Cornu Cutaneum - Alles wat je moet weten over deze Huidziekte

Case Report

Mass was developed as seen from the left nasal cavity of lateral wall of vestibule.

Lesion was excised by pedicle from vestibule.

Pathological examination showed keratin lamellas which showed papillomatous improvement apart from any living cells.

Normal physical examination was seen after 4 months postoperatively.

INTRODUCTION

This is a case report of cutaneous horn of upper lip vermillion with verrucous carcinoma at its base.

A59-year-old male reported with a chief complaint of a growth on the left side of upper lip. The lesion had been present for the last 6 months with gradual increase in size. Previously, the patient had undergone surgical excision of the lesion twice in the same area from an outside clinic only to notice it regrow again. He had the habit of smoking cigarettes for the past 25 years, around 20 cigarettes per day. The patient also gave a history of anemia for the past 1 month and was taking folic acid medication regularly. No other signs and symptoms were present.

On close clinical examination, an exophytic growth was seen on the left corner of upper lip. The growth was about 1.5 cm in length and was brown. On palpation, the growth was firm to hard in consistency and was slightly tender. Intraoral examination revealed a grayish-white patch on the left commissural mucosa and the dorsum of tongue measuring about 3 cm × 1 cm in dimension. Both the white patches were nontender and nonscrapable in nature. Hard tissue examination revealed several missing teeth (15, 16, 17, 25, 26, 27 and 46) and Grade II mobility with respect to teeth (11, 21, 22, 23, 31, 41, 42 and 47). Generalized gingival recession and attrition were also seen in Figure 1 .

Clinical presentation of cutaneous horn on upper lip vermillion

Excision of the lesion on the lip along with its adjacent grayish-white patch was done using CO2 laser. Satisfactory healing was observed after a week. The gross specimen received measured about 28 mm × 7 mm × 4 mm. One end of the specimen was soft in consistency, and the other end was firm which represents the horn [ Figure 2 ].

DISCUSSION

Cutaneous horn is a clinical diagnosis and includes various benign and malignant lesions at its base.[2] Lesions associated with cutaneous horn include keratosis, sebaceous molluscum, verruca, trichilemma, Bowen's disease, epidermoid carcinoma, malignant melanoma and basal cell carcinoma.[5] Cutaneous horn is most commonly encountered in Caucasians. It is relatively rare in Asians and even rarer in Africans. The possible explanation for this racial predilection may be the presence of more amount melanin pigmentation in the skin of Asians and Africans, which performs a protective role against ultraviolet rays-induced damage to epidermal cells. Long-term sun exposure and immunodeficiency have also been implicated in causation of this lesion.[4]

A sex predilection has not been shown in the literature, however, the possibility of harboring malignancy at the base of the lesion is increased in men when compared with age-matched women.[6,7] Cutaneous horn occurs mainly in individuals who are above 50 years of age, in both sexes, probably due to a major actinic and neoplastic degeneration occurring in elderly people.[8] Studies describe that the average age of patients with premalignant and malignant lesions is around 6 years more than that of the patients with benign alterations, and therefore, the chances of finding a malignant substratum on the base of a cutaneous horn would increase proportionally with age.[9]

The earliest well-documented case of cornu cutaneum from London in 1588 is of Mrs. Margaret Gryffith, an elderly Welsh woman. A showman had advertised it in a pamphlet. However, earliest observations on cutaneous horns in humans were described by the London surgeon Everard Home in 1791.[10] The largest study of 643 cutaneous horns was reported by Yu et al.[8] According to them, 39% of cutaneous horns were derived from malignant or premalignant epidermal lesions, and 61% from benign lesions. Other two studies on cutaneous horn showed 23%–37% of these to be associated with actinic keratosis or Bowen's disease and another 16%–20% with malignant lesions.[8,11,12]

Introduction

Cornu cutaneum is a relatively uncommon projectile, irregular, hyperkeratotic nodule that can be seen in places such as scalp, forehead, eyelids, ear, nose, lips, and upper extremities which are subjectable to sunlight [1]. Mostly they are believed to be benign lesions, but researches showed that they might be related to malignant or premalignant lesions [2]. It is believed that there is a relation between actinic keratosis, molluscum sebaceum, sebaceous carcinoma, warts, trichilemmoma, Bowen's disease, epidermoid carcinoma, malignant melanoma, and basal cell carcinoma and cornu cutaneum [3–5].

Cornu cutaneum is a painless, avascular, necrotic, or keratotic lesion with histopathological examination with no living cells. Certain diagnosis is always made with biopsy.

Treatment is surgery with radical margins [6]. Excisional biopsy is enough for treatment of the lesion on head and face [6]. Shaving is an option only when there is no possibility of total excision and in sensitive cosmetic areas. Electrocauterization, cryotherapy, and laser ablation are alternative methods [7]. A yearly postoperative examination should be done to control the primary malignancy and check if there are any additional malignancies.

We present an 82-year-old male patient with a necrotic lesion on the left nasal vestibule excised with excisional biopsy and diagnosed as cornu cutaneum.

Discussion

Cornu cutaneum is generally a slow developing mass. Our patient had nasal obstruction symptoms for more than 3 months and the mass became visible from outside the nose within a month. Cornu cutaneum is generally a benign lesion but is reported to have relation with malignant or premalignant diseases. Histological researches show that basal membrane invasion supporting differential diagnosis should include a wide range from seborrheic keratosis to squamous cell carcinoma [8, 9]. Predisposing factors include benign (seborrheic keratosis, viral verrucae, and molluscum contagiosum), premalignant (solar keratosis, arsenic keratosis, and Bowen's disease), and malignant (squamous cell carcinoma, basal cell carcinoma, metastatic renal cell carcinoma, granular cell tumours, sebaceous carcinomas, and Kaposi's sarcoma) diseases. Differential diagnosis can only be made by careful histopathological investigation of the basal lamina [1].

Excisional biopsy can be made for diagnosis and treatment. We treated and diagnosed our patient with excisional biopsy. Isolated cornu cutaneum has dead keratin cells without any living tissues [1]. Our pathological examination also showed papillomatous keratin lamellas without any alive cells.