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E-IJD CORRESPONDENCE
Year : 2016  |  Volume : 61  |  Issue : 1  |  Page : 124
Multiple giant cutaneous horns in a renal transplant recipient


1 Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Pathology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication15-Jan-2016

Correspondence Address:
C V Dincy Peter
Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.174156

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How to cite this article:
Dincy Peter C V, Jennifer A. Multiple giant cutaneous horns in a renal transplant recipient. Indian J Dermatol 2016;61:124

How to cite this URL:
Dincy Peter C V, Jennifer A. Multiple giant cutaneous horns in a renal transplant recipient. Indian J Dermatol [serial online] 2016 [cited 2020 Sep 23];61:124. Available from: http://www.e-ijd.org/text.asp?2016/61/1/124/174156


Sir,

Cutaneous horn is a clinical description of a hyperproliferation of compact keratin in response to a wide range of underlying benign and malignant pathologic changes. Here, we present a renal transplant recipient with multiple giant cutaneous horns.

A 51-year-old gentleman, presented with multiple warty lesions over the body of 5 years duration. He was on prednisolone (10 mg) and azathioprine (125 mg) following renal transplantation 12 years back. He had a large nontender right inguinal lymph node and multiple small axillary lymph nodes. There were multiple cutaneous horns of varying sizes over the forehead, right external ear, arm, and back. Keratinous outgrowths were seen arising from flesh colored nodules in these areas. The compact keratinous masses formed curved structures over the ear and arm and conical structure measuring about 6.5 cm over the back [Figure 1] and [Figure 2]. There were multiple hyperpigmented keratotic papules and plaques seen all over the body. Large verrucous plaque with peripheral hyperpigmented borders were seen over shoulder region, neck, and dorsa of fingers. The histopathology of all the cutaneous horns revealed keratoacanthoma [Figure 3] and [Figure 4], the plaque over the shoulder region showed Bowen's disease. The verrucous lesion (neck) and the inguinal lymph node revealed poorly differentiated squamous cell carcinoma. He was initiated on chemotherapy (cisplatin, 5-fluorouracil) along with radiotherapy. He was lost to follow-up.
Figure 1: (a) Curved compact hyperkeratosis arising from flesh colored nodule over external ear, (b) flesh colored nodule over forehead with central hyperkeratotic plug

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Figure 2: (a) Curved compact hyperkeratosis arising from flesh colored nodule over arm on a background of hyperpigmented stuck on papules, (b) conical compact hyperkeratosis arising from flesh colored nodule over back

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Figure 3: (a) The typical crateriform architecture of keratoacanthoma with a peripheral collarette (H and E, ×200), (b) well differentiated eosinophilic to pale staining glassy abundant cytoplasm characteristic of keratoacanthoma (H and E, ×400)

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Figure 4: (a) Keratin filled crater (H and E, ×50), (b) squamous cells with abundant glassy cytoplasm (H and E, ×100), (c and d) squamous cells with abundant glassy cytoplasm (H and E, ×200)

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Cutaneous horns are hard, conical, dense hyperkeratotic protrusion and resemble the horn of an animal. [1],[2] The height of a cutaneous horn should be 1΍ times its greatest diameter of the base. [2] The horn can be cylindrical, conical, pointed, corrugated transversely and longitudinally, or curved like a Ram's horn. They rarely grow beyond 1 cm. Giant cutaneous horns are extremely rare. The sites of predilection include chronically sun damaged skin of the face, ears, dorsa of hands in older individuals and very rarely, the penis. There can be underlying benign, premalignant, and malignant cutaneous diseases. Surrounding inflammation, infiltration, and tenderness of the base, wide base, low height to base ratio favor a malignant etiology. The conditions that can be seen at the base of a cutaneous horn have been shown in [Table 1]. Actinic keratoses have been reported as the most common horn base entity (37.4%) in a study of 230 horns. [3] In another study of 643 cutaneous horns, 61% had a benign base pathology, 23% had a premalignant, and 16% had a malignant base pathology. [4] Giant cutaneous horns have been reported over verruca vulgaris, burns scar, seborrheic keratosis, and squamous cell carcinoma. [5],[6],[7],[8]
Table 1: Underlying pathology that can be seen in a cutaneous horn


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There is a greater risk of malignant and premalignant skin lesions such as actinic keratoses, Bowen's disease, keratoacanthomas, squamous cell carcinomas in renal transplant recipients. All these entities can form a cutaneous horn. The risk of malignant skin lesions in renal transplant recipients is related to the degree of immunosuppression. Multiple giant cutaneous horns and the simultaneous presence of keratoacanthoma, squamous cell carcinoma, and Bowen's disease in a renal transplant recipient, as seen in our patient is a rare association.

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Korkut T, Tan NB, Oztan Y. Giant cutaneous horn : a0 patient report. Ann Plast Surg 1997;39:654-5.  Back to cited text no. 1
    
2.
Bart RS, Andrade R, Kopf AW. Cutaneous horns. A clinical and histopathologic study. Acta Derm Venereol 1968;48:507-15.  Back to cited text no. 2
[PUBMED]    
3.
Schosser RH, Hodge SJ, Gaba CR, Owen LG. Cutaneous horns : a0 histopathologic study. South Med J 1979;72:1129-31.  Back to cited text no. 3
[PUBMED]    
4.
Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol 1991;124:449-52.  Back to cited text no. 4
    
5.
Wollina U, Schönlebe J. Giant keratoacanthoma-like cutaneous horn of the upper leg: A case report. Acta Dermatovenerol Alp Pannonica Adriat 2010;19:29-30.  Back to cited text no. 5
    
6.
Kumaresan M, Kumar P, Pai MV. Giant cutaneous horn. Indian J Dermatol 2008;53:199-200.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Saraf S. Sebaceous horn: An interesting case. Indian J Dermatol 2007;52:59-60.  Back to cited text no. 7
  Medknow Journal  
8.
Leelavathy B, Kemparaj T, Sathish S, Khadri SI. Squamous cell carcinoma arising from a giant cutaneous horn : a0 rare presentation. Indian J Dermatol 2015;60:107.  Back to cited text no. 8
[PUBMED]  Medknow Journal  


    Figures

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