Controversies
Is the first-line treatment of keratoacanthomas surgical excision or injection of intralesional chemotherapy?

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Intralesional chemotherapy

The resolution rates of KAs treated with intralesional methotrexate and 5-fluorouracil are 88% to 94% and 96% to 98%, respectively.1, 2, 3, 4 In one study, the clearance rate with intralesional methotrexate dropped to 57% in KAs greater than 2 cm2. However, the KAs that did not completely resolve reduced in size.2 No KA recurrences have been noted after treatment with intralesional 5-fluorouracil and methotrexate with follow-up as long as 24 and 91 months, respectively.4 Table I shows the

Surgical excision

Mohs micrographic surgery (MMS), standard surgical excision with 5-mm margins, and electrodesiccation and curettage are the surgical techniques frequently used to remove KAs. The resolution rate of KAs treated with standard surgical excision and MMS is approximately 100%.2 The recurrence rates of KAs treated with standard surgical excision, MMS, and electrodesiccation and curettage have been shown to be approximately 0.9%, 0.8%, and 12.5%, respectively.5 Surgery carries a risk of pain,

Conclusion

In conclusion, surgical excision is considered the criterion standard for treating KAs, but intralesional chemotherapy can be considered a first-line treatment option for select patients.1,3 The final treatment decision will depend on several variables (Table II). Because of the lack of randomized controlled trials, it is difficult to recommend a treatment algorithm that applies to every patient. Based on our experience, we perform weekly injections of 50 mg/mL of 5-fluorouracil. If the KA does

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