 mm
PLA 1: near clear; a visible non-elevated SK lesion with a surface appearance different from the surrounding skin
PLA 0: no visible SK lesion with a surface appearance different from the surrounding skin.
A study out of India reported that 30% hydrogen peroxide as a cauterant was effective as therapy for SKs, often after only one treatment. Another product called WartPEEL has been suggested as an alternative. However, it is a prescription product.
My SKs quickly tingled, blanched white, and began to shrink. More than one daily application is sometimes needed for thick lesions. They tended not to disappear but lose bulk and flatten, retaining their coloration. Reasonable care is necessary to localize the chemical which is caustic to surrounding skin. But those symptoms quickly dissipate with no sequalae.
My recommendation to you all is: ignore your SKs. They don't hurt, become malignant, or interfere with life, and they are not contagious. If your SKs (cosmetically) bother someone else, that's their problem.
But if you want them gone, you can now personally, with a little common sense, use my preferred method of fingernail surgery; 30%, 35%, or 40% hydrogen peroxide; or perhaps some of the newer gels safely and effectively. Many SKs grow out of reach of the patient, such as on the back, so some partner may need to be recruited to apply the therapy.
Or you can continue to feed the AMIC with your own out-of-pocket money to your favorite dermatologist, plastic or general surgeon, or perhaps, your own primary care physician.
COMMENTARY
DIY: Seborrheic Keratosis Eradication
George Lundberg
DISCLOSURES
| April 09, 2024By recollection, my first encounter with a seborrheic keratosis (SK) was as a senior medical student in 1956. I was on a dermatology rotation when my father came to visit me. He was worried about a recently developed 1-cm–in–diameter, irregular, raised, scaly, darkly-pigmented cutaneous growth on his chest. I brought him to my dermatology professor who diagnosed SK, said it was benign, and removed it successfully with shave surgery. There was no Medicare back then, and my self-employed father was uninsured. Many physicians used to give "professional courtesy," but not this dermatologist. The bill arrived in the mail.
SKs run in families. My first SK appeared when I was 57 and grew rapidly on my cheek, under my left eye, visible to all. I did not like the way it looked; my dermatologist called it an SK and removed it with shave surgery. It healed under a big black scab and left a scar that gradually waned. Blue Cross paid the bill. So continued my SK odyssey.
Long-term readers of my Medscape column will recall that I first wrote about my personal use of fingernail surgery as a safe and effective treatment of SKs in 2006, with outcome follow-ups in 2016 and 2021.
How do you manage your own SKs? You don't have any? Look again if you are curious and older than 35.
Seborrheic Keratoses
Eighty million Americans are estimated to exhibit SKs at any one time.
As many as 90% of adults over the age of 65 are estimated to have at least one (and often many more) SKs.
Many of us have a multidecade personal experience with SKs. Because they are deemed cosmetic, removal is not medically necessary nor typically covered by health insurance. However, Americans are believed to spend as much as $90 billion each year to the cosmetics industry, of which, $18 billion is for aesthetic plastic surgery.
Here's what I've found out about SK removal:
- Yale Medicine: Treatments for SKs include cryotherapy, electrosurgery, curettage, laser treatment, and dermabrasion. (Imagine the fees generated for these in-office procedures.)
- Google generative artificial intelligence: Charges for SK removal range from $50-650, more than one patient visit is often required, and because SK removal is a cosmetic procedure, insurance often does not pay or reimburse.
- Bing: Shave excision costs $100-$500 per lesion plus pathology fees if sent for microscopic study. Cryotherapy is at least $400, and topical therapy runs $300 or more.
- Veterans Affairs Health: Does not offer surgical removal of SKs unless they are bleeding, irritated, or hamper daily activities, in other words, if removal is medical necessary.
- ChatGPT: States that "many millions" of Americans have SKs removed each year.
