A CME/CE-Certified Supplement to Update on Seborrheic Keratosis: Original Release Date: September 2017 Expiration Date: September 30, 2018 Estimated Time To Complete Activity: 1 hour Optimizing Patient Outcomes 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 FACULTY designed and achieving a passing score on the post- Brian Berman, MD, PhD Christopher B. Zachary, MBBS, FRCP test, you will be directed to a Web page that will allow Emeritus Professor of Dermatology Professor and Chair, Department of you to receive your certificate of credit via e-mail or you and Cutaneous Surgery Dermatology may print it out at that time. University of Miami University of California, Irvine School of Miller School of Medicine Medicine The online post-test and evaluation can be accessed at Miami, Florida Irvine, California http://tinyurl.com/SebK2017. Co-Director, Center for Clinical and Inquiries about continuing medical education (CME) Cosmetic Research accreditation may be directed to the University of Aventura, Florida Louisville Office of Continuing Medical Education & Professional Development (CME & PD) at cmepd@ eborrheic keratosis (SK) is a common benign survey of patients with SK found a slightly higher louisville.edu or (502) 852-5329. lesion, usually round or oval, ranging from rate among men.2 Furthermore, SK is thought to Accreditation Statement Physicians: This activity has been planned and light tan to dark brown. SK lesions afect 1 be more prevalent in Caucasians, but a variant form Sout of 5 Americans, particularly those older than known as dermatosis papulosa nigra can afect peo- implemented in accordance with the Essential Areas and Policies of the Accreditation Council for 50 years. Clinicians must accurately diagnose SK ple with Fitzpatrick skin type VI (Table 1).3,4 Continuing Medical Education (ACCME) through the lesions before removing them. SK lesions are be- These SK lesions can develop anywhere ex- joint providership of the University of Louisville and Global Academy for Medical Education, LLC. The nign and can be removed for cosmetic reasons cept the palms and soles. They appear most University of Louisville is accredited by the ACCME to if the patient desires; treatment may be indicat- frequently on the trunk and somewhat less often provide continuing medical education for physicians. ed—and reimbursable—if the lesion is irritated. on the arms, face, and neck.2,3 The lesions tend The University of Louisville Office of CME & PD In the case of suspicious lesions, clinicians should to be round or oval and are from 0.5 to 1.5 cm in designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should perform a shave biopsy to ensure that they are diameter; they can range in color from light tan claim only the credit commensurate with the extent not premalignant or malignant tumors. Choice to dark brown. The term seborrheic refers to the of their participation in the activity. of treatment is based on the number of lesions, lesions’ rough or waxy appearance (Figure).2,3,5 Continuing Nursing Education: Postgraduate Institute location on the body, skin pigmentation, thickness The presentation of SK lesions is highly variable, for Medicine (PIM) is accredited with distinction as a provider of continuing nursing education of the lesion, and overall esthetic considerations. which has led to the use of several synonyms by the American Nurses Credentialing Center’s Cryosurgery is the method preferred by most phy- to identify the condition, including basal cell Commission on Accreditation. This educational sicians for removing these lesions; other methods acanthoma, basal cell papilloma, benign acan- activity for 0.6 contact hour is provided by the PIM. include curettage, electrosurgery, lasers, and a thokeratoma, verruca seborrhoica (seborrheic This educational activity is designated for 0.1 contact 3 hour of pharmacotherapy credit for Advance Practice combination of modalities. Emerging topical ther- wart), and verruca senilis (senile wart). Registered Nurses. apies may provide efective lesion removal without A study of more than 4000 cases characterized Target Audience the adverse efects seen with cryotherapy, lasers, the subtypes of SK lesions. The 5 patterns found This journal supplement is intended for dermatologists, or other standard modalities. most frequently were5: pediatricians, family practitioners, internists, nurses, nurse practitioners, physician assistants, and other Some 83 million Americans—approximately • Multicomponent (19.9%) lesions, which involve clinicians who treat patients and practice medical or 20% to 25% of the population—are afected by a combination of ≥3 distinct structures aesthetic dermatology. SK.1,2 These