How should I approach the management of a keratoacanthoma in a patient with a history of skin cancer?

In managing a keratoacanthoma in a patient with a history of skin cancer, the primary approach should be prompt and complete surgical excision with histological examination to confirm diagnosis and exclude invasive squamous cell carcinoma, given the clinical and histological overlap between these entities and the patient's increased risk profile NICE NG230.

Because keratoacanthomas can behave aggressively and may represent a variant of squamous cell carcinoma, especially in patients with prior skin cancer, excision with clear margins is recommended to reduce recurrence and progression risk Tisack et al. 2021. Close clinical follow-up is essential due to the potential for new lesions or recurrence, particularly in patients with a history of skin malignancy NICE NG230.

In cases where surgery is contraindicated or lesions are multiple, alternative treatments such as intralesional methotrexate or systemic retinoids may be considered, although these are generally second-line and should be used cautiously, with specialist dermatology input Bray et al. 2025. Additionally, drug-induced eruptive keratoacanthomas require review of causative agents and may necessitate modification of therapy Bray et al. 2025.

Overall, the management strategy integrates the need for definitive diagnosis and treatment via excision, vigilant monitoring, and consideration of systemic therapies in complex cases, tailored to the patient's oncological history and risk factors NICE NG230; Tisack et al. 2021; Bray et al. 2025.