Keratosis seborrhoeic (overview) L82

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

acanthokeratosis benignus; Age warts; Basal cell papilloma; benign acanthokeratosis; Epithelioma intraepithelial of the bristle type; Epithelioma intraepithelial of the type Jadassohn; seborrheic keratosis; seborrheic nipple; seborrheic wart; Senile nipple; senile seborrhoeic nipple; SK; verrucae senilis; verruca seborrhoica; Verruca seborrhoica senilis; verruca senilis

Definition
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Frequent (most frequent tumour of the skin at all), in one or more cases occurring, benign, initially flat, but with a longer duration of existence also clearly exophytic, verrucous, benign, fibro-epithelial neoplasia, which occurs more frequently with increasing age (classic characteristic of the skin of the elderly) and can be a cosmetic problem if it occurs multiple times. Since seborrhoeic keratosis is usually dark in colour, it is the most important differential diagnosis (to be proven daily) to malignant melanoma .

Classification
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Clinical classification of seborrheic keratoses (SK):

  • Lentiginous type (flat, pigmented non-raised (early) SK)
  • Plaque type (flat raised, pigmented or non-pigmented SK)
  • Papillomatous type (pigmented papillomatous SK)
  • Filiform type (pigmented or non-pigmented filiform SK)
  • Special forms:

Histological differentiation of seborrheic keratosis:

  • 6 different types can be distinguished by their fine tissue, whereby the individual types often overlap histologically (see histology below):
    • Hyperkeratotic type
    • Acanthotic type
    • Reticular/adenoid type
    • Clonal type
    • Irritated type
    • Melanoacanthoma.

Occurrence/Epidemiology
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There are few statistically relevant, epidemiological data on prevalence, gender distribution (men/women equally distributed?), race (Caucasian population more affected?) or geographical distribution.

Clinical experience shows that beyond the age of 60 the prevalence is >90%.

Etiopathogenesis
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Familial predisposition is to be assumed. Possible autosomal dominant mode of inheritance. In a high percentage of cases, the disease was not inherited in seb. Warts 1 or 2 mutations (FGFR3-, PIK3CA-, KRAS-, HRAS- (see below Ras), EGFR-, AKT1-oncogene see below) were found in a high percentage of cases. growth factors) in the major oncogenes of carcinoma induction. The question why development of malignancy is practically excluded remains unanswered at present.

Manifestation
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Occurs mainly in older age. Rarely found in individuals < 30 years of age.

Localization
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Especially chest, back, also face, neck area, extensor sides of hands and forearms are affected. The palms of the hands and soles of the feet are always cut out.

Clinical features
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Sharply defined, solitary, but mostly multiple, disseminated, roundish to oval, a few millimetres to several centimetres in size, soft or soft-elastic, raised, grey-brown or black, broadly seated on the lower surface, with a jagged, warty surface, interspersed with black cracks(horn plugs, which are very good under the reflected light microscope). At an early stage of development, seborrhoeic keratoses appear as flat, skin-coloured or greyish-brown spots or plaques with a matt surface.

It is not uncommon for smaller or larger pieces of tissue to become detached due to mechanical influences (e.g. rubbing down). Complete detachments are also possible. Larger seborrhoeic warts appear as if they were "put on" the skin.

Passagonal itching may be present. Patients sometimes point to a wart that is identical to other seborrhoeic warts, which would itch again and again.

In intertriginous areas, seborrheic keratoses are found as smooth, flat, often skin-coloured plaques, sometimes weeping.

Reflected light microscopy shows the seb. keratoses show different images. The detection of horn beads is characteristic.

Stalked VS are found mainly in intertriginous spaces.

Clinically, the flat seborrhoeic keratoses include the differently pigmented verruca-plana-like SK (see below seborrhoeic warts, verruca-plana-like), which are mainly observed on the back of the hand.

