Keratoacanthoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Homa Najafi, M.D.[3]

Overview

Keratoacanthoma (KA) is a relatively common, benign, epithelial tumor that was previously considered to be a variant of squamous cell carcinoma (SCC). The etiology is unknown. No human papillomavirus-DNA sequences were detected in lesions by polymerase chain reaction. It is a disease of the elderly (mean age, 64 years) with an annual incidence rate of 104 per 100,000. It is not associated with internal malignancy. There may be a seasonal presentation of keratoacanthoma that suggests that ultraviolet radiation has an acute effect on the development of KA. KAs may develop in sites of previous trauma. Most cases are the “crateriform” type, which grow rapidly then undergo spontaneous regression. Less than 2% belong to the rare destructive variants with no regression and persistent invasive growth. These are referred to as keratoacanthoma marginatum centrifugum and mutilating keratoacanthomas and can lead to severe defects.

KA begins as a smooth, dome-shaped, red papule that resembles molluscum contagiosum. In a few weeks the tumor may rapidly expand to 1 or 2cm and develop a central keratin-filled crater that is frequently filled with crust. The growth retains its smooth surface, unlike a squamous cell carcinoma. Untreated, growth stops in approximately 6 weeks, and the tumor remains unchanged for an indefinite period. In the majority of cases it then regresses slowly over 2 to 12 months and frequently heals with scarring. The limbs, particularly the sun-exposed hands and arms, are the most common site; the trunk is the second most common site, but KA may occur on any skin surface, including the anal area. On occasion, multiple KAs appear, or a single lesion extends over several centimeters. These variants resist treatment and are unlikely to undergo spontaneous emission.

According to a review of literature by Robert A. Schwartz, KA was once considered a benign neoplasm that resembled a highly malignant one (pseudomalignancy), but it is now viewed in an opposite light as a cancer that resembles a benign neoplasm (pseudobenignity). KA is an abortive malignancy that rarely progresses into an invasive SCC. The KA may serve as a marker for the important autosomal dominant familial cancer syndrome, the Muir-Torre syndrome, as a result of a defective DNA mismatch repair gene.[4]


Diagnosis

Physical Examination

Skin

Face
Extremities
Ear
Scalp

Keratoacanthoma Pendulum

Keratoacanthoma-Linear Epidermal Nevus

Differentiating keratoacanthoma from other Diseases


Diseases Skin examination Diagnosis Additional findings
Type Color Texture Size Distribution Dermoscopic Findings Histopathology
Keratoacanthoma[2]
  • 1 to 2.5 cm
Merkel cell carcinoma[3]
  • Shiny
  • Flesh-colored or bluish-red
  • Firm
  • < 1 cm
  • Sun-exposed areas
  • Older individuals with light skin tones
  • Rapidly growing
Dermatofibroma[4][5]
  • Firm
  • 0.3- 1 cm
dermatofibrosarcoma protuberans[6][7]
  • Firm
  • 1-5 cm
Kaposi sarcoma[8][9]
  • Red/violaceous
  • Smooth
  • Rainbow pattern
  • scaly surface
  • Small brown globules
Cutaneous squamous cell carcinoma[10] SCC in situ (Bowen's disease)
  • Scaly
  • Variable
  • Fair-skinned individuals: sun-exposed areas
Invasive squamous cell carcinoma
  • Skin colored
  • 0.5 to 1.5 cm
  • Fair-skinned individuals: sun-exposed areas
  • In black individuals: legs, anus, and areas of chronic inflammation
Basal cell carcinoma[11] Nodular basal cell carcinoma
  • Flesh-colored
  • Variable
  • Focused, bright red, and branching arborizing vessels
  • Loosely arranged blue-gray dots
Superficial basal cell carcinoma
  • Scaly
  • 1 to > 10 cm
  • Sun-exposed areas
  • Head (cheek and nose)
  • Trunk
  • Large, hyperchromatic, oval nuclei
  • Minimal cytoplasm
  • Small basaloid nodules
Sclerosing basal cell carcinoma (morpheaform)[12]
  • Variable
  • Sun-exposed areas
Prurigo nodules[13][14]
  • Firm
  • Variable
Melanoma[15] Melanoma in situ (Lentigo Maligna)[16]
  • Variable (from light to dark brown, black, pink, red, or white)
  • Smooth
  • Around 1 cm
  • Asymmetric, pigmented follicular openings
  • Gray angulated lines
  • Gray areas, dots, and globules
  • Circle within a circle
Lentigo maligna melanoma[17]
  • Brown/tan
  • Variable
  • Asymmetric, pigmented follicular openings
  • Gray angulated lines
  • Gray areas, dots, and globules
  • Circle within a circle
  • Usually in older individuals
Superficial spreading melanoma[18]
  • Variably pigmented (red, blue, black, gray, and white)
  • Thin
  • 1 mm to > 1 cm
  • Asymmetry of shape
  • > 2 colors
  • Asymmetry of structures
Nodular melanoma[19][20]
  • Dark color
  • 6mm to > 1 cm
  • Two-thirds arise in normal skin, the rest in existing moles
  • Rapidly enlarging
Acral lentiginous melanoma[21]
  • Dark brown to black
  • Variable
  • Most common among dark skinned individuals
Amelanotic melanoma[22]
  • Around 6 mm
Common nevus[23][24]
  • 1 cm to > 20 cm
  • Also called Miescher nevus
Blue nevus[25]
  • Blue
  • Smooth
  • Variable
  • Structureless blue pigmentation
  • Structureless blue and white or blue and brown on some occasions
Spitz nevus[26][27] Nonpigmented Spitz nevus
  • Pink
  • Smooth
  • < 1 cm
Reed-like Spitz[28]
  • Smooth
  • < 1 cm
Solar lentigo[29]
  • Multiple spots
  • Brown
  • Smooth
  • Around 5mm
  • Associated with UV exposure and skin aging
Sebaceous hyperplasia[30]
  • Skin-colored to brownish
  • 2 - 6 mm
  • Structureless yellow to whitish center surrounded by short linear "crown vessels"
  • Usually in middle-aged or older patients
Lichen planus-like keratosis[31]
  • Gray to brown
  • Prominent
  • Variable
  • Appearance depends on stage of evolution


References

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