Cutaneous Horn 

  • Author: Fiona Larsen, MBChB, FRACP; Chief Editor: William D James, MD   more...
 
Updated: Jan 12, 2012
 

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.

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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,[8] keratoacanthoma,[9, 10] malignant melanoma,[11] Paget disease,[12] renal cell carcinoma,[13] sebaceous carcinoma,[14, 15] and squamous cell carcinoma.[16]

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Epidemiology

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.[17, 18] 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.[19]

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.

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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.

Specialty Editor Board

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 Dermatological Association, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

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.

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.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of 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 and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Nancy Silvis, MD, to the development and writing of this article.

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. 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].

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

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

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

  12. 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].

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

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

  15. 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].

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

  17. 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].

  18. 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].

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

  20. 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].

  21. 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].

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

  23. 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].

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

 
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A typical presentation of a cutaneous horn on the ear.
An unusually large cutaneous horn extending from the ear.
 
 
 
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