Eur J Plast Surg (2009) 32:257–259
DOI 10.1007/s00238-009-0338-3
CASE REPORT
Giant cutaneous horn on squamous cell carcinoma
of the lower lip
C. Skoulakis & E. Theos & P. Chlopsidis & A. G. Manios &
A. Feritsean & C. E. Papadakis
Received: 16 September 2008 / Accepted: 18 March 2009 / Published online: 20 May 2009
# Springer-Verlag 2009
Abstract Cutaneous horn is a clinical term describing morphologic or epithelial changes of the skin. These changes give
this lesion a conical shape characteristic that resembles a
miniature animal horn. Such lesions usually appear on sunexposed skin areas and can overlie certain benign, premalignant, or malignant lesions.
Keywords Cornu cutaneum . Cutaneous horn . Lower lip .
Bernard reconstructive technique . Squamous cell carcinoma
Introduction
Cornu cutaneum or cutaneous horn is the clinical description
of a hyperproliferation of compact keratin in response to a
wide array of underlying benign or malignant pathological
changes [1, 2]. Cornu cutaneum refers to a reaction pattern
rather than to a specific lesion. Different types of skin
C. Skoulakis : E. Theos : P. Chlopsidis
ENT Department, General Hospital of Volos,
Volos, Greece
A. G. Manios
Department of Plastic Surgery, University Hospital of Crete,
Crete, Greece
A. Feritsean
Dimitriados 50,
Volos 38333, Greece
C. E. Papadakis
ENT Department, Chania General Hospital,
Crete, Greece
C. Skoulakis (*)
Dimitriados 50,
Volos 38333, Greece
e-mail: [email protected]
e-mail: [email protected]
lesions underlie cutaneous horns such as keratoses, sebaceous molluscum, verruca, trichilemma, Bowen’s disease,
epidermoid carcinoma, malignant melanoma, and basal cell
carcinoma. Large cutaneous horns (>1 cm) are rare because
surgeons tend to remove them early [1, 3].
A unique case of a 72-year-old man with a large cutaneous
horn on the lower lip is presented. This is a very rare location
with only six previous reports in the literature [4, 5]. However,
none reported malignant transformation at the base. The
purpose of this report is to highlight the need for careful
management of such lesions due to the high incidence of
malignant or premalignant histological change.
Case report
A 72-year-old man presented at our outpatient clinic with a
hard keratinized conical lesion measuring 3.2×2.5 cm on
the vermilion of the lower lip. The lesion had been present
for 3 years and was gradually increasing in size despite the
patient having cut off its tip several times (Fig. 1).
Preoperative investigation included detailed clinical
examination and ultrasound which did not reveal any
suspicious masses in the neck. The possibility for distant
metastasis was extremely low, since the preoperative
assessment of the patient failed to reveal regional metastasis. Preoperatively, the patient had a chest X-ray (standard
protocol).
Under general anesthesia with nasotracheal intubation, the
lesion was excised with a 1-cm macroscopically tumor-free
margin. A large full-thickness defect was created involving
two thirds of the lower lip including the vermilion, the buccal
mucosa with its submucosal layers, and the skin down to the
mental region. Reconstruction was achieved with Bernard
flaps. We believe that this method and its modifications are
appropriate for sizable lower lip defects.
部分资料来自互联网，仅供科研和教学使用。如有异议，请及时和我们联系。www.medicool.cn
258
Fig. 1 Patient with cutaneous horn of the lower lip preoperatively,
profile (a) and fast (b) view
Histopathological examination revealed a completely
excised cutaneous horn with a well-differentiated squamous
cell carcinoma at its base invading the underlying muscle
(invasion depth: 1.5 cm) and surrounded by keratinization and
inflammation (Fig. 2). Postoperative period was uneventful.
The patient refused to receive postoperative radiation therapy.
Two years later, the patient is disease-free.
Discussion
The earliest well-documented case of cornu cutaneum was
that of an elderly Welsh woman from London in 1588. A
showman, who advertised it in a pamphlet, exhibited her
for money. However, according to an excellent historical
review by Bondeson, the earliest observations on cutaneous
horns in humans were described by London surgeon
Everard Home in 1791 [6]. Farris, from Italy, first described
the gigantic horn in man in a well-documented case report
with adequate histology [7].
Eur J Plast Surg (2009) 32:257–259
Nowadays, conical shape or resemblance to an animal
horn is not an absolute requisite for diagnosis of this
condition because specimens are frequently disrupted by
trauma during life or at removal [2, 8].
This article presents a large cutaneous horn on the lower
lip. This is a very rare location, and a literature review revealed
only six previous reports [4, 5, 8–12]. The case presented is
the first of a horn of the lower lip that was infiltrated by
squamous cell carcinoma at its base.
Cutaneous horns may arise from a wide range of epidermal
lesions, which may include benign lesions such as verruca
vulgaris, basal cell papillomas, viral warts, keratoacanthomas,
angiokeratoma, dermatofibroma solar keratosis, actinic keratoses, and premalignant or frankly malignant lesions such as
adenoacanthoma, basal cell carcinoma, sebaceous carcinoma,
Bowen’s disease, and squamous cell carcinoma [8, 13].
