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SAEM Clinical Image Series: What’s This Thing on My Face?

Posted by Jessica L. Smith, MD on

A 91-year-old female patient presented with her family after concern for multiple new lesions on her face and hands. The patient thinks the lesions grew over the course of a few months. There is no pain at the sites, no erythema, and no pruritis. She has caught the lesions on clothing and bedding, which has irritated the lesions on occasion, and the family is concerned/embarrassed by the growths on her face, which are harder to conceal than those on her hand.

Additional Images

Physical Exam

General: Alert, awake, oriented, and non-toxic without acute distress

Skin:

  • 4 hyperkeratotic papules were found: the first on the interweb space of the left hand, another on the dorsum of the left hand, and two on the bilateral cheeks
  • The height of the papules ranged from three-to-six millimeters

The remainder of the exam is unremarkable.

Laboratory Data

N/A

Case Question: What’s the name of this condition?

Cutaneous horn(s)

She has them in multiple areas as pictured: two on the face, two on the left hand.

Case Question: Who is at risk? What do we have to worry about?

Most cutaneous horns arise from actinic keratoses and squamous cell carcinomas, so sun exposure and people with lighter complexions are more likely to be affected. Peak occurrence is from age sixty to mid-seventies.

About 50% of the time, what is at the base is benign; however, malignancy has been reported at the base in up to 20% of lesions (usually squamous cell carcinoma). In another 23–37% of cases, premalignant actinic keratoses are at the base. It is critical to determine the histology of the underlying lesion, as no clinical features reliably distinguish between benign and malignant lesions.

Case Question: What’s the workup/treatment?

A definitive diagnosis is confirmed with a skin biopsy of sufficient depth to ensure that the base of the epithelium is obtained. A shave biopsy is often both diagnostic and therapeutic for benign lesions. Malignancies must be excised with appropriate margins. Patients discovered to have horns with an underlying squamous cell carcinoma should also be evaluated for metastasis.

Case Discussion

Take-Home Points

  • Cutaneous horns are reportedly rare and require only visual diagnosis to diagnose.
  • Prompt referral to dermatology for a biopsy is important, as 20% of cases are associated with malignancy, and another 20–40% are associated with precancerous actinic keratoses.
  • Although there are no preventative measures, using sunscreen diligently and limiting sun exposure may be of benefit.

References

  1. Copcu E, Sivrioglu N, Culhaci N. Cutaneous horns: are these lesions as innocent as they seem to be? World J Surg Oncol. 2004 Jun 3;2:18. doi: 10.1186/1477-7819-2-18. PMID: 15176977

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Author information

Jessica L. Smith, MD

Residency Program Director
Associate Professor (Clinician Educator)
Department of Emergency Medicine
The Alpert Medical School of Brown University
Rhode Island Hospital/The Miriam Hospital/Newport Hospital

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