benign lesions are usually seen in peo- • Reticular (14.9%) lesions which have a deep brown Educational Needs ple older than 50 years.2 SK lesions are equally dis- pigment with thin brown lines at the border, a Seborrheic keratosis (SK) is a common and benign tributed among men and women, although a recent pattern found in solar lentigo or Clark nevus skin lesion that affects more than 80 million Americans. Medical intervention is not required unless the diagnosis 4 is uncertain and a biopsy is indicated, or unless the SKs Table 1. Fitzpatrick Skin Phototypes are symptomatic (pruritus, irritation, or bleeding). Still, Skin Type Typical Features Tanning Ability many patients seek medical advice because of cosmetic issues or concerns about the possibly malignant nature I Pale white skin, Blue/green eyes, Always burns, Does not tan of the lesions. Current treatment modalities involve tissue Blond/red hair destruction, which poses a risk for scarring, hyper- or hypopigmentation, or other unwanted sequelae. Future II Fair skin, blue eyes Burns easily, tans poorly treatments may offer a topical approach that reduces III Darker white skin Tans after initial burn the risk of unacceptable outcomes. Clinicians should be able to diagnose SK accurately and efficiently, and should IV Light brown skin Burns minimally, tans easily be aware of current and emerging treatment strategies. Learning Objectives V Brown skin Rarely burns, tans darkly easily By reading and studying this supplement, participants should be better able to: VI Dark brown or black skin Never burns, always tans darkly • Differentiate seborrheic keratosis (SK) from other skin lesions • Describe current and emerging treatment options for SK This activity is jointly provided by This activity is supported by • Match patients with the most appropriate interventions an educational grant from for effective removal of SKs, including those in cosmet- Aclaris Therapeutics, Inc. ically sensitive areas, such as the face and neck To claim your CME/CE credit, go to http://tinyurl.com/SebK2017 • Update on Seborrheic Keratosis: Optimizing Patient Outcomes • globalacademycme.com/dermatology 1 EGFR.6 Furthermore, SK lesions are thought to occur in Figure. Types of Seborrheic Keratosis Lesions5 Disclosure Declarations the receptor tyrosine kinase/phosphatidylinositol Individuals in a position to control the content 3-kinase/Akt signaling cascade, which is seen in of this educational activity are required to squamous cell carcinoma.6 Preliminary evidence disclose: 1) the existence of any relevant fi- suggests that suppressing Akt signaling may induce a b c nancial relationship with any entity producing, 6 marketing, re-selling, or distributing health cell death of SK and thus eradicate the lesions. care goods or services consumed by, or used Patients often present to their clinicians because on, patients with the exemption of non-profit they are concerned about potential malignancy or or government organizations and non-health 2 d e f the unsightliness of the condition. Many dermatol- care related companies, within the past 12 ogists do not routinely recommend treatment for months; and 2) the identification of a commer- cial product/device that is unlabeled for use or benign SK lesions unless the lesions have become an investigational use of a product/device not irritated, leading to pruritus and/or bleeding. yet approved. g h i j The challenge for clinicians is that benign tumors Brian Berman, MD, PhD a. Multicomponent (≥3 distinctive structures); b. Reticular; may masquerade as more serious skin lesions, such Speakers Bureau: Aclaris Therapeutics, Inc. c. Bowenoid; d. Hairpin; e. Keratoacanthoma-like; f. Blue- as melanoma in situ or squamous cell carcinoma. Christopher B. Zachary, MBBS, FRCP, has like; g. Lichenoid; h. Hyperkeratotic; i. Clonal; j. Spitzoid. However, SK lesions are usually distinguished by no relevant financial relationships to disclose. 5 the horned cysts that can be seen on dermatoscope Staff and Advisory Board Disclosures: The Source: Squillace L, et al. Copyright © 2016, Karger 5 1,3 University of Louisville CME & PD Advisory Publishers, Basel, Switzerland. Used by permission. examination (Table 2). When examining a pigmented lesion, clinicians Board and office staff have nothing to disclose. For additional photos of SK lesions, visit the online version should use what is known as the 7-point checklist.7 CME/CE Reviewers: Cindy England Owen, of this supplement at https://tinyurl.com/sebksuppl17 MD, Assistant Professor, Division of This list, originally developed for British primary Dermatology, University of Louisville School • Bowenoid (13.0%) lesions, which have glomerular or care