The reported incidence of cutaneous horns with premalignant or malignant histological features varies considerably in the English literature. In 1979, Schosser et al. [15]
reported a series of 230 cutaneous horns, of which 58%
showed either premalignant or malignant changes at their
base. However, a more recent study of 643 cutaneous horns
found that 38.9% were derived from malignant or premalignant lesion [8].
Features associated with premalignant or malignant histopathological change at the base of a cutaneous horn were
advanced age, male gender, sun-exposed lesion site, and
geometry of the lesion. Lesions with a wide base or a low
height-to-base ratio are more likely to show (pre)malignant
base pathology [8]. In our case, the ratio was 1.5:1, posing
the strong possibility of a malignant lesion. Cutaneous horns
with a wide base or a low height-to-base ratio are more likely
to show either premalignant or malignant base pathology.
History of trauma or other skin malignancies is also
associated with malignant base pathology.
Fig. 2 Ten (a) days and one month (b) postoperatively
部分资料来自互联网，仅供科研和教学使用。如有异议，请及时和我们联系。www.medicool.cn
Eur J Plast Surg (2009) 32:257–259
The treatment of choice for cutaneous horns is wide
excision and histologic examination, particularly in the
facial region where the incidence of malignancy is much
higher [14, 15]. In cases of squamous cell carcinomas,
proper clinical and laboratory staging is recommended, in
addition to postoperative radiation treatment [10].
Reconstruction of large lower lips defects can be achieved
usually by Karapandzic or Bernard flap, or modifications of
these reconstructions. Though a very useful technique, the
drawback of Karapandzic flap is the considerable microstomia
that may result. We decided to use the Bernard technique
because, as can be seen in the illustrations, we had to virtually
excise the entire lower lip, which mathematically would lead
to microstomia and difficulties in the food intake of a 72-yearold man.
Conclusion
A cutaneous horn is an asymptomatic, variably sized,
cohesive, keratotic conical lesion that arises from the
superficial layers of the skin or implants deeply in the
cutis. Such lesions usually appear on exposed skin areas;
the upper part of the face and ears, probably, are the most
common areas. A number of primary lesions underlying the
horny material are known to cause this condition (benign,
premalignant, and malignant), and squamous cell carcinoma should always be included in the initial differential
diagnosis as a common cause of this entity, particularly in
the upper face.
259
References
1. Akan M, Yildirim S, Avci G, Akoz T (2001) Xeroderma pigmentosum with a giant cutaneous horn. Ann Plast Surg 46:665–
666
2. Gould JW, Brodell RT (1999) Giant cutaneous horn associated
with verruca vulgaris. Cutis 64(2):111–112
3. Görgü M, Aslan G, Ayhan M, Erdogan B (1999) Giant cutaneous
horn. Ann Plast Surg 43(6):674
4. Mutaf M (2007) A rare perioral lesion: cutaneous horn of the
lower lip. Eur J Plast Surg 29:339–341
5. Souza LN, Martins CR, de Paula AM (2003) Cutaneous horn
occurring on the lip of a child. Int J Paediatr Dent 13:365–367
6. Bondeson J (2001) Everard Home, John Hunter, and cutaneous
horns: a historical review. Am J Dermatopathol 23:362–369
7. Farris G (1953) Histological considerations on a case of a
voluminous cutaneous horn. Minerva Dermatol 28:159–165
8. Yu R, Pryce D, Macfarlane A, Stewart T (1991) A histopathological study of 643 cutaneous horns. Br J Dermatol 124:449–452
9. Baykal C, Savci N, Kavak A, Kurul S (2002) Palmoplantar
keratoderma and oral leucoplakia with cutaneous horn of the lips.
Br J Dermatol 146:680–683
10. Bizakis JG, Manios A, Karatzanis AD (2005) Giant cornu
cutaneum. Otolaryngol Head Neck Surg 133(4):645
11. Copcu E, Sivrioglu N, Culhaci N (2004) Cutaneous horns: are
these lesions as innocent as they seem to be? World J Surg Oncol
2:18–22
12. Monaghan AM (1993) Cutaneous horn occurring on the vermilion
border of the lower lip. Br Dent J 175:419–420
13. Stavroulaki P, Mal R (2000) Squamous cell carcinoma presenting
as a cutaneous horn. Auris Nasus Larynx 27:277–299
14. Skoulakis C, Stavroulaki P, Papadakis C, Drivas E, Valagiannis D
(2007) Bifurcate horn on the tip of the nose. Otolaryngol Head
Neck Surg 136:311–312
15. Schosser R, Hodge S, Gaba C, Owen L (1979) Cutaneous horns: a
histopathologic study. South Med J 72:1129–1131
部分资料来自互联网，仅供科研和教学使用。如有异议，请及时和我们联系。www.medicool.cn