Benign Lesion · Diagnosis First · CityLink Mall
A seborrhoeic keratosis is not a sun spot that has darkened, and it is not a wart — there is no virus involved. It is a benign overgrowth of the epidermis that sits on the skin rather than in it, and the only serious risk it carries is being assumed benign without being looked at properly.
A seborrhoeic keratosis is a benign tumour of keratinocytes — the ordinary cells of the epidermis, multiplying where they should not and stacking up. The lesion therefore grows outward rather than downward, which is why it can be felt with a fingertip and why it has the distinctive stuck-on quality patients describe: it looks as though it could be picked off, because in structural terms it is sitting on the surface rather than infiltrating what lies beneath. Small keratin-filled cysts within the lesion give it the fine pitted or crumbly surface visible up close.
It is not a wart, despite the common name. Warts are caused by human papillomavirus, are contagious, and behave quite differently. A seborrhoeic keratosis involves no virus, transmits to nobody, and will not spread from one part of the body to another by contact. Nor is it primarily a sun lesion, though it favours the trunk, face and neck. The dominant factors are age and inherited tendency — which is why patients frequently report the same lesions on a parent, and why they often appear in multiples rather than singly.
The colour is where confusion begins. A seborrhoeic keratosis can be flesh-coloured, tan, dark brown or nearly black, and in Asian skin the darker end of that range is common. Patients therefore present with what they believe to be a stubborn sun spot and are surprised to be told it is a different lesion requiring a different removal. The test is tactile, not visual: a solar lentigo is flat and cannot be felt; a seborrhoeic keratosis has height.
Dermatosis papulosa nigra deserves separate mention because it is common in this population and frequently misidentified. These are the small, dark, dome-shaped papules that appear on the cheeks and temples, often from early adulthood, often in clusters, and often in several members of a family. They are a variant of seborrhoeic keratosis, entirely benign, and they respond well to careful ablative removal — but the skin around them pigments readily, so technique and energy matter more than they would in paler skin.
The Distinction
Three things are regularly confused with a seborrhoeic keratosis, and the third is the reason no lesion is removed in this practice on the strength of a photograph. A destructive removal leaves nothing behind to examine, so the examination has to come first.
The risk with a benign lesion is never the lesion. It is the one that was assumed to be benign and removed without anyone looking at it properly.
The Decision
Seborrhoeic keratoses are removed for appearance or because they catch on clothing and jewellery and become irritated. There is no medical necessity in a lesion that is confidently benign, and it is worth saying that plainly rather than implying otherwise. Where removal is chosen, the methods are destructive — controlled ablation or superficial destruction of the raised tissue, performed with lesion removal technique appropriate to the site and the skin type, leaving a small area to re-epithelialise over the following week or two.
The order of operations is the part that matters. A destructive removal vaporises the lesion, which means there is no specimen left to examine if the diagnosis was wrong. Every lesion is therefore examined before treatment, and anything with an atypical feature — asymmetry, an irregular border, colour variation within it, ulceration, bleeding that was not provoked, or documented change over recent months — is referred for dermatological assessment and biopsy rather than treated on the day. This is inconvenient in perhaps one case in many, and correct in all of them.
In Fitzpatrick III to V skin the second consideration is what the removal leaves behind. Ablation is a controlled injury, and injury in this skin produces post-inflammatory hyperpigmentation readily — so a lesion removed too aggressively can be replaced by a brown mark that takes months to fade and is more conspicuous than what was there before. Conservative depth, strict aftercare and rigorous photoprotection during healing are what prevent that. Where many lesions are present, treating in stages is usually better practice than clearing a whole cheek in one sitting.
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