Cutaneous Horn

Background

Cutaneous horn is a clinical diagnosis referring to a conical projection above the surface of the skin that resembles a miniature horn. The base of the horn may be flat, nodular, or crateriform. The horn is composed of compacted keratin. Various histologic lesions have been documented at the base of the keratin mound, and histologic confirmation is often necessary to rule out malignant changes. No clinical features reliably distinguish between benign and malignant lesions. Tenderness at the base and lesions of larger size favor malignancy.

Pathophysiology

Cutaneous horns usually arise on sun-exposed skin but can occur even in sun-protected areas. The hyperkeratosis that results in horn formation develops over the surface of a hyperproliferative lesion. Most often, this is a benign verruca or seborrheic keratosis; or it could be a premalignant actinic keratosis. A malignancy has been reported at the base of a cutaneous horn in up to 20% of lesions. More than half of all cutaneous horns are benign.
Benign lesions associated with cutaneous horns include angiokeratoma, angioma, benign lichenoid keratosis, cutaneous leishmaniasis, dermatofibroma, discoid lupus, infundibular cyst, epidermal nevus, epidermolytic acanthoma, fibroma, granular cell tumor, inverted follicular keratosis, keratotic and micaceous pseudoepitheliomatous balanitis, organoid nevus, prurigo nodularis, pyogenic granuloma, sebaceous adenoma, seborrheic keratosis, trichilemmoma, and verruca vulgaris. Lesions with premalignant or malignant potential that may give rise to cutaneous horns include adenoacanthoma, actinic keratosis, arsenical keratosis, basal cell carcinoma, Bowen's disease, Kaposi sarcoma, keratoacanthoma, Paget's disease, renal cell carcinoma, sebaceous carcinoma, solar keratosis, and squamous cell carcinoma.

Mortality/Morbidity

The lesion at the base of the keratin mound is benign in the majority of cases. Malignancy is present in up to 20% of cases, with squamous cell carcinoma being the most common type. The incidence of squamous cell carcinoma increases to 33% when the cutaneous horn is present on the penis. Tenderness at the base of the lesion is often a clue to the presence of a possible underlying squamous cell carcinoma.

Race

Because of the proportion of cutaneous horns that arise from actinic keratoses and squamous cell carcinomas, races with lighter complexions tend to be preferentially affected.

Sex

A sex predilection for cutaneous horn has not been shown consistently. In men, the rate of malignancies at the base of the lesion is increased when compared with age-matched women.

Age

The peak occurrence of cutaneous horn is in persons aged 60 years to mid 70s. Lesions with malignancy at the base occur more frequently in patients aged 70 years or older.

History

Cutaneous horns usually are asymptomatic. Because of their excessive height, they can be traumatized. This may result in inflammation at the base with resulting pain. Rapid growth may occur.

Physical

The distribution of cutaneous horn usually is in sun-exposed areas, particularly the face, pinna, nose, forearms, and dorsal hands. It is a hyperkeratotic papule with the height greater than one-half the width of the base. Usually a cutaneous horn is several millimeters long.

Causes

Malignant lesions at the base of the horn usually are squamous cell carcinoma, although basal cell carcinoma has been rarely reported. These are predominately precipitated by ultraviolet radiation. Rare tumors at the base include Paget disease of the breast, sebaceous adenoma, and granular cell tumor. The premalignant lesion, actinic keratosis, is a frequent finding at the base. The human papilloma virus most frequently causes infectious etiology resulting in a verruca vulgaris. Molluscum contagiosum of the poxvirus group occasionally has formed a cutaneous horn. The only other infectious cause has been leishmaniasis.
Benign idiopathic causes are frequent and include seborrheic keratosis, epidermal nevus, trichilemmal cyst, trichilemmoma, prurigo nodule, and intradermal nevus.

Lab Studies

Diagnosis is confirmed with a skin biopsy. An adequate specimen usually can be obtained with a simple shave biopsy. The specimen must be of sufficient depth to ensure that the base of the epithelium is obtained for histologic examination.

