Photo Quiz

Large Growth on the Face



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Am Fam Physician. 2012 Aug 1;86(3):273-274.

A 78-year-old woman presented with a large growth on her face that had been present for 11 years. The lesion was located in the zygomatic region, a sun-damaged area with aged skin.

Physical examination showed a hard, elongated, gray to yellowish hyperkeratotic mass (see accompanying figure). The lesion was 7.2 cm in length with a base diameter of 0.7 cm.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Actinic keratosis.

B. Cutaneous horn.

C. Keratoacanthoma.

D. Seborrheic keratosis.

Discussion

The answer is B: cutaneous horn. Cutaneous horn, or cornu cutaneum, refers to elongated, keratinous, gray to yellowish projections that range in size from a few millimeters to several centimeters.1 The reason for retention of keratin is unknown. This is a rare clinical diagnosis, and the incidence and prevalence in the general population are unknown.1 Cutaneous horns usually occur in light-skinned patients older than 50 years, and are more common in men.1 Approximately 30 percent of cutaneous horns occur on the upper face and scalp. Other common locations include sun-exposed areas such as the ear, lip, chest, neck, and shoulder.1,2

Cutaneous horns occur in association with a wide variety of underlying benign, premalignant, and malignant diseases, such as keratosis, sebaceous molluscum, verruca, trichilemmal cyst, Bowen disease, squamous cell carcinoma, malignant melanoma, and basal cell carcinoma.13 To make a histologic diagnosis, the lesion should be biopsied at the base of the horn.3 Cutaneous horns can be removed with simple excision using cauterization and cryosurgery.1,3

Actinic keratoses are hyperkeratotic lesions. They are usually multiple and comprised of either macules or papules with a rough, scaly surface resulting from disorganized keratinization and a variable degree of inflammation. Lesions vary from less than 1 mm to more than 2 cm, and are usually asymptomatic.3

Keratoacanthoma is composed of keratinizing squamous cells originating from pilosebaceous follicles. It is characterized by rapid growth to a relatively large size, and a regular crateriform shape with a keratotic plug and undamaged surrounding skin.3

Seborrheic keratoses are composed of epidermal keratinocytes, varying from a dirty yellow to black color with greasy keratin on the surface. The size can be from 1 mm to several centimeters.3 They have a classic “stuck on” appearance.

Summary Table

Condition Characteristics

Actinic keratosis

Hyperkeratotic lesions, usually multiple; comprised of either macules or papules with a rough, scaly surface resulting from disorganized keratinization and a variable degree of inflammation; usually asymptomatic; less than 1 mm to more than 2 cm in size

Cutaneous horn

Elongated, keratinous, gray to yellowish projections; a few millimeters to several centimeters in size

Keratoacanthoma

Usually grows rapidly to a relatively large size; regular crateriform shape and keratotic plug with undamaged surrounding skin

Seborrheic keratosis

Composed of epidermal keratinocytes, varying from dirty yellow to black in color with greasy keratin on the surface; 1 mm to several centimeters in size

Summary Table

View Table

Summary Table

Condition Characteristics

Actinic keratosis

Hyperkeratotic lesions, usually multiple; comprised of either macules or papules with a rough, scaly surface resulting from disorganized keratinization and a variable degree of inflammation; usually asymptomatic; less than 1 mm to more than 2 cm in size

Cutaneous horn

Elongated, keratinous, gray to yellowish projections; a few millimeters to several centimeters in size

Keratoacanthoma

Usually grows rapidly to a relatively large size; regular crateriform shape and keratotic plug with undamaged surrounding skin

Seborrheic keratosis

Composed of epidermal keratinocytes, varying from dirty yellow to black in color with greasy keratin on the surface; 1 mm to several centimeters in size

Address correspondence to Aleksandar Janković, MD, PhD, at jakesnage@yahoo.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

1. Fernandes NF, Sinha S, Lambert WC, Schwartz RA. Cutaneous horn: a potentially malignant entity. Acta Dermatovenerol Alp Panonica Adriat. 2009;18(4):189–193.

2. Copcu E, Sivrioglu N, Culhaci N. Cutaneous horns: are these lesions as innocent as they seem to be? World J Surg Oncol. 2004;3(2):18.

3. Burns T, Breathnach S, Cox N, Griffiths C, eds. Rook's Textbook of Dermatology. 8th ed. Malden, Mass.: Wiley-Blackwell; 2010.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH

A collection of Photo Quizzes published in AFP is available at http://www.aafp.org/afp/photoquiz.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.



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