Giant Cutaneous Horn Overlying A Verruca at an Uncommon Site: Medical Marvel vs Superstitious Dilemma

Abstract

Cutaneous horn has been a matter of discussion to mankind since time immemorial and a subject of fascination for the layman. There have been instances where certain groups saw it with angst and disgust, with a person having a large cutaneous horn on an exposed area getting a dismal look. We present a case of a 64-year-old man with a giant cutaneous horn over his left gluteal region. Cutaneous horns more commonly present in the sun-exposed areas. In our case it has presented in an uncommon site. The patient had delayed and denied medical treatment due to his superstitious beliefs, after having sought advice from faith healers leading to progression of the disease. This case has been presented for its giant size (rare variety), its location being over the gluteal region (photo-protected site) and its benign histopathology suggestive of wart in spite of the giant size.

Case Report

A 64-year-old man presented with a hard growth over his left gluteal region since eight years. The growth was gradual in onset and slowly progressed until six months ago when patient noticed a rapid progress. All this while, the patient only sought help from faith healers. With increasing discomfort due to location and size of the cutaneous horn, he presented to our hospital. There was no history of associated pain or discharge from the growth. There was no history of similar lesion elsewhere on the body.

On examination, there was a solitary, woody hard hyperkeratotic growth over the left gluteal region that appeared to arise from the skin and subcutaneous tissue. The keratinous part measured about 15cm in length with the diameter of the base being about 10cm [Table/Fig-1,2]. There was no regional lymphadenopathy. A differential diagnosis of cutaneous horn with either an underlying viral wart or squamous cell carcinoma was considered. All laboratory parameters were within the normal range. Ultrasonography of the lesion confirmed the lesion was arising from the superficial plane involving up to the subcutaneous tissue with the muscles not appearing to be involved.

[Table/Fig-1]:

Cutaneous horn in the left gluteal region, patient in prone position

[Table/Fig-2]:

Cutaneous horn, patient in right lateral position

The lesion was surgically excised with 1 cm margin and the defect was closed by split skin graft. Histopathology examination (HPE) of the lesion revealed hyperkeratosis, papillomatosis with koilocytes showing perinuclear halo with no evidence of associated malignancy [Table/Fig-3]. Hence, HPE was consistent with verruca underlying cutaneous horn. The graft healed well and the patient was discharged with advice to follow up regularly.

[Table/Fig-3]:

Cutaneous horn caused by HPV virus (viral wart) -papillomatosis, hyperkeratosis with koilocytes showing perinuclear halo (H & E stain, 40x)

Discussion

A cutaneous horn morphologically refers to cohesive keratinized material protruding above the skin surface [1]. Cutaneous horns differ from animal horns by absence of an axially positioned, well-formed bone. There are reports of cutaneous horns associated with HPV and sun-exposure [2,3]. In a study of 230 horns, actinic keratoses have been reported as the most common horn base pathology (37.4%), but they may also result from seborrheic keratoses, warts, keratoacanthoma, squamous cell carcinoma and basal cell carcinoma [4,5]. Though giant cutaneous horns are more common in the sun-exposed areas, they can also occur in sun- protected areas as in our case where it was seen over the left gluteal region. Giant cutaneous horns are usually but not always associated with malignancy as in our case wherein histopathology did not reveal evidence of malignancy [6].

A study conducted by Yu R et al., on 643 cutaneous horns revealed that the cutaneous horns were more common in the sun-exposed areas of the body with a high incidence of malignant and premalignant lesions, with squamous cell carcinoma being the most common malignant histological change [7]. Horns overlying a malignant pathology do not differ clinically from those having a benign underlying pathology although they are more commonly associated with male sex, older age, photo-exposed areas, and giant horns characterized by a wide base or a low height to base ratio [7]. The study also found that 61% of the cutaneous horns were derived from benign lesions and 39% were derived from premalignant (23.2%) or malignant (15.7%) epidermal lesions [7]. In another study by Mantese S et al., out of the 222 cases of cutaneous horns, 94% of the malignant lesions were squamous cell carcinoma by histology. This study also showed that cutaneous horns showed female predilection (64.86%) [8].

The underlying associations are more important than the overlying fascination. Hence, surgical excision remains the treatment of choice [3,9]. A full thickness wide local excision with an adequate margin should be obtained [2]. Lesion tenderness within the lesion and giant size generally point towards malignancy. The high association of premalignant and malignant lesions requires the surgical specimen to be sent for histopathological assessment, as the base of the horn will display the characteristic feature of the pathologic process responsible for the development of the horn, which in our case was verruca [8,10].

Other options for treatment include electro cautery, cryotherapy, carbon dioxide and Nd YAG laser [11]. These are probably used only in low index of suspicion for malignancy. Going by the association of premalignant and malignant lesions, such patients should be followed up regularly to look for malignancy. In case of lesions, which are more commonly seen in the sun-exposed areas, sunscreens may have a role in prevention [8].

Conclusion

Giant cutaneous horns are fascinating lesions with medical implications. Surgical excision with appropriate margin should be the standard of care. The present case of cutaneous horn has been reported for its giant size, photo protected site distribution and its benign nature in spite of its size and duration. The lack of awareness, misperceptions, superstitious beliefs and gross personal neglect pertaining to cutaneous horn has been highlighted in the present case.

Financial or Other Competing Interests

None.