Histologic Findings

The horn is composed of compact hyperkeratosis, which may be either orthokeratotic or parakeratotic in nature. Associated acanthosis is a common finding. The base will display features of the pathologic process responsible for the underlying lesion.

Surgical Care

Treatment recommendation is contingent upon the type of lesion at the base. In order to rule out a malignancy, it is essential to perform a biopsy of the lesion that includes the base of the horn. In the case of benign lesions at the base of the horn, the biopsy is both diagnostic and therapeutic.
Excise malignancies with appropriate margins. Patients discovered to have horns with an underlying squamous cell carcinoma also should be evaluated for metastasis.
Local destruction with cryosurgery is first-line treatment for verruca vulgaris, actinic keratosis, and molluscum contagiosum. Benign lesions do not require any further therapy after the diagnostic biopsy.

Media file 1: A typical presentation of a cutaneous horn on the ear.
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Media file 2: An unusually large cutaneous horn extending from the ear.
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Rhino Cutaneous Horn In A Sun-Protected Area:
A Rare Case With Historical Review

Rajesh, MS (ENT. P.G.I. CHANDIGARH)
Associate Professor
Department of ENT & Head and Neck Surgery
Himalayan Institute of Medical Sciences
Jollygrant, Dehradun Uttranchal India

Pallavi, M.B.B.S. Std.
SGRD Institute of Medical Sciences
Amritsar India

Abstract

Cornu cutaneum or cutaneous horn is a rare clinical presentation resembling an animal horn. The lesion is often seen arising from sun-exposed skin surface. We report a case of Rhino-cutaneous horn which developed from the sun-protected surface of nasal vestibule. The broad based lesion was completely excised and microscopically proved to be non-malignant

Introduction

Cornu cutaneum or cutaneous horn is a relatively uncommon clinical entity consisting of a compacted hyperkeratosis over a hyperproliferative lesion and it resembles an animal horn1. The base of the lesion may be flat, nodular or crateriform. Cutaneous horn most often arises on the sun-exposed skin surface in elderly men, usually after fifth decade2. The lesion is found on scalp, face, pinna, eyelids, nose, neck, shoulders, hands and penis. The possibility of malignancy at the base of the lesion increases in men when compared with the age-matched women. Various histological variants have been documented at the base of the keratin mound therefore histopathological confirmation is often necessary to rule out benign, premalignant and malignant changes.

Case report

A 32 year old female house wife with fair complexion attended the ENT out patient department with complains of projectile mass from the left nostril (Fig.1) associated with pain and a sense of embarrassment since 8 months duration. There was no history of epistaxis or respiratory obstruction.

Figure 1: Rhino cutaneous horn

The clinical examination showed a hard keratotic conical mass protruding from the left nostril, painful on palpation. On careful anterior rhinoscopy a sessile mass was seen arising from the lateral wall of the vestibule about one cm. from the free margin. No such lesion was detected in the right nostril or other parts of the body. Examination of the neck did not reveal any clinical positive lymph nodes. The mass was clinically diagnosed as Rhino cutaneous horn from a sun-protected area of the vestibule of the left nostril. The lesion was excised (Fig.2) under local anesthesia after infiltrating the surrounding area of the lesion with 1:200,000 adrenline in xylocain with sufficient depth and safety margin. There was a minimal; bleeding and the defect was closed primarily by undermining the margins with 3-0 silk. An anterior nasal dressing with ribbon gauge impregnated with Fusidin(R) (sodium fusidate BP 20mg) ointment was done and a bolster applied. The patient was given an injection of Voltran(R) (diclofanic sodium) 75 mg. I/M and advised to take tablet of Voltran three times a day after meals for a period of two days. The anterior nasal pack was removed after 48 hours and thereafter only Fucidin ointment was applied locally for 5 days. The stitches were removed on day 5. Follow up period was uneventful without signs of recurrence. The histopathological examination showed squamous epithelial cells with keratine debris indicating a benign lesion.

