eMedicine Specialties > Dermatology > Benign Neoplasms

Cutaneous Horn

Author: Fiona Larsen, MBChB, FRACP, Dermatologist/Dermatopathologist, Private Practice; Consultant Dermatologist, Waitemata District Healthboard
Coauthor(s): Carlos Ricotti, MD, Fellow, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern School of Medicine; Clay J Cockerell, MD, Director, Clinical Professor, Department of Dermatology, Division of Dermatopathology, University of Texas Southwestern Medical Center
Contributor Information and Disclosures

Updated: Jun 18, 2009

Introduction

Background

Cutaneous horn is a clinical diagnosis referring to a conical projection above the surface of the skin that resembles a miniature horn. The base of the horn may be flat, nodular, or crateriform. The horn is composed of compacted keratin. 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 at the base and lesions of larger size favor malignancy.

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. Most often, this is a benign verruca or seborrheic keratosis; or it could be a premalignant actinic keratosis. More than half of all 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.

Benign lesions associated with cutaneous horns include angiokeratoma, angioma, benign lichenoid keratosis, cutaneous leishmaniasis,1 dermatofibroma, discoid lupus,2 infundibular cyst, epidermal nevus, epidermolytic acanthoma, fibroma, granular cell tumor,3 inverted follicular keratosis, keratotic and micaceous pseudoepitheliomatous balanitis, organoid nevus, prurigo nodularis, pyogenic granuloma,4 sebaceous adenoma, seborrheic keratosis, trichilemmoma,5 and verruca vulgaris.6

Lesions with premalignant or malignant potential that may give rise to cutaneous horns include adenoacanthoma, actinic keratosis, arsenical keratosis, basal cell carcinoma,7 Bowen disease, Kaposi sarcoma, keratoacanthoma, malignant melanoma,8 Paget disease,9 renal cell carcinoma,10 sebaceous carcinoma,11,12  and squamous cell carcinoma.13

Mortality/Morbidity

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.14,15 Tenderness at the base of the lesion is often a clue to the presence of a possible underlying squamous cell carcinoma.

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. A cutaneous horn in a black African woman has been reported.16

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.

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.

Clinical

History

Cutaneous horns usually are asymptomatic. Because of their excessive height, they can be traumatized. This may result in inflammation at the base with resulting pain. Rapid growth may occur.

Physical

The distribution of cutaneous horn usually is in sun-exposed areas, particularly the face, pinna, nose, forearms, and dorsal hands.17,18 It is a hyperkeratotic papule with the height greater than one-half the width of the base. Usually a cutaneous horn is several millimeters long.

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

A typical presentation of a cutaneous horn on the ear.

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

A typical presentation of a cutaneous horn on the ear.



An unusually large cutaneous horn extending from ...

An unusually large cutaneous horn extending from the ear.

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An unusually large cutaneous horn extending from ...

An unusually large cutaneous horn extending from the ear.

Causes

Malignant lesions at the base of the horn usually are squamous cell carcinoma, although basal cell carcinoma has been rarely reported. These are predominately precipitated by ultraviolet radiation. Rare tumors at the base include Paget disease of the breast, sebaceous adenoma, and granular cell tumor. The premalignant lesion, actinic keratosis, is a frequent finding at the base. The human papilloma virus most frequently causes infectious etiology resulting in a verruca vulgaris.14 Molluscum contagiosum of the poxvirus group occasionally has formed a cutaneous horn. The only other infectious cause has been leishmaniasis.

Benign idiopathic causes are frequent and include seborrheic keratosis, epidermal nevus, trichilemmal cyst, trichilemmoma, prurigo nodule, and intradermal nevus.

More on Cutaneous Horn

Overview: Cutaneous Horn
Differential Diagnoses & Workup: Cutaneous Horn
Treatment & Medication: Cutaneous Horn
Follow-up: Cutaneous Horn
Multimedia: Cutaneous Horn
References
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References

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

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

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

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

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

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

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

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

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

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

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

  12. 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].

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

  14. 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. Nov 1990;23(5 Pt 2):969-72. [Medline].

  15. 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].

  16. Nthumba PM. Giant cutaneous horn in an African woman: a case report. J Med Case Reports. December 2007;1:170. [Medline].

  17. 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. Sep 2004;31(8):539-43. [Medline].

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

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

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

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Further Reading

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Keywords

cutaneous horn, cornu cutaneum, angiokeratoma, angioma, benign lichenoid keratosis, cutaneous leishmaniasis, dermatofibroma, discoid lupus, infundibular cyst, epidermal nevus, epidermolytic acanthoma, fibroma, granular cell tumor, inverted follicular keratosis, keratotic pseudoepitheliomatous balanitis, micaceous pseudoepitheliomatous balanitis, organoid nevus, prurigo nodularis, pyogenic granuloma, sebaceous adenoma, seborrheic keratosis, trichilemmoma, verruca vulgaris, adenoacanthoma, actinic keratosis, arsenical keratosis, basal cell carcinoma, Bowen disease, Kaposi sarcoma, keratoacanthoma, malignant melanoma, Paget disease, renal cell carcinoma, sebaceous carcinoma, solar keratosis, squamous cell carcinoma

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Contributor Information and Disclosures

Author

Fiona Larsen, MBChB, FRACP, Dermatologist/Dermatopathologist, Private Practice; Consultant Dermatologist, Waitemata District Healthboard
Disclosure: Nothing to disclose.

Coauthor(s)

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.

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 Academy of Pathology, International AIDS Society, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, Society for Investigative Dermatology, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

R Stan Taylor, MD, Professor of Dermatology, University of Texas Southwestern Medical School; Director of Skin Surgery and Oncology Clinic, Department of Dermatology, 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 Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

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, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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