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So You Think You Have an SK…

Should you go to a dermatologist or a primary care physician? Your choice may make a difference.

Do you think you have an SK? It’s tempting to ask your primary care doc for a quick look-see at your next check-up. But you might be better off going straight to the gurus of skin growths. Dermatologists are the physicians more skilled at distinguishing between benign and malignant growths just by looking at them. So you might just spare yourself the inconvenience, pain, and worry of a biopsy. By comparison, primary care physicians (PCPs) are more likely to depend on biopsies to make the distinction between a benign and a malignant growth. A biopsy is a procedure that is performed when the doctor is unsure of a diagnosis and cuts out the lesion (or a portion of the lesion) and sends it to a laboratory for evaluation and a definitive diagnosis.

Consider the results of a study by researchers at Wake Forest’s Center for Dermatology Research in Winston-Salem, NC comparing the treatment SK patients received from dermatologists vs. non-dermatologists.* Non-dermatologists were nearly three times more likely than dermatologists to rely on a biopsy to make a diagnosis of seborrheic keratosis vs. skin cancer.

“None of us is perfect, but I’m not surprised that dermatologists would outperform PCPs in diagnosing skin growths. Doctors who do this every day are going to be more proficient than someone who does this once a month,” comments Robert Brodell, M.D., professor and chair of the department of dermatology at the University of Mississippi Medical Center in Jackson.

What’s more, the study showed that when non-dermatologists did biopsy a lesion, they used an aggressive and often unnecessary form of biopsy—the excisional biopsy—at five times the rate of dermatologists. When an excisional biopsy is performed, patients need wound care and sometimes major repair work because so much skin is removed. Infection is a concern and oral antibiotics may have to be utilized. After the wound heals, a scar may remain.

“For many lesions, excision is overkill. It’s more than what you need to do,” says Dr. Brodell. An excisional biopsy is appropriate for an obvious melanoma or a highly suspicious lesion. “Occasionally, an SK mimics a melanoma. That’s when an excision should be performed–to biopsy those lesions that appear indistinguishable from a melanoma. Then you can remove the whole thing with a margin to get the best possible specimen. A dermatologist has a great deal of training and experience to identify those particular lesions that warrant an excisional biopsy,” he says.

“Essentially some of the non-dermatologists in the study were treating SKs as if they were melanomas,” notes Dr. Brodell.

In most cases of suspicious SKs, including lesions that may be squamous cell carcinoma or basal cell carcinoma, the more appropriate biopsy method is a simple shave biopsy procedure. “It avoids stitches, minimizes scarring, and produces a specimen that likely will permit an assessment of the full lesion,” says Dr. Brodell. Sometimes, a deep shave, or ‘saucerization,’ is required if the lesion has a thick part or if the dermatologist thinks it’s not melanoma but can’t rule it out. In the Wake Forest study of SK biopsies, dermatologists used some form of shave biopsy about 90% of the time and excisional biopsy 10% of the time. For non-dermatologists, it was about 50-50.

PCPs shouldn’t feel singled out. “I have seen SKs treated with excisional biopsy by plastic surgeons and general surgeons, so this tendency to overtreat extends to non-dermatologists in general,” says Jerome Potozkin, M.D., a board-certified dermatologist in private practice in Danville, CA, and professor of dermatology at UCSF Medical School. He adds a key point: while dermatologists’ trained eyes allow them to more easily recognize SK lesions, they also have the use of dermoscopy at their fingertips. A dermoscope is a special magnifying glass that can aid their inspection of an SK and help them to make the correct diagnosis in the office. It’s a basic tool of the trade that dermatologists have been trained to use, but one that family practice doctors or internists may not have. “I don’t know any PCPs in my area that use dermoscopy,” he says.

Reassuringly, a 2014 survey found that roughly 85% of patients do go to dermatologists for diagnosis and treatment of their SKs.

The rest tend to see PCPs. This preference for seeing dermatologists for SKs is important because it leads to the best treatment possible—and spares a lot of time, expense, and scars along the way. As one of the Wake Forest study’s authors sums up: “If you think you have an SK, remember that less aggressive, more appropriate medical care is delivered by those with greater expertise,” says Alan Fleischer, Jr., M.D. F.A.A.D.

So are you ready to take the next step and make an appointment? If you don’t have a dermatologist, you can easily find one in your area by going to the American Academy of Dermatology’s website at https://www.aad.org. ** Look for the words “Find a Dermatologist” on the home page and type in your zip code in the box in the upper right corner. You’ll find some choices and contact information. If you want to know further details, such as where the doctor went to medical school and areas of focus in his or her practice, you can then Google the doctor’s name.

** If you click on this link, you will be leaving www.sebker.org to go to a website that is not operated by Aclaris Therapeutics, Inc. Aclaris is not responsible for the content or availability of linked sites.

* Duque M, Jordan JR, Fleischer A, et al.  Frequency of Seborrheic Keratosis Biopsies in the United States:  A Benchmark of Skin Lesion Care Quality and Cost Effectiveness. Dermatol Surg, 2003;29:796-801.