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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.85 no.2 Rio de Janeiro Mar./Apr. 2010
Cutaneous horn: a retrospective histopathological study of 222 cases*
Sônia Antunes de Oliveira ManteseI; Priscila Miranda DiogoII; Ademir Rocha (in memoriam)III; Alceu Luiz Camargo Villela BerbertIV; Ana Karolina Mariano FerreiraV; Thais Camargos FerreiraV
Professor of Dermatology, Federal University of Uberlândia. PhD of Dermatology
from the Federal University of São Paulo (UNIFESP)- São Paulo
IIUndergraduate medical student, Federal University of Uberlândia (UFU)-Uberlândia (MG), Brazil
IIIProfessor of Especial Pathology II, Federal University of Uberlândia (UFU)-Uberlândia (MG), Brazil
IVAssistant Professor of Dermatology, Federal University of Uberlândia, MSc of Clinical Medicine from the Federal University of Uberlândia(UFU) - Uberlândia(MG), Brasil
VMedical doctor graduated from the Federal University of Uberlândia (UFU) Uberlândia(MG), Brazil
Cutaneous horn is a keratotic, conical and circumscribed lesion that can hide
both benign or malignant lesions.
OBJECTIVE: To identify,from a histopathological point of view, the main clinical dermatoses that are presented ,from a clinical point of view, as cutaneous horn.
METHODS: RETROSPECTIVE HISTOPATHOLOGICAL STUDY OF 222 CASES OF CUTANEOUS HORNS THAT WERE CLASSIFIED AS SUCH BY ANATOMICAL-PATHOLOGICAL REPORTS OF THE UNIVERSITY HOSPITAL (HOSPITAL DE CLÍNICAS DE UBERLÂNDIA) FROM 1990 TO 2006.
RESULTS: The average age of patients was 67,42. The female sex was more affected (64,86%). The average time of clinical evolution was 16,92 months. Lesions were mostly frequent located on the head (35,14%) and upper limbs (31,08%). Histopathological analysis considered 41,44 % of the lesions as benign and 58,56% as pre-malignant or malignant among the 222 cases of cutaneous horns studied. Within the group of pre-malignant lesions, actinic keratosis was found in 83,84% of the cases; within the group of malignant lesions, squamous cell carcinoma was found in 93,75% of the cases.
CONCLUSIONS: This study showed that the majority of cutaneosus horns occured in areas of the body that are exposed to the sun, predominantly head and upper limbs. Considering the high frequency of pre-malignant lesions and also the presence of malignant lesions it is suggested surgical exeresis followed by histopathological study of the cutaneous horns for confirmation of specific diagnosis.
Keywords: Skin diseases; Skin neoplasms; PathologY
The expression cutaneous horn (cornu cutaneum) is the morfological designation for the conical, predominantly keratotic protuberance similar to the horn of an animal1-3. Primary diagnosis, in most cases, is suggested by the aspect and clinical development of the lesions4 that can be one and only or multiple, of white or yellowish5 staining, straight or curve forme occurring usually in regions exposed to the sun, especially the face6-8.
From a histopathological point of view lesions can be classified as benign, premalignant and malignant 9-13 according to the cellular pattern on the basis of the cutaneous horn. In general, malignant lesions tend to be harder on their bases due to inflammatory process5,14,15. The presence of malignant lesions in other parts of the body of patients increases largely the probability of the basis of the cutaneous horn to present premalignant or malignant1,16,17 alterations.
The age group in which cutaneous horn is most prevailing is above 50 years of age, for both sexes1,15-17 and the average age for the occurence of lesions in patients with premalignant and malignant lesions is around six years more than that of patients with benign alterations15.
It is more commonly observed the appearance of cutaneous horns in the regions of the body closer to the higher areas of the face and next to the external ear4. It also occurs on the scalp, upper limbs, stem, lower limbs and penis, although in a smaller scale16,18-23.
The procedure used for the treatment of cutaneous horn is surgical excision followed by histopathological examination for confirmation of specific diagnosis5,7,16,17,24,25. This procedure is indicated not only because it is an immediate treatment but also because it considers the possibility of the existance of a premalignant or malignanton lesion on the basis with developmental tendencies. The surgical excision should be as conservative as possible and should also garantee a sufficient security margin8,26,27.
