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Hyperkeratotisch papilloom - Huidziekten en Behandelingsopties

Pathophysiology

A cutaneous horn is a well-circumscribed, hyperkeratotic lesion with a height that is more than half of the diameter of its base. It can arise from any part of the skin or mucosa, with its pathophysiology being dependent upon the underlying disease. Lesions associated with benign disease processes tend to grow slowly over a few months to years.[6] However, diseases with a higher mitotic activity rate, such as SCC, can lead to a rapid growth phase and the development of horns. The more significant cumulative actinic damage and higher rates of neoplastic degeneration found in older adults make this population more prone to malignant horns.[7] Lesions with a wider base are more likely to be malignant than those with a narrower base.[6]

Montgomery (1941) classified cutaneous horns into 5 types. These subtypes were distinguished by appearance, histological structure, and causation.[14]

Papillomatous cutaneous horn developing from the keratinizing stratified squamous epithelium Filiform cutaneous horn arising from normal or hyperkeratotic skin

The dermatology community has since moved away from Montgomery’s classic subtypes in favor of a classification system focused on underlying etiology. Although patients may still be described as having a Montgomery Type 5 cutaneous horn,[14] histopathological analysis of the underlying lesion and subsequent determination of the underlying pathology is the current model for cutaneous horn classification, namely, benign, premalignant, or malignant with a distinct variety of underlying causations defined for each category.

Introduction

Seborrheic keratoses (SKs) are the most common benign epithelial tumours of humanity with an increasing incidence with age. The predilection zones of SKs are trunk and forehead. An important clinical sign is the formation of multiple horn pearls [1]. In dermoscopy, comedo-like openings, milia-like cysts, and fissures and ridges are characteristic [2]. Although most SKs have a maximum diameter of less than 4 cm, sometimes giant lesions develop that raises some possible differential diagnoses including Buschke-Löwenstein tumours [3].

On the histologic level six subtypes can be differentiated: - hyperkeratotic type, - acanthotic type, - reticular/adenoid type, - clonal type, - irritated type, - melanoakanthoma [1]. Multiple eruptive SKs was known as Leser-Trélat-syndrome gain importance as a paraneoplasia [4].

Hoe vaak komt actinische keratose voor?

Ongeveer de helft van alle mannen boven 45 jaar en een derde van de vrouwen boven de 45 jaar heeft tenminste één actinische keratose. Dat komt neer op ongeveer 1,4 miljoen Nederlanders. Het komt dus erg vaak voor. Dit komt onder andere door veranderende vrijetijdsbesteding, zonnebanken en zonvakanties. Actinische keratose komt vaker voor bij mensen met een blank huidtype (blond haar en blauwe ogen).

Ongeveer 10% van de patiënten met actinische keratosen ontwikkelt een huidkanker, meestal het plaveiselcelcarcinoom. De kans dat iemand een plaveiselcelcarcinoom krijgt is afhankelijk van de hoeveelheid actinische keratosen. Dit is ongeveer 1% als iemand minder dan vijf actinische keratosen heeft, tot 20% als iemand meer dan twintig actinische keratosen heeft.

Prognosis

The prognosis is dependent upon the classification of the underlying proliferative lesion at the base of the horn (eg, actinic keratosis, squamous cell carcinoma)

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. [28, 33] Tenderness at the base of the lesion is often a clue to the presence of a possible underlying squamous cell carcinoma. [4] Bleeding at the base of the lesion, as well as larger size, have been suggested as an indication of underlying malignancy. [2, 32]

