Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Cutaneous Horn

  • Author: Patrick S Rush, DO; Chief Editor: William D James, MD  more...
 
Updated: Apr 27, 2015
 

Background

Cutaneous horn is a clinical diagnosis referring to a conical projection of cornified material above the surface of the skin that resembles a miniature horn. Historically, it is also referred to by its Latin name, cornu cutaneum, and less commonly and more eponymously, as cornu cutaneum of Rokitansky, after the German pathologist Baron Carl von Rokitansky.[1]

The horn is composed of compacted keratin. The base of the horn may be flat, nodular, or crateriform. Various histologic lesions have been documented at the base of the keratin mound, and histologic confirmation is often necessary to rule out malignant changes. No clinical features reliably distinguish between benign and malignant lesions. Tenderness or bleeding at the base and lesions of larger size, however, favor malignancy.

Historically, London surgeon Everard Home was credited with the earliest descriptions of cutaneous horns in 1791. However, cases from as early as the 16th and 17th centuries have been described in the medical literature. Most notable among these was by the Danish anatomist Thomas Bartholin in 1670.[2]

The image below depicts a typical presentation of a cutaneous horn.

A typical presentation of a cutaneous horn on the A typical presentation of a cutaneous horn on the ear.

See Nonmelanoma Skin Cancers You Need to Know, a Critical Images slideshow, to help correctly identify these lesions.

Next

Pathophysiology

Cutaneous horns usually arise on sun-exposed skin but can occur even in sun-protected areas. The hyperkeratosis that results in horn formation develops over the surface of a hyperproliferative lesion. While the protruding, compact keratin may be the most prominent clinical feature, it is the process at the base of the lesion that is of most importance.

Most often, this is a benign verruca or seborrheic keratosis; however, cutaneous horns complicate a number of conditions, including premalignant actinic keratoses and frank malignancy. More than half of all of the inciting lesions at the base of cutaneous horns are benign, and a further 23-37% are derived from actinic keratoses. A malignancy has been reported at the base of a cutaneous horn in up to 20% of lesions.[3, 4, 5, 6]

The true pathobiology for the formation of cutaneous horns over each underlying base lesion remains unknown.

Benign lesions associated with cutaneous horns include angiokeratoma, angioma, benign lichenoid keratosis, cutaneous leishmaniasis,[7] dermatofibroma, discoid lupus,[8] infundibular cyst, epidermal nevus, epidermolytic acanthoma, fibroma, granular cell tumor,[9] inverted follicular keratosis, keratotic and micaceous pseudoepitheliomatous balanitis, organoid nevus, prurigo nodularis, pyogenic granuloma,[10] sebaceous adenoma, seborrheic keratosis, trichilemmoma,[11] and verruca vulgaris.[12]

Lesions with premalignant or malignant potential that may give rise to cutaneous horns include adenoacanthoma, actinic keratosis, arsenical keratosis, basal cell carcinoma,[13] Bowen disease, Kaposi sarcoma,[14] keratoacanthoma,[15, 16] malignant melanoma,[17] Paget disease,[18] renal cell carcinoma,[19] sebaceous carcinoma,[20, 21] and squamous cell carcinoma.[22]

Previous
Next

Epidemiology

Frequency

International

While these lesions are almost uniformly referred to as “rare” in the literature, neither the true incidence nor prevalence has been well described.[15, 23]

Mortality/Morbidity

Cutaneous horns often cause little physical discomfort unless struck or if arising in areas prone to physical irritation. Cosmetically, however, they can cause significant concern for the patient, as they can be socially disconcerting. In fact, historically, prior to modern medicine, people with giant cutaneous horns had been persecuted as having “magical power” and were often displayed as sideshow attractions.[15, 2]

The lesion at the base of the keratin mound is benign in the majority of cases. Malignancy is present in up to 20% of cases, with squamous cell carcinoma being the most common type. The incidence of squamous cell carcinoma increases to 33% when the cutaneous horn is present on the penis.[24, 25] Tenderness at the base of the lesion is often a clue to the presence of a possible underlying squamous cell carcinoma.[4] Bleeding at the base of the lesion, as well as larger size, have been suggested as an indication of underlying malignancy.[2, 26]

Race

Because of the proportion of cutaneous horns that arise from actinic keratoses and squamous cell carcinomas, races with lighter complexions tend to be preferentially affected. However, several cases of cutaneous horns have been reported in patients of darker complexion, including those of African and Mexican descent.[1, 27, 28]

Sex

A sex predilection for cutaneous horn has not been shown consistently. In men, the rate of malignancies at the base of the lesion is increased when compared with age-matched women, and some studies also have shown premalignant lesions to be slightly more common in men.[26]

Age

The peak occurrence of cutaneous horn is in persons aged 60 years to mid 70s. Lesions with malignancy at the base occur more frequently in patients aged 70 years or older.