Some studies of histopathological lesions clinically identified as cutaneous horns showed predominance of benign lesions22.214.171.124 while others showed a predominancy of a malignant or premalignant17.29 substratum.
The fact that there is little research being carried out about the theme, the developmental characteristic of the disease and the fact that there is a connexion between the disease and malignant tumours motivated the accomplishment of this study.
Besides that, an epidemiologic study could efficiently and objectively contribute to an early diagnosis and to the development of preventive models.
The present study is a retrospective study that aims at recognising the histopathologic lesions on the basis of cutaneous horns found in patients who sought for medical assistance in the Dermathology service of the University Hospital(Hospital de Clínicas de Uberlândia) during the period 1990 to 2006. It also aims at delimiting an epidemiologic profile of patients that presented a clinical-histopathologic diagnosis of cutaneous horn within the previously mentioned period.
Medical reports of patients who had clinical diagnosis and had had surgical excisions of cutaneous horn lesions and also that had had their respective histopathologic reports and plates reviewed, during the period 1990 to 2006 were analyzed.
A standardized card was designed for this study and it contained data collected from patientsrecords such as age; sex; gradual development of the disease; diameters of the base and height of the lesions; probable etiological diagnosis and the coexistence of premalignant or malignant lesions. As information about the diameter of the base and height of the lesions had not been recorded in the control cards of patients, they were measured through microscopic histopathologic analysis of plates.
Data obtained was analysed, related and made available for visual display in charts/tables and graphs, using computer software (Microsoft Word and Microsoft Excel).
Qualitative data was presented in terms of absolute frequency and percentage frequency and the results of the survey were also presented in tabular form considering absolute and average deviation and standard deviation.
As for age, DAgostino and Kolmogorov- Smirnov tests were used.
As for the distribution of nonparametric values (gradual development of the disease, height and base of the lesions) were used the median and first quartile (or lower quartile) and third quartile (or upper quartile). Q-statistic was used to verify the possible associations among variables using the BioEstat 5.0 software, considerig as significance level p< 0,05.
Out of a total number of 21.085 cutaneous biopsies carried out during the period 1996 to 2000, 304 (1,44%) had previous clinic diagnosis of cutaneous horn although histopathogic exams confirmed as cutaneous horns 222 lesions of 211 patients. All data from this research refer to those 222 lesions with a histopathogic definition of cutaneous horn.
Within the 222 lesions, 92 cutaneous horns (41,44%) presented benign histopathologic alterations on their bases being the most frequent: viral wart (29; 31,52%), keratic acanthoma (24; 26,09%), keratosis seborrhoeica (20; 21,74%), benign epithelial hyperplasia (6;6,52%), trichilemmoma (3; 3,26%) and others (10; 10,87%) (Graph 1). One hundred and fourteen lesions (51,35%) were premalignant and 16 (7,21%) malignant (Table 1).
The average age of patients the moment the diagnosis was made was 67,42 years of age (standard deviation of Â±18,36 varing from 14 to 95 years of age). There was no sifnificant divergency between data obtained and a normal curve.
The age group with a higher prevalence of cutaneous horn was the one with patients varing from 50 to 89 years of age with predominance of premalignant histopathologic lesions on the basis (96; 84,21%); it was also observed a high frequency of benign lesions (76; 83,51%). There was no record of only case. (Graph 2).
144 lesions (64,68%) were detected in female patients and 78 lesions (35,14%) in male patients. The distribution of benign, premalignant and malignant lesions in relation to the female and male sexes was respectively: benign (60 and 27,03%; 32 and 14,41%), premalignant (72 and 32,43%; 42 and 18,92%) and malignant (12 and 5,41%, 4 and 1,80%) (Graph 3).
Premalignant lesions occurred predominantly on the head, upper limbs and stem while lower limbs presented more benign lesions of histopathologic base. 26 cases were not recorded: 13 benign lesions of histopathologic base, 11 premalignant and 2 malignant(Graph 4).
Cutaneous horns were more commonly found in female patients. 39,58% of these women presented them on the upper limbs and 31,44% on the head. There was no information about where these lesions were found in the control cards of 17 patients.
41% of the male patients developed lesions located on the head and 24,64% on the stem. There was no information about where these lesions were found in the control cards of 9 patients (Graph 5).
Concerning the color of skin, in 169 patients it was white (80,10%) and in 33 patients (15,64%) it was not white. In nine control cards (4,26%) there was no information about the color of skin of patients. From those 169 patients mentioned above, 94 of them (55,62%) had premalignant lesions of histopathologic base, 63 (37,28%) benign and 12 (7,10%) malignant.