References
  1. Durkee S. Human Horn (Cornu Cutaneum of Rokitansky). Boston Med Surg J. 1866 Feb. 74:9-11.
  2. Bondeson J. Everard Home, John Hunter, and cutaneous horns: a historical review. Am J Dermatopathol. 2001 Aug. 23(4):362-9. [QxMD MEDLINE Link].
  3. Kumar S, Bijalwan P, Saini SK. Carcinoma buccal mucosa underlying a giant cutaneous horn: a case report and review of the literature. Case Rep Oncol Med. 2014. 2014:518372. [QxMD MEDLINE Link]. [Full Text].
  4. Zhou Y, Tang Y, Tang J, Xia B, Dai Y. Progression of penile cutaneous horn to squamous cell carcinoma: A case report. Oncol Lett. 2014 Sep. 8(3):1211-1213. [QxMD MEDLINE Link]. [Full Text].
  5. Fatani MI, Hussain WM, Baltow B, Alsharif S. Cutaneous horn arising from an area of discoid lupus erythematosus on the scalp. BMJ Case Rep. 2014 Apr 3. 2014:[QxMD MEDLINE Link].
  6. Jhuang JY, Liao SL, Tsai JH, Chang HC, Kuo KT, Liau JY. Extraocular well-differentiated sebaceous tumors with overlying cutaneous horns: four tumors in three patients. J Cutan Pathol. 2014 Aug. 41(8):650-6. [QxMD MEDLINE Link].
  7. Srebrnik A, Wolf R, Krakowski A, Baratz M. Cutaneous horn arising in cutaneous leishmaniasis. Arch Dermatol. 1987 Feb. 123(2):168-9. [QxMD MEDLINE Link].
  8. Dabski K, Stoll HL. Cutaneous horn arising in chronic discoid lupus erythematosus. Arch Dermatol. 1985 Jul. 121(7):837-8. [QxMD MEDLINE Link].
  9. Cardis MA, Kirkorian AY. Giant Cutaneous Horn Arising in an Epidermal Nevus. Pediatr Dermatol. 2017 Sep. 34 (5):e290-e291. [QxMD MEDLINE Link].
  10. Goette DK. Cutaneous horn overlying granular cell tumor. Int J Dermatol. 1987 Nov. 26(9):598-9. [QxMD MEDLINE Link].
  11. Nahata VL. Cutaneous Horn Overlying Inverted Follicular Keratosis: A Rare Case Report. Indian Dermatol Online J. 2021 Jul-Aug. 12 (4):636-638. [QxMD MEDLINE Link]. [Full Text].
  12. Findlay RF, Lapins NA. Pyogenic granuloma simulating a cutaneous horn. Cutis. 1983 Jun. 31(6):610-2. [QxMD MEDLINE Link].
  13. Brownstein MH, Shapiro EE. Trichilemmomal horn: cutaneous horn overlying trichilemmoma. Clin Exp Dermatol. 1979 Mar. 4(1):59-63. [QxMD MEDLINE Link].
  14. Gould JW, Brodell RT. Giant cutaneous horn associated with verruca vulgaris. Cutis. 1999. 64:111-2. [QxMD MEDLINE Link].
  15. Kheshvadjian AR, Erickson C, Calame A, et al. Cutaneous Horn Revisited: A Woman With a Verruca Vulgaris-Associated Cornu Cutaneum. Cureus. 2021 Nov. 13 (11):e19925. [QxMD MEDLINE Link]. [Full Text].
  16. Sandbank M. Basal cell carcinoma at the base of cutaneous horn (cornu cutaneum). Arch Dermatol. 1971 Jul. 104(1):97-8. [QxMD MEDLINE Link].
  17. Onak Kandemir N, Gun BD, Barut F, Solak Tekin N, Ozdamar SO. Cutaneous Horn-Related Kaposi's Sarcoma: A Case Report. Case Report Med. 2010. 2010:[QxMD MEDLINE Link]. [Full Text].
  18. Yang JH, Kim DH, Lee JS, et al. A case of cutaneous horn originating from keratoacanthoma. Ann Dermatol. 2011 Feb. 23(1):89-91. [QxMD MEDLINE Link]. [Full Text].
  19. Wollina U, Schonlebe J. Giant keratoacanthoma-like cutaneous horn of the upper leg: A case report. Acta Dermatovenerol Alp Panonica Adriat. 2010. 19(2):29-30. [QxMD MEDLINE Link].
  20. Abelenda P, Navarrete J, Guerra A, Mazzei ME, Magliano J, Bazzano C. Malignant Melanoma With Massive Crust Mimicking a Cutaneous Horn: An Unexpected Finding. Am J Dermatopathol. 2017 Sep 12. [QxMD MEDLINE Link].
  21. Cristobal MC, Urbina F, Espinoza A. Cutaneous horn malignant melanoma. Dermatol Surg. 2007 Aug. 33(8):997-9. [QxMD MEDLINE Link].
  22. Dabski K, Stoll HL Jr. Paget's disease of the breast presenting as a cutaneous horn. J Surg Oncol. 1985 Aug. 29(4):237-9. [QxMD MEDLINE Link].
  23. Georgy JT, Mathuram AJ, George AA, Chandramohan J. Renal cell carcinoma presenting as a cutaneous horn and nodules on the gingiva and scalp. BMJ Case Rep. 2017 Aug 18. 2017:[QxMD MEDLINE Link].
  24. Peterson JL, McMarlin SL. Metastatic renal-cell carcinoma presenting as a cutaneous horn. J Dermatol Surg Oncol. 1983 Oct. 9(10):815-8. [QxMD MEDLINE Link].
  25. Brauninger GE, Hood CI, Worthen DM. Sebaceous carcinoma of lid margin masquerading as cutaneous horn. Arch Ophthalmol. 1973 Nov. 90(5):380-1. [QxMD MEDLINE Link].
  26. Kitagawa H, Mizuno M, Nakamura Y, Kurokawa I, Mizutani H. Cutaneous horn can be a clinical manifestation of underlying sebaceous carcinoma. Br J Dermatol. January 2007. 156(1):180-2. [QxMD MEDLINE Link].
  27. Korkut T, Tan NB, Oztan Y. Giant cutaneous horn: a patient report. Ann Plast Surg. 1997 Dec. 39(6):654-5. [QxMD MEDLINE Link].
  28. Solivan GA, Smith KJ, James WD. Cutaneous horn of the penis: its association with squamous cell carcinoma and HPV-16 infection. J Am Acad Dermatol. 1990 Nov. 23(5 Pt 2):969-72. [QxMD MEDLINE Link].
  29. Sathyanarayana SA, Deutsch GB, Edelman M, Cohen-Kashi KJ. Cutaneous horn: a malignant lesion? A brief review of the literature. Dermatol Surg. 2012 Feb. 38(2):285-7. [QxMD MEDLINE Link].
  30. Leppard W, Loungani R, Saylors B, Delaney K. Mythology to reality: case report on a giant cutaneous horn of the scalp in an African American female. J Plast Reconstr Aesthet Surg. 2014 Jan. 67(1):e22-4. [QxMD MEDLINE Link].
  31. Nthumba PM. Giant cutaneous horn in an African woman: a case report. J Med Case Rep. 2007 Dec 5. 1:170. [QxMD MEDLINE Link].
  32. Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol. 1991 May. 124(5):449-52. [QxMD MEDLINE Link].
  33. Vera-Donoso CD, Lujan S, Gomez L, Ruiz JL, Jimenez Cruz JF. Cutaneous horn in glans penis: a new clinical case. Scand J Urol Nephrol. 2009. 43(1):92-3. [QxMD MEDLINE Link].
  34. Al-Zacko SM, Mohammad AS. Cutaneous Horn Arising From a Burn Scar: A Case Report and Review of Literature. J Burn Care Res. 2018 Jan 1. 39 (1):168-170. [QxMD MEDLINE Link].
  35. Mencia-Gutierrez E, Gutierrez-Diaz E, Redondo-Marcos I, Ricoy JR, Garcia-Torre JP. Cutaneous horns of the eyelid: a clinicopathological study of 48 cases. J Cutan Pathol. 2004 Sep. 31(8):539-43. [QxMD MEDLINE Link].
  36. Vano-Galvan S, Marques A, Munoz-Zato E, Jaen P. A facial cutaneous horn. Cleve Clin J Med. 2009 Feb. 76(2):92-5. [QxMD MEDLINE Link].
  37. Solanki LS, Dhingra M, Raghubanshi G, Thami GP. An innocent giant. Indian J Dermatol. 2014 Nov. 59(6):633. [QxMD MEDLINE Link]. [Full Text].
  38. Uchiyama N, Shindo Y, Saida T. Perforating pilomatricoma. J Cutan Pathol. 1986 Aug. 13(4):312-8. [QxMD MEDLINE Link].
  39. Sirka CS, Dash G, Pradhan S, et al. Cutaneous Rhinosporidiosis Presenting as Cutaneous Horn and Verrucous Plaque. Indian Dermatol Online J. 2019 Mar-Apr. 10 (2):178-179. [QxMD MEDLINE Link]. [Full Text].
  40. Mantese SA, Diogo PM, Rocha A, Berbert AL, Ferreira AK, Ferreira TC. Cutaneous horn: a retrospective histopathological study of 222 cases. An Bras Dermatol. 2010 Apr. 85(2):157-63. [QxMD MEDLINE Link].