Figure 2: Excised specimen

Discussion

Rhino cutaneous horn consist of a superficial hyperkeratosis over a hyperproliferative skin lesion resembling an animal horn. But the difference between animal horns is the presence of a central bone which is not seen in cutaneous horns in human beings. The earliest well documented case of cornu cutaneum from London in 1588 is of Mrs. Margaret Gryffith, an elderly Welsh woman. A showman, who advertised it in a pamphlet, exhibited her for money. However, earliest observations on cutaneous horns in humans were described by the London surgeon Everard Home in 17913. Farris from Italy first described the gigantic horn in man as a well documented a case report with adequate histology4. According to a largest study by Yu et al,5 61% of cutaneous horns were derived from benign lesions and 39% were derived from malignant or premalignant epidermal lesions. The important consideration in these cases is not the horn, but the underlying pathology which may be benign (seborrheic keratosis, viral warts, histiocytoma, inverted follicular keratosis, verrucous epidermal nevus, molluscum contagiosum, etc.), premalignant (solar keratosis, arsenical keratosis, Bowen's disease) or malignant (squamous cell carcinoma, rarely, basal cell carcinoma, metastatic renal carcinoma, granular cell tumor, sebaceous carcinoma or Kaposi's sarcoma6 Histopathological examination, specially of the base of the lesion7,8is necessary to rule out associated malignancy and full excision and reconstruction whenever required is the treatment of choice.

Conclusion

Cutaneous horn is a rare clinical diagnosis and is frequently seen over the sun-exposed skin surface but is rarely present in the sun-protected site. Although 2/3rd cases are benign the rest are premalingant and malignant may require an aggressive management.

Address for Correspondence

Dr Rajesh
Associate Professor
Himalayan Institute of Medical Sciences, Jollygrant, Dehradun,
Uttranchcal
India
E mail - drrajeshent@rediffmail.com

References

1. Korkut T, Tan NB, Oztan Y: Giant cutaneous horn: a patient report.Ann Plast Surg 1997, 39:654-655.

2. Baruchin A ,Sagi A, Lupo L, Hauben DJ:Cutaneous horn(cornu cutaneum).Int J Tissue React.1984;6(4):355-7

3. Bondeson J: Everard Home, John Hunter, and cutaneous horns: a historical review.Am J Dermatopathol 2001, 23:362-369

4. Farris G. Histological considerations on a case of a voluminous cutaneous horn. Minerva Dermatol 1953; 28:159-65.

5. Yu RC, Pryce DW, Macfarlane AW, Stewart TW: A histopathological study of 643 cutaneous horns.Br J Dermatol 1991, 124:449-452.

6. Copcu E, Sivrioglu N, Culhaci N. Cutaneous horns: Are these lesions as innocent as they seem to be? World J Surg Oncol 2004; 2:18.

7. Gould JW, Brodell RT. Giant cutaneous horn associated with verruca vulgaris. Cutis 1999; 64:111-2.

8. Kastanioudakis I, Skevas A, Assimakopoulos D, Daneilidis B. Cutaneous horn of the article. Otolaryngol Head Neck Surg 1998; 118:735.

Cutaneous horns: are these lesions as innocent as they seem to be?

Abstract

Background

Cutaneous horns (cornu cutaneum) are uncommon lesions consisting of keratotic material resembling that of an animal horn. Cutaneous horn may arise from a wide range of the epidermal lesions, which may be benign, premalignant or malignant.

Patients and methods

In this respective study, we describe our experience of eleven patients with cutaneous horn treated at our centre between January 2000 and January 2004. The clinical, pathological and treatment details were extracted from the case records. Data is presented as frequency distribution.

Results

There were 8 male and 3 female patients with a median age of 57 years. Most of the lesions were located on the ear, hand and scalp. Surgical resection was carried out in all the lesions. There were two cases of squamous cell carcinoma, and one case of basal cell carcinoma, other 8 cases were benign. None of the lesions recurred and no adjuvant treatment was given to any of the malignant lesions.