Previous
 
 
Contributor Information and Disclosures
Author

Patrick S Rush, DO Chief Resident, Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics

Patrick S Rush, DO is a member of the following medical societies: American Society for Clinical Pathology, American Society of Dermatopathology, College of American Pathologists, United States and Canadian Academy of Pathology, International Society of Bone and Soft Tissue Pathology, Digital Pathology Association, Wisconsin Society of Pathologists

Disclosure: Nothing to disclose.

Coauthor(s)

Clay J Cockerell, MD Director, Clinical Professor, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern Medical Center

Clay J Cockerell, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, International AIDS Society, International Academy of Pathology, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, Society for Investigative Dermatology, Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

R Stan Taylor, MD The JB Howell Professor in Melanoma Education and Detection, Departments of Dermatology and Plastic Surgery, Director, Skin Surgery and Oncology Clinic, University of Texas Southwestern Medical Center

R Stan Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Fiona Larsen, MBChB, FRACP Dermatologist/Dermatopathologist, Private Practice; Consultant Dermatologist, Waitemata District Healthboard

Disclosure: Nothing to disclose. Carlos Ricotti, MD Fellow, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern School of Medicine

Carlos Ricotti, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, and International Society of Dermatopathology

Disclosure: Nothing to disclose.

Nancy Silvis, MD Medical Director of Dermatology Clinic, Assistant Professor, Department of Internal Medicine, Adobe Dermatology

Disclosure: Nothing to disclose.

References
  1. Durkee S. Human Horn (Cornu Cutaneum of Rokitansky). Boston Med Surg J. 1866 Feb. 74:9-11.

  2. Bondeson J. Everard Home, John Hunter, and cutaneous horns: a historical review. Am J Dermatopathol. 2001 Aug. 23(4):362-9. [Medline].

  3. Kumar S, Bijalwan P, Saini SK. Carcinoma buccal mucosa underlying a giant cutaneous horn: a case report and review of the literature. Case Rep Oncol Med. 2014. 2014:518372. [Medline]. [Full Text].

  4. Zhou Y, Tang Y, Tang J, Xia B, Dai Y. Progression of penile cutaneous horn to squamous cell carcinoma: A case report. Oncol Lett. 2014 Sep. 8(3):1211-1213. [Medline]. [Full Text].

  5. Fatani MI, Hussain WM, Baltow B, Alsharif S. Cutaneous horn arising from an area of discoid lupus erythematosus on the scalp. BMJ Case Rep. 2014 Apr 3. 2014:[Medline].

  6. Jhuang JY, Liao SL, Tsai JH, Chang HC, Kuo KT, Liau JY. Extraocular well-differentiated sebaceous tumors with overlying cutaneous horns: four tumors in three patients. J Cutan Pathol. 2014 Aug. 41(8):650-6. [Medline].

  7. Srebrnik A, Wolf R, Krakowski A, Baratz M. Cutaneous horn arising in cutaneous leishmaniasis. Arch Dermatol. 1987 Feb. 123(2):168-9. [Medline].

  8. Dabski K, Stoll HL. Cutaneous horn arising in chronic discoid lupus erythematosus. Arch Dermatol. 1985 Jul. 121(7):837-8. [Medline].

  9. Goette DK. Cutaneous horn overlying granular cell tumor. Int J Dermatol. 1987 Nov. 26(9):598-9. [Medline].

  10. Findlay RF, Lapins NA. Pyogenic granuloma simulating a cutaneous horn. Cutis. 1983 Jun. 31(6):610-2. [Medline].

  11. Brownstein MH, Shapiro EE. Trichilemmomal horn: cutaneous horn overlying trichilemmoma. Clin Exp Dermatol. 1979 Mar. 4(1):59-63. [Medline].

  12. Gould JW, Brodell RT. Giant cutaneous horn associated with verruca vulgaris. Cutis. 1999. 64:111-2. [Medline].

  13. Sandbank M. Basal cell carcinoma at the base of cutaneous horn (cornu cutaneum). Arch Dermatol. 1971 Jul. 104(1):97-8. [Medline].

  14. Onak Kandemir N, Gun BD, Barut F, Solak Tekin N, Ozdamar SO. Cutaneous Horn-Related Kaposi's Sarcoma: A Case Report. Case Report Med. 2010. 2010:[Medline]. [Full Text].

