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Egyptian Dermatology Online Journal
Vol. 10 No 2: 8, December 2014
Multiple Keratoacanthoma, A Case Report
Tawfik S, Sultan A, Amer H, Sadek AM, Mahmoud S.
Cairo Hospital for Dermatology & Venereology "AlHaud AlMarsoud", Cairo, Egypt.
Egyptian Dermatology Online Journal 10 (2): 9, December 2014
Corresponding Author:Ahmed Sadek
E-mail : [email protected]
Summary
A 40-year-old male presented with itchy small nodules over the thigh, scrotum and pubic area
of gradual onset and progressive course of 9 months duration. Histopathologic examination
revealed horn filled crater with lip like projection at the side of the crater.
Introduction
Keratoacanthoma (KA) is a relatively common low-grade malignancy that originates in the
pilosebaceous glands and pathologically resembles squamous cell carcinoma (SCC). In fact,
strong arguments support classifying KA as a variant of invasive SCC [1]. In most
pathology/biopsy reports, dermatopathologists refer to the lesion as "squamous cell carcinoma,
keratoacanthoma-type".
KA is characterized by rapid growth over a few weeks to months, followed by spontaneous
resolution over 4-6 months in most cases. KA reportedly progresses, although rarely, to
invasive or metastatic carcinoma; therefore, aggressive surgical treatment often is advocated.
Whether these cases were SCC or KA, the reports highlight the difficulty of distinctly
classifying individual cases [2, 3, 4, and 5].
Case Presentation
A 40-year-old-male, working as a car mechanic, presented with itchy small nodules over the
groin area of gradual onset and progressive course of 9 months duration. On examination, there
were multiple pinkish-red dome-shaped firm nodules which were sharply marginated with
raised borders and measuring 0.5 to 1mm. The closer inspection of the lesions revealed smooth
crater filled with central keratin plug that was projecting like a horn on the smooth shiny
surface of the nodules which were localized to the skin of the thigh, scrotum and pubic area.
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Egyptian Dermatology Online Journal
Vol. 10 No 2: 8, December 2014
Fig 1: multiple pinkish-red dome-shaped firm well defined nodules affecting the
scrotum and groin
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Egyptian Dermatology Online Journal
Vol. 10 No 2: 8, December 2014
Fig 2: The well-defined nodules show a smooth crater filled with central keratin
plug.
Differential diagnosis included: giant warts, multiple keratoacanthoma, prurigo nodularis and
squamous cell carcinoma. Histopathologic examination revealed horn like crater surrounded by
lip like projection and the strands of the epidermis were protruding in to the dermis. Those
findings were consistent with diagnosis of multiple keratoacanthoma.
Fig 3: H&E stained specimen form the groin lesions showing horn like crater
surrounded by lip like projection and the strands of the epidermis were protruding
in to the dermis (10x)
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Vol. 10 No 2: 8, December 2014
Discussion
Keratoacanthoma (KA) typically grows rapidly, attaining 1-2 cm within weeks, followed by a
slow involution period lasting up to 1 year and leaving a residual scar if not excised
preemptively. Since expedient therapy almost always is instituted, the true natural course of the
tumor cannot be confirmed with certainty.
Physical findings in KA are limited to the skin. The lesions typically are solitary beginning as
firm, roundish, skin-colored or reddish papules that rapidly progress to dome-shaped nodules
with a smooth shiny surface and central crateriform ulceration or keratin plug that may project
like a horn. Most keratoacanthomas occur on sun-exposed areas. The face, neck, and dorsum of
the upper extremities are common sites, while truncal lesions are rare.
Both sunlight and chemical carcinogens have been implicated as pathological factors in growth
of the tumor. Trauma, human papilloma virus, genetic factors, and immunocompromised status
also have been implicated as etiologic factors. In this case, the patient being a car mechanic
exposed to tar and trauma, the lesions developed in hidden areas of the body other than sun
exposed ones.
KA is less common in darker-skinned individuals, rarely affects persons less than 20 years, the
incidence increases with age and male-to-female ratio for is 2:1. It may be a component of
Muir-Torre syndrome, which is a cancer-associated genodermatosis with multiple sebaceous
neoplasms (adenomas, epitheliomas, carcinomas, Keratoacanthomas), and gastrointestinal
malignancies (most commonly colon), although other carcinomas have been reported
(genitourinary, pulmonary, endometrial). When Muir-Torre syndrome is diagnosed, an ageappropriate cancer screening workup is indicated. An approximately equal number of internal
malignancies are diagnosed before and after the cutaneous neoplasm. These internal
malignancies tend to be low grade, but early diagnosis is important. Colonoscopy, rather than
flexible sigmoidoscopy, is recommended, since the colon cancer frequently is found in the right
ascending colon, proximal to the hepatic flexure.
KA is believed to have a good prognosis; however, it has been reclassified as SCC-KA type to
reflect the difficulty in histological differentiation, as well as the uncommon but potentially
aggressive nature of KA. It infrequently presents as multiple tumors and may enlarge (5-15
cm), become aggressive locally, or rarely, metastasize [6, 7].
The treatment includes surgical excision (primary intervention), radiotherapy and medical
treatment using systemic steroids, systemic retinoids, intralesional methotrexate, 5-fluorouracil
and bleomycin.
References
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Surg. 1998; 40 :469-72.
2. Schwartz RA. Keratoacanthoma. J Am Acad Dermatol. 1994; 30: 1-19.
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3. Magalhães RF, Cruvinel GT, Cintra GF, Cintra ML, Ismael AP, de Moraes AM. Diagnosis
and follow-up of keratoacanthoma-like lesions: clinical-histologic study of 43 cases. J Cutan
Med Surg. 2008; 12: 163-73.
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Dermatol. 1996; 35: 648-50.
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multiple eruptive keratoacanthomas: case report and review of a controversial therapy.
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