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Keratoacanthoma

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Keratoacanthoma

Keratoacanthoma
Keratoacanthoma.
Classification and external resources
ICD-10 D23 (ILDS D23.L71) (ICD10.v4 L85.8)
ICD-9-CM 238.2
DiseasesDB 29383
eMedicine derm/206
MeSH D007636

Keratoacanthoma (KA) is a common low-grade (unlikely to metastasize or invade) skin tumour that is believed to originate from the neck of the hair follicle.[1]

The defining characteristic of KA is that it is dome-shaped, symmetrical, surrounded by a smooth wall of inflamed skin, and capped with keratin scales and debris. It grows rapidly, reaching a large size within days or weeks, and if untreated for months will almost always starve itself of nourishment, necrose (die), slough, and heal with scarring. KA is commonly found on sun-exposed skin, often face, forearms and hands.[2]

Under the microscope, keratoacanthoma very closely resembles squamous cell carcinoma. In order to differentiate between the two, almost the entire structure needs to be removed and examined. While some pathologists classify KA as a distinct entity and not a malignancy, about 6% of clinical and histological keratoacanthomas do progress to invasive and aggressive squamous cell cancers; some pathologists may label KA as "well-differentiated squamous cell carcinoma, keratoacanthoma variant", and prompt definitive surgery may be recommended.[3][4][5][6]

Contents

  • Classification 1
  • Cause 2
  • Diagnosis 3
  • Treatment 4
  • See also 5
  • References 6

Classification

Keratoacanthomas (molluscum sebaceum) may be divided into the following types:[7]:763–764[8]:643–646

  • Giant keratoacanthomas are a variant of keratoacanthoma, which may reach dimensions of several centimeters.[7]:763
  • Keratoacanthoma centrifugum marginatum is a cutaneous condition, a variant of keratoacanthomas, which is characterized by multiple tumors growing in a localized area.[7]:763[8]:645
  • Multiple keratoacanthomas (also known as "Ferguson–Smith syndrome," "Ferguson-Smith type of multiple self-healing keratoacanthomas,") is a cutaneous condition, a variant of keratoacanthomas, which is characterized by the appearance of multiple, sometimes hundreds of keratoacanthomas.[7]:763[8]:644
  • A solitary keratoacanthoma (also known as "Subungual keratoacanthoma") is a benign, but rapidly growing, locally aggressive tumor which sometimes occur in the nail apparatus.[7]:667,764[8]:644
Picture of the face of a patient Generalized eruptive keratoacanthomas
  • Generalized eruptive keratoacanthoma (also known as "Generalized eruptive keratoacanthoma of Grzybowski") is a cutaneous condition, a variant of keratoacanthomas, characterized by hundreds to thousands of tiny follicular keratotic papules over the entire body.[7]:763[8] :645 Treatments are not successful for many patients with Generalized eruptive keratoacanthoma. Use of emollients and anti-itch medications can ease some symptoms. Improvement or complete resolutions of the condition has occurred with the application of the following medications: Acitretin, Isotretinoin, Fluorouracil, Methotrexate, Cyclophosphamide.

Cause

Keratoacanthoma usually occurs in older individuals. As with squamous cell cancer, it seems likely that ultraviolet light from the sun causes the development of KA.[9] As with squamous cell cancer, sporadic cases have been found co-infected with the human papilloma virus (HPV).[10]

Many new treatments for Melanoma are also known to increase the rate of Keratoacanthoma, such as the B-Raf inhibitor drugs Vemurafenib and Dabrafenib.[11]

Diagnosis

Keratoacanthoma presents as a fleshy, elevated and nodular lesion with an irregular crater shape and a characteristic central hyperkeratotic core. Usually the patient will notice a rapidly growing dome-shaped tumor on sun-exposed skin.

Skin keratoacanthoma whole slide

If the entire lesion is removed, the pathologist will probably be able to differentiate between keratoacanthoma and squamous cell carcinoma. If only part of the lesion is removed, confident diagnosis may be impossible.

Treatment

Excision of the entire lesion, with adequate margin, will remove the lesion, allow full tissue diagnosis, and leave a planned surgical wound which can usually be repaired with a good cosmetic result. However, removing the entire lesion (especially on the face) may present difficult problems of plastic reconstruction. (On the nose and face, Mohs surgery may allow for good margin control with minimal tissue removal, but many insurance companies require the definitive diagnosis of a malignancy before they are prepared to pay the extra costs of Mohs surgery.) Especially in more cosmetically-sensitive areas, and where the clinical diagnosis is reasonably certain, alternatives to surgery may include no treatment (awaiting spontaneous resolution).[12]

On the trunk, arms, and legs, electrodesiccation and curettage often suffice to control keratoacanthomas until they regress. Other modalities of treatment include cryosurgery and radiotherapy; intralesional injection of methotrexate or of 5-fluorouracil have also been used.[13]

Recurrence after electrodesiccation and curettage is common; it can usually be identified and treated promptly with either further curettage or surgical excision.

See also

References

  1. ^ Fisher, B.K., Elliot, G.B. Keratoacanthoma: Reflections on an Unusual Lesion. Can Med Assoc J. 1965 August 7; 93(6): 272–273.
  2. ^ Schwartz RA. The Keratoacanthoma: A Review. J Surg Oncol 1979; 12:305–17.
  3. ^ Ko CJ, Keratoacanthoma: facts and controversies. Clin Dermatol. 2010; 28(3):254–61 (ISSN: 1879-1131)
  4. ^ http://www.emedicine.com/derm/topic206.htm
  5. ^ Kossard S; Tan KB; Choy C; Keratoacanthoma and infundibulocystic squamous cell carcinoma. Am J Dermatopathol. 2008; 30(2):127–34 (ISSN: 1533-0311)
  6. ^ Weedon DD, et al. Squamous cell carcinoma arising in keratoacanthoma: a neglected phenomenon in the elderly. Am J Dermatopathol. 2010; 32(5):423–6
  7. ^ a b c d e f Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0.
  8. ^ a b c d e James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0-7216-2921-0.
  9. ^ Schwartz RA (February 2004). "Keratoacanthoma: a clinico-pathologic enigma". Dermatol Surg 30 (2 Pt 2): 326–33; discussion 333.  
  10. ^ Niebuhr M, et al. Giant keratoacanthoma in an immunocompetent patient with detection of HPV 11. Hautarzt. 2009; 60(3):229–32 (ISSN: 1432-1173)
  11. ^ Niezgoda, Anna; Niezgoda, Piotr; Czajkowski, Rafal (2015) Novel Approaches to Treatment of Advanced Melanoma: A Review of Targeted Therapy and Immunotherapy BioMed Research International
  12. ^ Keratoacanthoma. Désirée Ratner. 2004. http://www.medscape.com/viewarticle/467069 accessed 23 June 2015
  13. ^ Keratoacanthoma. Désirée Ratner. 2004. http://www.medscape.com/viewarticle/467069 accessed 23 June 2015
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