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There exist different treatments to remove a seborrheic keratosis, such as cryotherapy and curettage+electrodesiccation {2,3}. I wonder what the difference in cosmesis of the treatment of a seborrheic keratosis between cryotherapy and curettage+electrodesiccation is.

I have only found one study {1}:

There are, however, statistically significant differences between the 2 techniques in blinded physician ratings at both time points. More redness at 6 weeks and tendency for hypopigmented scar formation at greater than 12 months occurred with curettage. Leftover SK lesion occurred more frequently with cryotherapy in the short and long term.

However, the study dates back from 2013 and the sample size is only 25, and interestingly the patients, unlike the physicians, didn't see any difference in cosmesis:

There are no statistically significant differences in subject ratings for cosmesis at either time point.

Are there more recent and larger studies comparing the difference in cosmesis of the treatment of a seborrheic keratosis between cryotherapy and curettage?

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Summary: there exist a few more recent studies but they all have a small sample size (<35 patients) and there's no clear trend as to which treatment is the best: both curettage+electrodesiccation and cryotherapy seem to give a very similar outcome in terms of efficacy and cosmesis.

From my litterature search so far, I found 3 studies: 2 studies very slightly favor cryotherapy over curettage+electrodesiccation {1,3}, and 1 study {2} very slightly favor curettage+electrodesiccation over cryotherapy.

My overall sense is that curettage+electrodesiccation are more likely to cause scarring while cryotherapy is more likely to cause hypopigmentation (which may be barely noticeable on light skin, or even not noticeable to the untrained eye). As a result, the choice the treatment to optimize the cosmesis may depend on the patient's preferences (scar vs. hypopigmentation) and the patient's skin color (light vs. dark).

The 2021 study {2} indicates that curettage and electrodesiccation (C&E) (also known as electrodesiccation and curettage (ED&C)) has a slightly better cosmesis outcome than cryotherapy in the treatment of a seborrheic keratosis (SK):

The study was carried out on 30 patients each with four similar facial SKs. Each lesion was assigned to be treated with cryotherapy, electrodesiccation, CO2 laser, and Er:YAG laser in a random fashion. Therapeutic results were evaluated 8 weeks after the interventions through clinical and dermatoscopic assessment. Treatment improvement criteria for each lesion included the texture of the lesion, severity of the pigmentation, and an overall assessment of the healing. In the assessment of overall lesion healing by two dermatologists, the improvement rate was significantly higher in the CO2, Er:YAG lasers and electrodesiccation group compared to the cryotherapy (p < 0.001). However, the CO2 and Er:YAG laser and the electrodesiccation groups showed no significant difference (p > 0.05). Moreover, no significant difference was observed in posttreatment pigmentation and texture between the groups (p > 0.05). The pain and burning severity after the interventions were negligible in all four groups. Prolonged erythema was not observed in any of the cases; however, the duration of erythema in the Er:YAG laser group was significantly longer (p < 0.001). Patient satisfaction in the cryotherapy group was significantly lower than the other three groups (p < 0.001). The efficacy of treatment and patient satisfaction rate is highly comparable between electrodesiccation, CO2 laser, and Er:YAG laser but significantly higher than cryotherapy.

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However, the same 2021 study {2} mentions another study {3} that yielded a different conclusion:

In the study of Ethington et al. {3}, both electrodesiccation and cryotherapy showed similar efficacy in the treatment of SK lesions and there was no significant difference in the terms of patient satisfaction; there was a nominal but not statistically significant difference in the posttreatment hyperpigmentation favoring cryosurgery over electrodesiccation group.

More details from {3}:

In this randomized, blinded clinical trial, 33 eligible subjects with two similar truncal SKs were assigned to receive treatment with cryosurgery and electrodesiccation applied to separate lesions. Both treatment modalities were similar in terms of efficacy (p=0.50). Skin texture was rated similarly (p=0.64); however, lesions treated with cryosurgery were nominally less likely to have posttreatment hyperpigmentation compared to lesions treated with electrodesiccation (odds ratio: 0.35, 95% confidence interval: 0.12–1.002; p=0.0504). Conclusion: Cryosurgery and electrodesiccation are both effective treatment modalities for truncal SKs. While cosmetic outcomes were similar, cryosurgery resulted in less postinflammatory hyperpigmentation.

Note that {3} mentions that the likelihood of hyperpigmentation is higher in patients with dark skin:

Two effective treatment modalities that we commonly use for the resolution of SKs are cryosurgery and electrodesiccation. However, negative features of these techniques include pain, the need for local anesthetic, scarring, and, particularly in patients with dark skin, hyperpigmentation. [... In our study] most patients (91%) had Fitzpatrick Type II skin.

Lastly, {3} the treatment efficacy is about the same:

Controlling for lesion size and depth, there was no difference in the odds of a higher efficacy score between lesions treated with cryosurgery versus electrodesiccation (OR: 0.61, 95% CI: 0.14–2.62; p=0.50).

and they note that lack of studies on the topic:

Our findings are in line with and add to the limited data available in the literature. Although SKs are one of the most common reasons for dermatologic consultation, there remains a paucity of data and research on available treatments and comparative outcomes.

I also found some two overview studies {5,6}. From {5}:

  • In a study of 80 patients, most preferred cryosurgery because the wound care was not as extensive as it was for curettage or excision.
  • There are no guidelines or efficacy studies on the best way to remove SK lesions. Approximately two thirds of dermatologists prefer cryosurgery with liquid nitrogen, which can be performed in the office, generally without a topical anesthetic.

From {6}:

On average, dermatologists treat 43% of their SK patients to remove lesions. Cryosurgery is the most common removal method. Other commonly employed removal methods include shave excision, electrodessication, curettage or a combination of these. While these procedures can be used to remove SK lesions effectively, each has potential drawbacks and careful patient selection is required to optimize cosmetic results particularly in skin of color patients and patients with thick or numerous lesions. While there is great interest from both patients and providers in a topical non-invasive treatment for SK, no effective topical therapeutic agent has been developed, and this remains an area of unmet need.

{7} indicates that cryotherapy shouldn't cause scarring:

Freezing for less than 30 seconds beyond initial freeze ball formation does not result in scarring because of the preservation of fibroblasts and the collagen layer of the dermis, which allows for in-migration of the cellular components in the healing process and normal integrity of the skin layers.

Another treatment option for seborrheic keratosis is 40% hydrogen peroxide (a.k.a. Eskata) but cosmesis and efficacy seem inferior to cryotherapy or curettage+electrodesiccation. From {4}:

Hydrogen peroxide 40% (Eskata) is a topical solution for the in-office treatment of raised seborrheic keratosis lesions. Although the mechanism of action is not fully understood, supraphysiologic concentrations of hydrogen peroxide may cause oxidative damage and death to seborrheic keratosis cells. [...] Skin reactions are common with the application of hydrogen peroxide 40%. Most patients will experience erythema (99%), stinging (97%), edema (91%), scaling (90%), crusting (81%), and pruritus (58%) within 10 minutes of application, although less than 20% of cases will be severe. One week after treatment, scaling (72%), crusting (67%), and erythema (66%) often persist. Long-term skin changes are common and include erythema (21%), hyperpigmentation (18%), scaling (16%), crusting (12%), and hypopigmentation (7%). A small number of patients will develop scarring (3%).

Also, from {8}:

according to the clinical trial data that Aclaris submitted to the FDA, less than 10 percent of patients experienced complete clearance of all treated SK lesions.

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