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E-IJD CORRESPONDENCE |
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| Year : 2016 | Volume
: 61
| Issue : 1 | Page : 124 |
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| Multiple giant cutaneous horns in a renal transplant recipient |
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CV Dincy Peter1, Anne Jennifer2
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 Publication | 15-Jan-2016 |
Correspondence Address:
C V Dincy Peter
Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
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 |
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
Click here to view |
 | 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
Click here to view |
 | 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)
Click here to view |
 | 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)
Click here to view |
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]
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Korkut T, Tan NB, Oztan Y. Giant cutaneous horn : a0 patient report. Ann Plast Surg 1997;39:654-5.  |
| 2. | Bart RS, Andrade R, Kopf AW. Cutaneous horns. A clinical and histopathologic study. Acta Derm Venereol 1968;48:507-15. [ PUBMED] |
| 3. | Schosser RH, Hodge SJ, Gaba CR, Owen LG. Cutaneous horns : a0 histopathologic study. South Med J 1979;72:1129-31. [ PUBMED] |
| 4. | Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol 1991;124:449-52. |
| 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. |
| 6. | Kumaresan M, Kumar P, Pai MV. Giant cutaneous horn. Indian J Dermatol 2008;53:199-200. [ PUBMED]  |
| 7. | Saraf S. Sebaceous horn: An interesting case. Indian J Dermatol 2007;52:59-60. |
| 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. [ PUBMED] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1] |
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