Conclusion

Cutaneous horn is a clinical diagnosis that refers to a conical projection above the surface of the skin. The lesions typically occurs in sun exposed areas, particularly the face, ear, nose, forearms, and dorsum of hands. Even though our 60% of the cutaneous horns are benign possibility of skin cancer should always be kept in mind.

Introduction

Cutaneous horn (cornu cutaneum), is a projectile, conical, dense, hyperkeratotic nodule that resembles the horn of an animal [1]. The horn is composed of compacted keratin. A number of skin lesions can be found at the base of this keratin mound. Cutaneous horns most frequently occur in sites that are exposed to actinic radiation or burns, and hence, are typically found on upper parts of the face. Other locations include scalp, nose, eyelid, ear, lip, chest, neck and shoulder. Forearm, cartilaginous portion of the ear, leg and back of hands may also be involved [2]. Over 60% of the lesions are benign, however, malignant or premalignant lesions might be associated with it [3]. Keratosis, sebaceous molluscum, verruca, trichilemma, Bowen's disease, epidermoid carcinoma, malignant melanoma, and basal cell carcinoma have all been described in association with cutaneous horns [4]. For appropriate histopathological diagnosis, this lesion should undergo biopsy at the base of the horn for smaller lesions excision should be considered. A sex predilection has not been shown; however the possibility of harboring malignancy at the base of the lesion is increased in men when compared with age-matched women. This article describes our experience with cutaneous horns.

Patients and methods

Eleven patients with cornu cutaneum treated between January 2000 and January 2004 at the Department of Plastic and Reconstructive Surgery, Adnan Menderes University forms the basis of this report. These patients were diagnosed preoperatively based on the appearance of their lesions. After careful and detailed physical examinations all patients underwent surgical excision under local anesthesia. Defects were closed primarily if diameter was less than 2 cm, split thickness skin grafting was performed if the defects could not be closed primarily. Specimens were evaluated microscopically. Patients with malignant lesions were followed-up for minimum six months for any signs of recurrence. Data is presented as frequency.

Results

The age of the patients ranged from 45 to 67 years with a median age of 57 years. Median age was 55 years in males and 65 years in females. A male to female ratio of 3:8 was observed. All patients had history of long-term sun exposure due to farm activities and had solar keratosis on face and extremities. Three patients had past history of skin cancer (Table 1). Majority of the lesions were located on ears (4/11) (Figure 1 and 2). Three patients had a lesion on the scalp and two patients on the hand (Figure 3, and 4). One patient each had a cornu cutaneum on the lip and the buccal mucosa (Figure 5). The diagnosis of cutaneous horn was confirmed histopathologically (Figure 6). Base of the lesions were diagnosed as solar keratosis in four patients, well differentiated squamous cell carcinoma in two, actinic keratosis in two, keratoacanthoma in two, and basal cell carcinoma in one patient. One of the squamous cell carcinoma was located on ear and other on hand, while basal cell carcinoma was located on buccal mucosa. Surgical margins of the specimens were tumor free in all patients. There was no recurrence and complication in postoperative period. No adjuvant therapy given to the patients with skin cancer. Sun protection was advised to all patients.
Table 1. Patient characteristics

Figure 1. Cornu cutaneum on the left ear. Histologically lesion was reported as actinic keratosis.

Figure 2. Cornu cutaneum on the right ear histologically reported as well differentiated squamous cell carcinoma.

Figure 3. Cornu cutaneum due to solar keratosis of the scalp.

Figure 4. Cornu cutaneum on the hand due to keratoacanthoma.

Figure 5. Cornu cutaneum on the lip due to actinic keratosis.

Figure 6. Photomicrograph showing diffuse hyperkeratosis and parakeratosis consistent with cutaneous horn. (Hematoxylin & Eosin ×100).

