Surgical excision of a keratoacanthoma

Dr Geoff Butler talks through the surgical excision of a keratoacanthoma

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Two thirds of keratoacanthomas occur on the face; the rest occur elsewhere including the ears (usually sun damaged, hair bearing skin). They arise from hair follicle skins cells for unknown reasons. The lesions usually start as a small pink papule which rapidly enlarges over the following few months. Eventually (6-12 months), the lesions spontaneously regress, leaving an ugly scar. Many are removed to exclude squamous cell carcinomas (SCCs) and to prevent scarring.

Key learning points from the video

  • 74-year-old patient with an evolving lesion on his left arm
  • Lesion on the patient started as a small scaling lesion on the arm
  • Developed by building up around the base with a central evolving area
  • Likely that under the scale will be ulceration
  • Diagnosis of keratoacanthoma variant of a squamous cell carcinoma derived from pilosebaceous cells
  • For excision it requires good surgical margins but taking as little tissue as possible
  • Langer’s lines or skin tension lines will dictate the direction of the excision
  • Lignocaine with adrenaline can be used for local anaesthetic
  • Elliptical excision is required in this case in one fluid motion
  • Cut down to subcutaneous tissue so the lesion is floating up
  • Keratoacanthomas generally do not extend deeper into underlying tissues
  • Start from the apex and work backwards once lateral excisions in place
  • It is important to see subcutaneous flat underneath the lesion with a yellow sheen underneath
  • Check for any signs that invasion has occurred under the lesion
  • It is important to ensure the excision is deep enough so that closure is made easier
  • Suture lesion at the two thirds and third point to then close across the middle

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