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Home , Cutaneous horn, Keratoacanthoma

BMJ 2019;364:l595 doi: 10.1136/bmj.l595 (Published 7 March 2019) Page 1 of 2

Endgames BMJ: first published as 10.1136/bmj.l595 on 7 March 2019. Downloaded from

ENDGAMES

SPOT DIAGNOSIS Just a cutaneous (keratotic) horn?

Jane Wilcock general practitioner, Yvonne Savage

Silverdale Medical Practice, Salford, Manchester, UK

A 70 year old woman attended a dermatologist with a lesion on In this case, the speed of growth made a a the dorsum of her right hand (fig 1). It had appeared over eight possibility. However, the patient also had several risk factors weeks and was painless but unsightly. She reported good health for squamous cell cancer: age, sun exposure, past lymphoma,1 and no history of . Fifteen years ago, she had lymphoma past , and no history of warts. Other invasive treated by chemotherapy; her last treatment (biological therapy) features of squamous cell cancer relevant to this case include had finished seven years ago and she had been well since. She the lesion’s arrival over eight weeks and its wide, thick, red base had holidayed in Australia for three months at a time over the with a diameter larger than the height of the horn. About 35% 2 last three years and more recently had driven frequently from of keratotic horns are invasive squamous cell cancers. http://www.bmj.com/ northern England to the south coast while a close relative was Invasive squamous cell cancer is a non-melanotic skin ill. She said she was careful to use sunscreen. with a good prognosis but may metastasise to the lymph nodes. One study reported a micro-metastasis rate of 3.4% at sentinel lymph node excision.3 Typically, squamous cell cancers present as palpable, rough, persistent scaly lesions in sun exposed sites, including ears,

eyelids, and lips. They can be nodular and create a horn or they on 1 August 2019 by Anne Meneghetti. Protected copyright. may be indurated or ulcerated with no .4 Risk factors for invasive squamous cell cancers are age, fair skin, sun damage including UVA light, sunbed use, psoralen and UVA therapy, outdoor work, family history, high risk HPV, (eg, after organ transplant, HIV, leukaemia), Keratotic horn lesion on dorsum of the right hand lymphoma, chronic skin ulceration, burns, and past radiotherapy, actinic , and Bowen’s disease.4 5 In this patient, features associated with invasive squamous cell The lesion had a red, firm base 2 × 1 cm and 3 mm with a cancer were redness of the horn base, pain, a horn height less protruding another 5 mm. than the diameter of the base, and no terraced morphology of 2 She had cryocautery twice by her general practitioner which the horn. did not alter the lesion and so chose to attend a private England and Wales do not report rates of non-melanoma skin dermatologist. The lesion was excised. cancer (also called keratinocyte ). Scotland does, What is the most likely diagnosis? however, and the incidence of all skin cancers is rising. In 2016 there were 12 929 skin cancers reported in Scotland, of which Answer (to the nearest integer) 11% were malignant melanomas, 63% Invasive squamous cell cancer masquerading as keratotic horn. were basal cell , and 26% were squamous cell cancers.6 An Australian study using clinical judgement with A keratotic horn is derived from the superficial keratinocyte dermatoscopy followed by histology of cutaneous horns at a layer of the skin. private practice revealed that 13% were actinic keratoses, 23% Differential diagnoses include (seborrheic were Bowen’s disease, 30% were benign keratoses, and 35% ); human papilloma virus (HPV) wart and keratoacanthoma were invasive squamous cell cancers.2 (benign); , which is pre-malignant; Bowen’s Other differentials are disease, which is a non-invasive squamous cell cancer; and invasive squamous cell cancer.

Correspondence to J Wilcock [email protected]

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2019;364:l595 doi: 10.1136/bmj.l595 (Published 7 March 2019) Page 2 of 2