Histology
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Exophytically growing intraepidermal proliferation of mature spindle-cell or basaloid squamous epithelia with horny and pseudohorn cysts and varying degrees of hyperkeratosis.
  • Hyperkeratotic type: Sawtooth-like surface relief with distinct papillomatosis. Voluminous orthohyperkeratosis as well as focal and parahyperkeratosis are present. Moderately pronounced acanthosis with predominant occurrence of spindle-cell differentiated keratinocytes. Missing or only moderate hyperpigmentation. No horn or pseudohorn cysts.
  • Acanthotic type (most common histological type): Massive homogeneous or reticular acanthosis with moderate or slight hyperkeratosis and papillomatosis. Numerous horn and pseudohorn cysts. Predominantly basaloid differentiated tumor parenchyma with distinct hyperpigmentation especially in the dermo-epidermal junctional zone. In the dermis there is often a thin lympho-histiocytic infiltrate.
  • Adenoid/reticular type: The reticular type is also called adenoid type, although there is no glandular etiology. The histological picture is due to a reticular acanthosis in moderate or mild hyperkeratosis and papillomatosis. The interconnected epithelial strands are 2-3 rows. Hardly any corneal and pseudohorn cysts. Predominantly basaloid differentiated tumor cells. Clear hyperpigmentation of the tumor parenchyma with accentuation of the dermoepidermal junctional zone. The dermis often shows a thin lympho-histiocytic infiltrate.
  • Clonal type: Severe irregular acanthosis and papillomatosis in orthohyperkeratosis. Within the spindle-cell differentiated tumor parenchyma there are clearly separated nests with basaloid or also paler larger nests (see also Borst-Jadassohn phenomenon).
  • Irritated type: Proliferation of spindle-cell differentiated eosinophilic squamous epithelia, partly in onion-skin-like or vertebral arrangement. Basaloid formations are usually completely absent. Occasionally there are also dyskeratoses. Rarely acantholysis.
  • Melanoacanthoma: Image of the acanthotic type of Verruca seborrhoica with homogeneous proliferation of mature, predominantly basaloid epithelial cells. Little or no hyperkeratosis. Numerous melanocytes distributed over all layers of the tumor. Dense layer of melanophages in the dermis. Small, spongy inflammatory infiltrate.

Differential diagnosis
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Therapy
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Remember! In case of suspicion of reader-Trélat syndrome: Extensive tumour search.

In cosmetically disturbing cases or to exclude other pigmentary tumours, removal with a sharp spoon, with an electric snare or by means of Erbium-Yag orCO2 laser. Caution! Histology is not possible in blind procedures. Subsequent wound treatment, e.g. with antiseptic ointments such as polyvidon-iodine ointment(e.g. R204, Braunovidon ointment) or ointments containing antibiotics (e.g. Fucidine ointment) and fatty gauze (e.g. Oleo-Tuell, Jelonet) and a loose dressing. Alternatively, drying disinfectant topicals such as 0.5% methylrosanilinium chloride solution.

Progression/forecast
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Cheap. No evidence of development of malignancy.

Note(s)
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  • The term 'seborrhoeic' misleadingly refers to 'seborrhoea'. However, the seborrhoeic wart has nothing to do with the sebaceous gland or its function.
  • Stuccokeratosis is a special clinical form. Histologically the hyperkeratotic type is found.
  • The eruptive occurrence of multiple Verrucae seborrhoicae is known as paraneoplastic syndrome ( reader-Trélat syndrome) and requires an intensive tumor search.
  • Familial occurrence of multiple verrucae seborrhoicae especially in colored people is called Dermatosis papulosa nigra.
  • The diagnosis "seborrheic keratosis" is on the one hand a "simple" diagnosis for the experienced physician. The most important thing, however, is its reliable differentiation from a malignant melanoma. This distinction cannot be made with the necessary certainty by a non-physician. In this respect, lay or remote diagnoses of any kind should only be considered "preliminary" and not reliable. In any case, they require a qualified examination by a proven expert.

Literature
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  1. Argenziano G et al (2003) Melanoma simulating seborrheic keratosis: a major dermoscopy pitfall. Arch Dermatol 139: 389-391
  2. Braun RP et al (2002) Dermoscopy of pigmented seborrheic keratosis: a morphological study. Arch Dermatol 138: 1556-1560
  3. Duque MI (2003) Frequency of seborrheic keratosis biopsies in the United States: a benchmark of skin lesion care quality and cost effectiveness. Dermatol Surgery 29: 796-801
  4. Hafner C et al (2010) Multiple oncogenic mutations and clonal relationship in spatially distinct benign human epidermal tumors. Proc Natl Acad Sci 107:20780-20785
  5. Inamadar AC, Palit A (2003) Eruptive seborrhoeic keratosis in human immunodeficiency virus infection: a coincidence or 'the sign of reader trelat'? Br J Dermatol 149: 435-436
  6. Izikson L et al (2002) Prevalence of melanoma clinically resembling seborrheic keratosis: analysis of 9204 cases. Arch Dermatol 138: 1562-1566
  7. King R (2003) Desmoplastic seborrheic keratosis. At J Dermatopathol 25: 210-214
  8. Kwon OS et al (2003) Seborrheic keratosis in the Korean males: causative role of sunlight. Photodermatol Photoimmunol Photomed 19: 73-80
  9. Miracco C et al (2003) Carcinoma with eccrine differentiation arising in a seborrhoeic keratosis. Br J Dermatol 148: 831-833
  10. Nakamura S, Nishioka K (2003) Enhanced expression of p16 in seborrhoeic keratosis; a lesion of accumulated senescent epidermal cells in G1 arrest. Br J Dermatol 149: 560-565
  11. Nakamura H et al (2001) Clonal nature of seborrheic keratosis demonstrated by using the polymorphism of the human androgen receptor locus as a marker. J Invest Dermatol 116: 506-510
  12. Pesce C, Scalora S (2000) Apoptosis in the areas of squamous differentiation of irritated seborrheic keratosis. J Cutan cathode 27: 121-123

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Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020