When to Refer

Recognising seborrhoeic keratosis allows you to reassure patients and reduce unnecessary referrals. But this module would be incomplete without being clear about the boundaries of that confidence.

Refer when the pattern is not unequivocal

The word unequivocal does the heavy lifting here. You should feel genuinely confident that the classic features are present before labelling a lesion as seborrhoeic keratosis.

If the features are mostly there but something does not quite fit — an area of unusual colour, an asymmetric distribution of structures, or a section of the lesion that looks different from the rest — treat the lesion as uncertain. Uncertain is not the same as concerning, but it does mean the lesion needs further evaluation rather than reassurance.

Refer when the clinical context raises concern

Even a lesion with apparently classic seb K features may warrant referral if:

• The patient reports it is new and rapidly growing
• It has changed significantly in a short period
• It is the patient's only lesion of this type (ugly duckling principle)
• There is a history of previous skin cancer at the same site
• The patient is immunosuppressed

Refer when there is diagnostic uncertainty between seb K and a mimicker

If you find yourself debating whether a lesion is a seborrhoeic keratosis or a pigmented BCC — or a seb K or melanoma — that debate itself is the answer. A clearly benign pattern should not generate significant internal deliberation. When the differential includes malignancy, err on the side of further evaluation.

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