Histopathology

The histopathological analysis will reveal compact, redundant hyperkeratosis with or without orthokeratosis or parakeratosis. Unlike animal horns, human cutaneous horns contain cystic structures lined by trichilemmal-type epithelium and lack centrally positioned bone.[17] Giant horns (>1 cm in height) are less suitable for microscopic analysis. Histopathology of the underlying disease will be found beneath the cornified projection.[1]

Upon tactile discrimination, the examiner will find a firmly rooted exophytic growth. Absolute widths can vary from a few millimeters to several centimeters in diameter. Absolute heights of cutaneous horns are greater on average than widths by definition but still within the range of millimeters to several centimeters. They are referred to as "giant" when they have a height greater than 1 cm.[19] Although giant horns are rarely encountered, horns up to 25 cm have been reported.[5] Currently, there is no documented correlation between the lifespan of the cutaneous horn and its classification as a benign, premalignant, or malignant lesion.

Regardless of their classification, cutaneous horns are evident, keratinous, elongated, yellowish, or white projections of various sizes.[5] These exophytic projections are conical, cylindrical, pointed, or curved, like a ram’s horn. The base of these lesions may be seen as flat, nodular, or crateriform. Surrounding erythematous inflammation is rare and indicates underlying malignancy. Cutaneous horns may be challenging to distinguish from conditions such as an ectopic nail, consequently, excision and histopathological analysis are required to confirm the suspicion of the cutaneous horn, but more importantly, to assess the underlying etiology of the lesion.[20]

Terrace morphology, indicative of benign disease, and base erythema, prognostic for malignant potential, are likely findings on dermoscopy. Terrace morphology, defined as structural horizontal contours on the side of the horn, was recorded in most cases of benign keratosis, actinic keratosis, and SCC in situ. Invasive SCC recorded the lowest significant incidence of terrace morphology. Base erythema is defined by a red, erythematous area in the base of the horn compared with the background skin within 5 mm from the horn base boundary. Base erythema occurred in over 55% of the 4 diagnostic categories studied by Pyne et al,[1] which include benign keratosis, actinic keratosis, SCC in situ, and invasive SCC. Invasive SCC displayed the greatest incidence (77%) of base erythema. Lastly, horns with a height one-to-two times greater than the base diameter have a higher incidence of malignant potential than those with lower height-to-base diameter ratios.

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