INTRODUCTION The term cutaneous horn, also known as cornu cutaneum, is a descriptive designation for a protuberant projection of packed keratin that resembles an animal horn. It is more common in elderly individuals, but can be seen in young adults as well. It is associated with a large variety of benign, premalignant, and malignant lesions at the base, thus masking the true diagnosis. About 60% to 75% of such inciting lesions are benign and 8% to 10% malignant. Malignant diagnoses tend to occur more commonly in males and in patients 8 to 10 years older than those with benign diagnoses. The most common inciting diagnoses are seborrheic keratosis, actinic kerato-sis, and squamous cell carcinoma.
CLINICAL PRESENTATION Cutaneous horns are usually seen on areas of exposed skin. They may attain a very large size causing mechanical ptosis or other eyelid malpositions, and may completely occlude vision. Lesions present as a dry, white to yellowish, firm, hornlike projection of keratin that extends upward from the skin surface. It may have several distinct projections that coalesced at the base.
HISTOPATHOLOGY Cutaneous horn is a clinical diagnosis that corresponds histologically to a protuberant mass of keratin. To be designated a "horn", the height should exceed at least one-half of the greatest diameter of the lesion from which it arises. Cutaneous horns are most commonly associated with actinic (solar) keratosis, verruca vulgaris, seborrheic keratosis, squamous cell carcinoma, inverted follicular keratosis, or tricholemmoma.
DIFFERENTIAL DIAGNOSIS The cutaneous horn is easy to diagnose, but its significance is determining the underlying lesion. They can develop from a variety of underlying lesions, including seborrheic keratosis, actinic keratosis, inverted follicular keratosis, verruca vulgaris, tricholemmoma, subepidermal calcified nodules, basal cell carcinoma, squamous cell carcinoma, metastatic tumors, and other epidermal tumors.
TREATMENT Treatment is dependent on the underlying cause. For benign lesions simple excision or shave biopsy may be adequate. However, when the basal lesion is malignant, surgical excision with adequate clear margins will be necessary to affect a cure. In most cases, however, the diagnosis is not apparent until the specimen has been submitted for histologic examination. Because of the possibility of an underlying malignant lesion, complete surgical excision should be performed.
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