Within the above mentioned group of 33 patients whose color of skin was classified as "not white", 18 (54,55%) had premalignant lesions, 12 (36,36%) benign and 3 (9,09%) malignant (Table 2).
The length of time of the gradual development of the disease varied from one week to 240 months (average of 16,92 monthsÂ± 29,43 months).
Out of the total number of patients (211), 199 had one only lesion and 12(5,69%) had multiple lesions.
Among the 211 patients with cutaneous horns, it was possible to measure the diameter of height in 196 patients and in 203 patients it was possible to measure the diameter of the base of the lesion. Height varied between 0,2 to 4 cm (median of 0,6, interquartile amplitude from 0,4 to 0,83 cm), and the diameter of the base varied between 0,1 and 4 cm (median of 0,5 cm, interquartile amplitude from 0,3 to 0,8 cm) (Tables 3 and 4).
The majority of the patients (179; 84,83%) did not present coexistence of other lesions. Besides cutaneous horns, it was found in the control cards the following diagnoses: basal cell carcinoma (CBC) (11 patients; 5,20%), hypertrophic actinic keratosis (9 patients; 4,26%), squamous cell carcinoma (CEC) (6 patients; 2,83%), actinic keratosis (4 patients; 1,92%), Bowen disease (1 patient; 0,48%), CEC and CBC (1 patient; 0,48%).
From all the control cards analyzed only in 27 of these cards there reports of symptoms the moment the clinical diagnosis of cutaneous horn was made. The most common symptoms reported were local pain (5; 18,51%) and itch (6; 22,22%).
Cutaneous horn is a clinical denomination which describes a highly keratotic, conical and circumscribed lesion, white or yellowish in color, that varies from a few milimetres to many centimetres and that can hide either benign or malign lesions. Therefore, what is really important is not the cutaneous horn itself but the subjacent disease. As a great number of cases of cutaneous horns corresponds to premalignant and malignant lesions it is justifiable the concern with its surgical excision for the histopathologic diagnosis of its base16.
Some studies appointed a probable association between the length of time of the gradual development of the disease and the diameter of the base of the lesion with the histopathological type. It was observed that the longer the time to develop the disease and the bigger its base, the higher the risk of the lesions being premalignant or malignant17. There are reports about a direct correlation between the size of the base of the lesion and its malignance1, fact not confirmed by some authors17. In this research there was a larger number of premalignant lesions and larger base suggesting a possible correlation, which could be better assessed in later studies as in the clinical cards of the patients there is information about the measures of the base and height of cutaneous horn lesions.
The present casuistry appointed a larger number of cases with premalignant histopathologic characteristics (51,35%), followed by benigm lesions (41,44%). It was found a smaller frequency of associations with malignant lesions (7,21%). These findings were similar to the findings of Castilho et al17 who, in a retrospective study of 77 cases, observed 46% of benign lesions, 41% of premalignant lesions and 13% of malignant. Yu et al found predominance of benign histopathological lesions (61%) in relation to the premalignant and malignant lesions (39%) in the cases of cutaneous horns studied. Festa and cols16, in a retrospective study of 514 cases of cutaneous horn, found 25,4% of lesions with histopathologic characteristics of benignity, 49,3% of premalignant lesions and 25,3% of malignant lesions.
The benign lesions more frequently found on the base of cutaneous horns in this research were viral wart; keratic acanthoma and keratosis seborrheica. Bart et al1, among benign lesions, found keratosis seborrheica; benign epithelial hyperplasia and angioma; Yu et al5, benign epithelial hyperplasia, basal cell papiloma and vulgar wart, Festa and cols,wart; benign epithelial hyperplasia and keratosis seborrheica.
Lesions with malignant histopathologic base corresponded to 7,21 % of the total number of cases, and the squamous cell carcinoma was the most frequent lesion found (93,75%), fact which was in accordance with the dermatologic literature16,17.
