Dr. George D. Lundberg
Looking back, I first encountered seborrheic keratosis (SK) in 1956 as a medical student. I was on my dermatology rotation when my dad came to visit. He was concerned about a recent 1 cm diameter, irregular, raised, scaly, darkly pigmented skin tumor on his chest. I took him to a dermatology professor, who diagnosed SK, said it was benign, and successfully removed it with shaving surgery. There was no Medicare back then, and my father, who was self-employed, was uninsured. Many doctors used to exhibit “professional decorum,” but this dermatologist did not. The bill arrived by mail.
SK is family owned and operated. My first SK appeared when I was 57 years old and grew quickly on the cheek below my left eye and was obvious to everyone. I didn’t like the look of it. My dermatologist called it SK and removed it with shave surgery. It healed under a large black scab, leaving a scar that gradually disappeared. Blue Cross paid the bill. So my SK journey continued.
Longtime readers of my Medscape column will know that I first wrote about my personal use of nail surgery as a safe and effective treatment for SK in 2006 and tracked the results in 2016 and 2021. You remember that you did your research.
How do you manage your SK? Don’t have any? If you are interested, or if you are over 35 years old, please take a look again.
seborrheic keratosis
It is estimated that 80 million Americans exhibit SK at any one time.
It is estimated that as many as 90% of adults over the age of 65 have at least one (and sometimes more) SK.
Many of us have decades of personal experience with SK. Because they are for cosmetic purposes, their removal is not medically necessary and is not usually covered by health insurance. However, it is believed that Americans spend as much as $90 billion each year on the cosmetics industry, of which $18 billion goes to cosmetic surgery.
Here’s what I learned about deleting SK:
Yale Medicine: Treatments for SK include cryotherapy, electrosurgery, curettage, laser therapy, and dermabrasion. (Imagine the fees incurred for these in-office procedures.) Google Generated Artificial Intelligence: SK removal costs range from $50 to $650 and often require multiple patient visits. Because it is a cosmetic procedure, it is often not covered by insurance. Bing: Shave excision costs between $100 and $500 per lesion, plus the cost of pathology if it is sent for microscopic examination. Cryotherapy costs at least $400, and topical treatments cost more than $300. Veterans Affairs Health: We do not offer surgical removal of SK unless it causes bleeding, irritation, or interference with daily life, meaning removal is medically necessary. ChatGPT: States say “millions” of Americans have their SKs removed every year. Accurate data is difficult to obtain. Since SK is not malignant, it does not seem to be registered. Insurance typically does not pay for SK removal, so there is no claims data available for your search. There is not much American research on SK, so it is rarely reported in the scientific literature.
Still, despite vague data, estimating that 80 million people are affected, 30% to 50% of those seeking removal encounter 24 to 40 million SK removal treatments annually. . With fees ranging from $50 to $650 per removal, the minimum annual cost is $1.2 billion and the maximum annual cost is $26 billion. I am aware that these high amounts are unreasonable, especially since these are out-of-pocket costs.
According to survey data from Medscape, the average income for dermatologists in the United States in 2023 was $443,000. There are approximately 11,000 dermatologists in the United States. Dividing the lower limit ($1.2 billion) by 11,000 results in $109,090 per dermatologist per year. Mainly cosmetic SK removal costs pretty good money. Of course, plastic surgeons, general surgeons, family physicians, and other specialists also treat SK.
Is it time to destroy this one lucrative element of the American Medical Industrial Complex (AMIC)? Is there another path for patients?
DIY extermination experience
Of course, there is also “nail surgery.” There is no way to know how many SKs are simply scraped away by a patient. But judging by the comments of previous readers, there were probably a lot of them.
A few years ago, Aclaris Pharmaceuticals developed a 40% hydrogen peroxide product called Eskata for topical disinfection of SK and received FDA marketing and sales approval in 2017. The company discontinued the product after two years. Escata was intended to be prescribed by doctors, but that didn’t seem to be enough to sustain business. When Aclaris reviewed its direct-to-consumer (DTC) advertising, it received a warning from the FDA for misleading and incomplete disclosure of potential adverse effects.
It seems clear that doctors are very happy with the way they are already practicing and making a good income. Economics may not have worked to persuade doctors to introduce new treatments simply because the market was too crowded with treatment options. We did not find any serious efforts to change Eskata’s marketing strategy to DTC. Of course, the ingredients are already available and very cheap, so big pharmaceutical companies won’t mess with it. There is very little money to be made by manufacturing and promoting this treatment for the SK market.
Published studies support the topical use of 40% hydrogen peroxide as one of the treatments for SK.
A Massachusetts company called DermBiont recently announced promising results from late-stage clinical trials of an investigational drug called SM-020 gel, an AKT inhibitor aimed at home DIY chemical SKs removal.
DermBiont uses the Physician Lesion Assessment (PLA) score to assess progress toward eradication.
PLA 3: Thick. Visibly raised SK lesions >1 mm thick PLA 2: Thin. Visibly raised SK lesions with thickness ≤ 1 mm PLA 1: Almost transparent. Visible non-raised SK lesions with a different surface appearance than the surrounding skin PLA 0: No visible SK lesions with a different surface appearance than the surrounding skin.
A study in India reported that 30% hydrogen peroxide as a cautery agent was effective as a treatment for SK, often with a single treatment. Another product called WartPEEL has been proposed as a replacement. However, it is a prescription product.
Following in the footsteps of medical journalist Ron Piana, who successfully used 35% hydrogen peroxide to eradicate oral leukoplakia, and urological surgeon Bert Forstmann, who successfully used hydrogen peroxide to treat cutaneous squamous cell carcinoma. Encouraged by my experience with Escata, I decided to: Try 35% food grade hydrogen peroxide on my PLA 3 SK (after applying a cotton ball to a stick, wearing protective gloves, and sterilizing the area with isopropyl alcohol).
My SK immediately started to tingle, turn white, and shrink. Thick lesions may require multiple applications per day. They didn’t disappear, but they tended to become bulky, flattened, and retain their color. Proper care must be taken to localize corrosive chemicals to the surrounding skin. However, these symptoms quickly disappear without any sequelae.
My recommendation to everyone is to ignore SK. It doesn’t hurt, it doesn’t become malignant, it doesn’t interfere with your life, and it’s not contagious. If your SK (ostensibly) annoys others, that’s their problem.
However, if you want to get rid of your nails, you can personally use my preferred method of nail surgery with a little common sense. 30%, 35%, or 40% hydrogen peroxide. Alternatively, you can use some of the new gels that are safe and effective. Many SKs grow in areas that are inaccessible to the patient, such as the back, so it may be necessary to recruit a partner to apply the treatment.
Alternatively, you can continue to fund your AMIC with your own out-of-pocket costs at your favorite dermatologist, plastic surgeon, general surgeon, or perhaps your own primary care physician.
It’s your choice.