ENDGAMES

• Seborrheic keratosis (seborrheic wart)—a persistent palpable, •Most squamous cell cancers do not present as cutaneous dry, rough, often mid brown pigmented keratotic skin lesion keratotic horns, but rates of squamous cell cancer in the BMJ: first published as 10.1136/bmj.l595 on 7 March 2019. Downloaded from that occurs in 75% of people over 70 and can be seen from the base of horns range from 41 to 77%.3 7 age of 40. Lesions can be multiple, large, flat or raised, smooth •Refer patients with risk factors and features suggestive of or fissured, of various sizes, and are very common. Patients may invasive squamous cell cancer to departments. find them unsightly. Pigmentation in seborrheic keratosis may make differentiation from malignant melanoma difficult, especially for the public. Patient outcome • Skin wart—rough, raised, usually small and often multiple Histology of the excised lesion confirmed invasive squamous palpable lesions. These often present on fingers. They can occur cell cancer. Cancerous cells were evident in the deep margin, at all ages and are transmissible by touch although personal therefore the patient underwent further . Second operative immunity plays a factor in susceptibility and persistence. They histology revealed no residual squamous cell cancer present. are caused by low risk human papilloma virus infections, often types 1, 2, 3, 4, 10, 27, or 57.8 Resolution is spontaneous but Patient consent obtained. varies from weeks to years. Competing interestsThe BMJ has judged that there are no disqualifying financial • Keratoacanthoma—a rapidly growing, benign, usually solitary ties to commercial companies. The authors declare the following other interests: nodular 1-2 cm diameter circular tumour with a keratotic none. appearance. Height varies but is often about 0.5 cm. It may be Further details of The BMJ policy on financial interests is here: https://www.bmj. mistaken for a basal cell in appearance but its rapid com/about-bmj/resources-authors/forms-policies-and-checklists/declaration- growth (over 12 weeks) would suggest a squamous cell cancer competing-interests and therefore it is usually excised. If left, it will usually regress Provenance and peer review: not commissioned; externally peer reviewed. over another 12 weeks and vanish, although cases are reported of squamous cell cancer transformation and it can be challenging 1 Brewer JD, Shanafelt TD, Khezri F, etal . Increased incidence and recurrence rates of to differentiate the histology from that of a squamous cell nonmelanoma skin cancer in patients with non-Hodgkin lymphoma: a Rochester 9 Epidemiology Project population-based study in Minnesota. J Am Acad Dermatol cancer. Although a keratoacanthoma can regress completely, 2015;72:302-9. 10.1016/j.jaad.2014.10.028 25479909 usual treatment is to refer and remove in case of invasive 2 Pyne J, Sapkota D, Wong JC. Cutaneous horns: clues to invasive 9 being present in the horn base. Dermatol Pract Concept 2013;3:3-7. squamous cell cancer. 10.5826/dpc.0302a02 23785640 3 Samsanavicius D, Kaikaris V, Cepas A, Ulrich J, Makstiene J, Rimdeika R. Importance • Actinic keratosis (solar keratosis)—a persistent, dry, palpable of sentinel lymphatic node biopsy in detection of early micrometastases in patients with keratotic lesion or a flaky skin lesion, often multiple and cutaneous squamous cell carcinoma. J Plast Reconstr Aesthet Surg 2018;71:597-603. http://www.bmj.com/ occurring on sites exposed to sun. It is commonly seen on upper 10.1016/j.bjps.2017.10.019 29174519 4 Motley RJ, Preston PW, Lawrence CM. Multi-professional guidelines for the management foreheads and bald scalps of older men. It can be red or keratotic of the patient with primary cutaneous squamous cell carcinoma at: http://www.bad.org. and varies in size. Actinic keratosis lesions can become uk/library-media%5Cdocuments%5CSCC_2009.pdf 5 Risks and causes. Skin cancer. Cancer Research UK. https://www.cancerresearchuk.org/ squamous cell cancers, although the risk is small. The 2017 about-cancer/skin-cancer/risks-causes British Association of Dermatology guideline suggests that for 6 Cancer statistics. ISD Scotland. http://www.isdscotland.org/Health-Topics/Cancer/Cancer- Statistics/Skin/#non-melanoma people with seven or more actinic keratoses, the risk of 7 Seborrheic keratoses. Patient Information Leaflet. British Association of Dermatology. 10 developing squamous cell skin cancer over 10 years is 10%. http://www.bad.org.uk/for-the-public/patient-information-leaflets/seborrhoeic-keratosis/ 8 Sterling JC, Gibbs S, Haque Hussain SS, Mohd Mustapa MF, Handfield-Jones SE. British on 1 August 2019 by Anne Meneghetti. Protected copyright. • Bowen’s disease (squamous cell carcinoma in situ)—usually Association of Dermatologists’ guidelines for the management of cutaneous warts 2014. a red keratotic patch of skin, often on the lower leg and can vary http://www.bad.org.uk/search?search=wart 9 Kwiek B, Schwartz RA. Keratoacanthoma (KA): An update and review. J Am Acad Dermatol in size. Transformation to an invasive squamous cell cancer can 2016;74:1220-33. 10.1016/j.jaad.2015.11.033 26853179 occur in up to 3% of patients with a squamous cell carcinoma 10 de Berker D, McGregor JM, Mohd Mustapa MF, Exton LS, Hughes BR. British Association 11 of Dermatologists’ guidelines for the care of patients with actinic keratosis 2017. http:// in situ and therefore it is actively treated. www.bad.org.uk/shared/get-file.ashx?id=4289&itemtype=document 11 Bowen’s disease. Primary Care Dermatology Society. http://www.pcds.org.uk/clinical- Learning points guidance/bowens-disease Published by the BMJ Publishing Group Limited. For permission to use (where not already •Consider squamous cell cancer in cutaneous keratotic horn. granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions

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