Discussion

Cutaneous horns, though grossly similar to horns in animals are histologically quite different from them. The animal horns are composed of superficial hyperkeratotic epidermis, dermis, and centrally positioned bone. No such axially positioned well-formed bone is observed in the gigantic human horns. On the other hand, no cystic structures lined by trichelemmal-type epithelium are seen in of the true animal horns [5]. The earliest well documented case of cornu cutaneum from London in 1588 is of Mrs. Margaret Gryffith, an elderly Welsh woman. A showman, who advertised it in a pamphlet, exhibited her for money. However, earliest observations on cutaneous horns in humans were described by the London surgeon Everard Home in 1791 [6]. Farris from Italy first described the gigantic horn in man as a well documented a case report with adequate histology [7]. A cutaneous horn (cornu cutaneum) is a protrusion from the skin consisting of cornified material organized in the shape of a horn. These horns can be derived from a variety of benign or malignant epidermal lesions. The histological appearance of the basal layer of the cutaneous horn is in the spectrum of seborrheic keratosis to infiltrated squamous cell carcinoma [1,6]. The important issue is not the horn itself which is dead keratin, but rather the underlying condition, which may be benign (seborrheic keratosis, viral warts, histiocytoma, inverted follicular keratosis, verrucous epidermal nevus, molluscum contogiosum, etc.), premalignant (solar keratosis, arsenical keratosis, Bowen's disease) or malignant (squamous cell carcinoma, rarely, basal cell carcinoma, metastatic renal carcinoma, granular cell tumor, sebaceous carcinoma or Kaposi's sarcoma). Most commonly, they are single and arise from a seborrheic keratosis lesion [8]. Largest study of 643 cutaneous horns was reported by Yu et al [6]. According to them 39% of cutaneous horns were derived from malignant or premalignant epidermal lesions, and 61% from benign lesions. Two other larger studies on cutaneous horn too showed 23–37% of these to be associated with actinic keratosis or Bowen's disease and another 16–20% with malignant lesions [3,9]. In the study of Bart et al [10] 44% patients had underlying malignancy. Three of their patients had past history of skin cancers [10]. Spira and Rabonovitz concluded that cutaneous horns in associated with a malignant or premalignant base is more common in patients with a past history of other malignant or premalignant lesions [11]. In our part of the country exposure to the sun is most common. Majority of the population is involved in farm activity mostly without sun protection. We believe that sun exposure is the most important etiological factor in pathogenesis of the cornu cutaneum like other skin lesions. Histopathological examination of the base of the lesion is necessary to rule out associated carcinoma, and full excision is the treatment of choice. In general, malignant or premalignant conditions are more common in older male patients, especially when the cutaneous horn is found on the face, pinna, dorsum of hands, forearms, or scalp, or when it has a larger base or base-height ratio [3]. Surgical excision remains the treatment of choice.

Conclusions

Cutaneous horns are predominantly benign lesions; however possibility of nearly one third of them harboring malignant or premalignant skin lesions should be kept in mind.

Competing interests

None declared.

Authors' contributions

EC conceived the study and prepared the manuscript draft for submission. NS and NC did the literature search and participated in the preparation of the manuscript.
All authors read and approved the final manuscript.

References

1. Korkut T, Tan NB, Oztan Y: Giant cutaneous horn: a patient report.

Ann Plast Surg 1997, 39:654-655. PubMed Abstract

Selasa, 16 Agustus 2016

Cutaneous Horn

Cutaneous Horn

Background

Pathophysiology

Mortality/Morbidity

Race

Sex

Age

History

Physical

Causes

Lab Studies

Histologic Findings

Surgical Care

Rhino Cutaneous Horn In A Sun-Protected Area: A Rare Case With Historical Review

Abstract

Introduction

Case report

Discussion

Conclusion

Address for Correspondence

References

Abstract

Background

Patients and methods

Results

Conclusion

Introduction

Patients and methods

Results

Discussion

Conclusions

Competing interests

Authors' contributions

References

Abstract

Introduction

Case presentation

Conclusion

Introduction

Case presentation

Discussion

Conclusion

Competing interests

Authors' contributions

Consent

Acknowledgements

References

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Rhino Cutaneous Horn In A Sun-Protected Area:
A Rare Case With Historical Review