Accurate data are difficult to come by. SKs are not malignant, so there seems to be no registries. Because insurance generally does not pay for SK removal, no claims data are available to search. Without much American research being done on SKs, the scientific literature has little to report.Still, despite fuzzy data, extrapolating 80 million affected, the 30%-50% of people who seek removal yields 24-40 million therapeutic encounters for SK removal yearly. Charges ranging from $50 to $650 per removal would translate to a low of $1,200,000,000 and a high of $26,000,000,000,000 annually — absurd, I know, especially because these hefty sums represent out-of-pocket costs.
According to Medscape survey data, the average US dermatologist income was $443,000 in 2023. There are approximately 11,000 dermatologists in the United States. Taking the low end ($1,200,000,000) and dividing by 11,000 results in $109,090 per year per dermatologist. Pretty good money for primarily cosmetic SK eradications. Of course, plastic surgeons, general surgeons, family physicians, and other specialists also treat SKs.
Is it time to disrupt this one lucrative element of the American medical industrial complex (AMIC)? Might there be another path for patients to take?
Experience With DIY Eradication
Of course, there is "fingernail surgery." There is no way to know how many SKs are simply scraped off by patients. Judging from earlier reader comments, however, probably a lot.
Several years ago, Aclaris Pharmaceuticals developed a 40% hydrogen peroxide product called Eskata for topical eradication of SKs and obtained FDA approval for marketing and sales in 2017. After 2 years the company, ceased to sell the product. Eskata was intended for physicians to prescribe and apparently not enough did so to sustain the business. When Aclaris considered direct-to consumer (DTC) advertising, it was warned by the FDA for misleading and incomplete disclosure of potential adverse effects.
It seems obvious that physicians are quite happy with the methods they already practice and for which they earn a pretty penny. The market may simply have been too crowded with treatment options, so the economics did not work for the introduction of yet another new therapeutic modality for physicians. I have not discovered any serious effort to change the marketing strategy of Eskata to DTC. Of course, the ingredients are already available and very inexpensive, so no large pharmaceutical company would likely touch it. There is very little money to be made by manufacturing and pushing this treatment for the SK market.
Published research supports the topical use of 40% hydrogen peroxide as one treatment for SKs.
A company in Massachusetts named DermBiont recently announced promising results in late-stage clinical trials of an investigational drug named SM-020 gel, an AKT inhibitor intended for home use DIY chemical ablation of SKs.
DermBiont uses the physician lesion assessment (PLA) score to gauge progress toward eradication:
A study out of India reported that 30% hydrogen peroxide as a cauterant was effective as therapy for SKs, often after only one treatment. Another product called WartPEEL has been suggested as an alternative. However, it is a prescription product.
Following the lead of medical journalist Ron Piana on his successful use of 35% hydrogen peroxide to eradicate his oral leukoplakia and urologic surgeon and Burt Vorstman who used it successfully on his cutaneous squamous cell cancers and being bolstered by the published Eskata experience, I decided to try 35% food-grade hydrogen peroxide on my PLA 3 SKs (using a cotton ball on a stick, wearing protective gloves and after isopropyl alcohol site sterilization).
My SKs quickly tingled, blanched white, and began to shrink. More than one daily application is sometimes needed for thick lesions. They tended not to disappear but lose bulk and flatten, retaining their coloration. Reasonable care is necessary to localize the chemical which is caustic to surrounding skin. But those symptoms quickly dissipate with no sequalae.
My recommendation to you all is: ignore your SKs. They don't hurt, become malignant, or interfere with life, and they are not contagious. If your SKs (cosmetically) bother someone else, that's their problem.
But if you want them gone, you can now personally, with a little common sense, use my preferred method of fingernail surgery; 30%, 35%, or 40% hydrogen peroxide; or perhaps some of the newer gels safely and effectively. Many SKs grow out of reach of the patient, such as on the back, so some partner may need to be recruited to apply the therapy.
Or you can continue to feed the AMIC with your own out-of-pocket money to your favorite dermatologist, plastic or general surgeon, or perhaps, your own primary care physician.
Your choice.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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