Although there was divergency in relation to the degree of malignity, various authors detected actinic keratosis as the main lesion on the base of cutaneous horn15-17,29,30 being the cutaneous horn classified by some authors as a especial type of hypertrophic actinic keratosis7. Actinic keratosis, also known as senile keratosis, results from the proliferation of atypical keratinocytes as a consequence of long exposition to ultraviolet radiation and it has been considered a premalignant lesion which may evove to squamous cell carcinoma1,4,7,25.However, Duncan and Leffell7 considered actnic keratosis already as squamous cell carcinoma in progress. Keratosis actinic was found in this study as the most frquent hyspathologic base (39,64%) of the total number of cases, and among these, 4,39% alreday presented hystopathologic alterations of transformation into squamous cell carcinoma. These numbers were similar to the numbers Schosser et al29 and Festa and cols16 reported.
Cutaneous horn occurs mainly in individuals who are above 50 years of age, in both sexes1,15-17, probably due to a major actnic and neoplastic degeneration occurring in elderly people16. Studies describe that the average age of patients with premalignant and malignant lesions is around 6 years more than that of patients with benign alterations and therefore the chances of finding a malignant substratum on the base of a cutaneous horn would increase proportionally with the age15,17. In this present research the age group which presented a higher prevalence of cutaneous horn corresponding to premalignant and malignant lesions was that of patients who varied from 50 to 89 years of age. In a similar way, Festa and cols16 showed this rising tendency as age increases probably due to more exposition of the skin to sun light. In the present casuistry, however, there were no significant differences as far as age is concerned in relation to malignancy of lesions.
Although some studies presented the male group as the group with a higher prevalence of cutaneous horn more recent studies present the female group as the one that was more taken by it. Contrasting with some series1,15,17 , it was found in this present study a higher frequency of cutaneous horn in the female sex, with a predominance of lesions with a premalignant histopathologic base. The predominance of cutaneous horns in the female sex might be due to the fact that women seek more medical treatment than men for esthetics reasons as it was also suggested by Festa and cols16. In the medical literature benign lesions are more frequent in women and, premalignant and malignant ones in men15-17.
In the cases analyzed cutaneous horns were more frequently located on the head (35,13%) and upper limbs (31,08%) in accordance with dermatologic literature15-17 being the majority of the lesions lesions situated in areas of a higher actinic damage. Other series showed that the body areas where it is mostly common observed the occurence of them are the upper regions of the face and next to the external ear4. Lesions on the stem and lower limbs were also observed but in smaller scale. Some studies showed that benign lesions16,17 are most frequently found in areas less exposed to the sun, like the lower limbs. On the other hand, areas more exposed to the sun such as nose, dorsum of the hands, scalp, forearm and arm have twice more chances of presenting premalignant or malignant lesions on the base of the cutaneous horn if compared to any other part of the body15 According to Festa and col16 the areas of the body most frequently affected, in decreasing order of importance were: malar, frontal, dorsum of the nose, neck, auricularis, lips and upper eyelid.
Cutaneous horn was defined by Bart et al 1as a hyperkeratotic lesion in which height corresponds to at least half of the diameter of its base. However, in casuistry presented and confirmed by hystopathologic examination as being cutaneous horn, this proportion only occured in 23,98% of the lesions. It is important to point out that there is possibility of it being higher if its clinical progression had not been interrupted by surgical excision.
In this study it was found as most frequent histophatologic base the actinic keratosis and as most affected areas the head and upper limbs, areas more exposed to sun light. Therefore, it is essential to inform patients about photoprotection as preventive action bearing in mind that ultraviolet radiation is the principal physical factor which induces cutaneous carcinogenesis.
The majority of the cutaneous horns analyzed in this study appeared either on the head or on the upper limbs, areas which are more exposed to sun light. Daily use of photoprotectors could help to prevent the disease by minimizing the action of ultraviolet radiation that is widely known as an important factor in the genesis of cutaneous tumors. Considering the high frequency of premalignant and malignant lesions in this research, surgical excision followed by histopathological studies of the cutaneous horns is suggested to confirm the specific diagnosis of its base.
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Received on July
7th, 2009. *
The present study was carried out in the services of Dermatology and Pathology
of the University Hospital( Hospital de Clínicas de Uberlândia)
, Federal University of Uberlândia (UFU) - Uberlândia(MG), Brazil.
Approved by the Peer Review Board and accepted for publication on July 7th, 2009.
Conflict of interest: None
Financial funding: None
Received on July
* The present study was carried out in the services of Dermatology and Pathology of the University Hospital( Hospital de Clínicas de Uberlândia) , Federal University of Uberlândia (UFU) - Uberlândia(MG), Brazil.