  15. Yang JH, Kim DH, Lee JS, et al. A case of cutaneous horn originating from keratoacanthoma. Ann Dermatol. 2011 Feb. 23(1):89-91. [Medline]. [Full Text].

  16. Wollina U, Schonlebe J. Giant keratoacanthoma-like cutaneous horn of the upper leg: A case report. Acta Dermatovenerol Alp Panonica Adriat. 2010. 19(2):29-30. [Medline].

  17. Cristobal MC, Urbina F, Espinoza A. Cutaneous horn malignant melanoma. Dermatol Surg. 2007 Aug. 33(8):997-9. [Medline].

  18. Dabski K, Stoll HL Jr. Paget's disease of the breast presenting as a cutaneous horn. J Surg Oncol. 1985 Aug. 29(4):237-9. [Medline].

  19. Peterson JL, McMarlin SL. Metastatic renal-cell carcinoma presenting as a cutaneous horn. J Dermatol Surg Oncol. 1983 Oct. 9(10):815-8. [Medline].

  20. Brauninger GE, Hood CI, Worthen DM. Sebaceous carcinoma of lid margin masquerading as cutaneous horn. Arch Ophthalmol. 1973 Nov. 90(5):380-1. [Medline].

  21. Kitagawa H, Mizuno M, Nakamura Y, Kurokawa I, Mizutani H. Cutaneous horn can be a clinical manifestation of underlying sebaceous carcinoma. Br J Dermatol. January 2007. 156(1):180-2. [Medline].

  22. Korkut T, Tan NB, Oztan Y. Giant cutaneous horn: a patient report. Ann Plast Surg. 1997 Dec. 39(6):654-5. [Medline].

  23. Sathyanarayana SA, Deutsch GB, Edelman M, Cohen-Kashi KJ. Cutaneous horn: a malignant lesion? A brief review of the literature. Dermatol Surg. 2012 Feb. 38(2):285-7. [Medline].

  24. Solivan GA, Smith KJ, James WD. Cutaneous horn of the penis: its association with squamous cell carcinoma and HPV-16 infection. J Am Acad Dermatol. 1990 Nov. 23(5 Pt 2):969-72. [Medline].

  25. Vera-Donoso CD, Lujan S, Gomez L, Ruiz JL, Jimenez Cruz JF. Cutaneous horn in glans penis: a new clinical case. Scand J Urol Nephrol. 2009. 43(1):92-3. [Medline].

  26. Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol. 1991 May. 124(5):449-52. [Medline].

  27. Leppard W, Loungani R, Saylors B, Delaney K. Mythology to reality: case report on a giant cutaneous horn of the scalp in an African American female. J Plast Reconstr Aesthet Surg. 2014 Jan. 67(1):e22-4. [Medline].

  28. Nthumba PM. Giant cutaneous horn in an African woman: a case report. J Med Case Rep. 2007 Dec 5. 1:170. [Medline].

  29. Mencia-Gutierrez E, Gutierrez-Diaz E, Redondo-Marcos I, Ricoy JR, Garcia-Torre JP. Cutaneous horns of the eyelid: a clinicopathological study of 48 cases. J Cutan Pathol. 2004 Sep. 31(8):539-43. [Medline].

  30. Vano-Galvan S, Marques A, Munoz-Zato E, Jaen P. A facial cutaneous horn. Cleve Clin J Med. 2009 Feb. 76(2):92-5. [Medline].

  31. Solanki LS, Dhingra M, Raghubanshi G, Thami GP. An innocent giant. Indian J Dermatol. 2014 Nov. 59(6):633. [Medline]. [Full Text].

  32. Uchiyama N, Shindo Y, Saida T. Perforating pilomatricoma. J Cutan Pathol. 1986 Aug. 13(4):312-8. [Medline].

  33. Mantese SA, Diogo PM, Rocha A, Berbert AL, Ferreira AK, Ferreira TC. Cutaneous horn: a retrospective histopathological study of 222 cases. An Bras Dermatol. 2010 Apr. 85(2):157-63. [Medline].

 
Previous
Next
 
A typical presentation of a cutaneous horn on the ear.
An unusually large cutaneous horn extending from the ear.
Medium power view of the mixed hyperparakeratosis and hyperorthokeratotic keratin that makes up the actual horn (hematoxylin and eosin [H&E] stain, original magnification 20x).
Low power view of a cutaneous horn overlying an actinic keratosis (hematoxylin and eosin [H&E] stain, original magnification 20x).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.