Hyperkeratotic Lesions Research Articles

Factores asociados a diagnósticos premalignos y malignos en cuernos cutáneos

IntroductionCutaneous horn (CC) is a conical hyperkeratotic tumor lesion, the importance of which lies in the underlying pathology. Objectives1) To characterize the CC according to sex, age, anatomical location and histopathological diagnosis; 2) Evaluate the association of these variables with diagnoses of malignancy in CC. MethodologyProspective longitudinal observational study, in subjects with a preoperative diagnosis of cutaneous horn, carried out in a dermatology service between January 2018 and December 2019. Age, sex, location and histopathological diagnosis were recorded. Statistical analysis performed using the Stata program (Stata/SE 16.0 for Windows). Results57 patients were included, with a median (RIC) age of 75 (19) years. 31 (54.3%) patients were men. The lesions in the photoexposed area were 47 (82.5%). The most common histopathological diagnosis was actinic keratosis (n = 20; 35%). Premalignant/malignant and benign histopathological diagnoses corresponded to 39 (68.4%) and 18 (31.5%), respectively. The age (median (IQR)) of subjects with a histopathological diagnosis of premalignant/malignant lesion (79 (18) years) was significantly higher than that of subjects with benign lesion (65.5 (14) years) (p < 0.01). The frequency of localization in photoexposed area in subjects with premalignant/malignant lesion versus benign lesion was 92.31% (36/39) versus 61% (11/18), respectively (p < 0.01). There was no significant difference for males in premalignant/malignant versus benign lesions. ConclusionsPrecursor lesion of CC is of an uncertain nature, for which reason its removal is essential for histopathological study. Advanced age and chronic photoexposure are variables associated with premalignancy/malignancy in CC.

A case of elephantiasis nostras verrucosa treated successfully by a new type of compressive garment

Elephantiasis nostras verrucosa (ENV) is a clinical manifestation composed of hyperkeratotic, verrucous, and papillomatous lesions and dermal fibrosis, which complicate chronic lymphedema. There is currently no cure for ENV, however, several measures have been used to reduce lymphedema and the resultant pseudoepidermal hyperplasia. Supportive dressings and compression therapy still constitute an important part of the treatment. In this report, we present a 69-year-old male patient with ENV developed due to chronic lymphedema caused by venous insufficiency. After failure of healing with conventional two- and three-layered bandages, and elastic stockings, he was successfully treated by a new type of compression garment. We recommend this user friendly garment for prevention of frictional trauma, contact dermatitis, and secondary infection, which all may complicate compression treatments.

IFSI-guideline on chronic prurigo including prurigo nodularis

Chronic prurigo (CPG) is a highly burdensome pruritic disease characterized by chronic itch, a prolonged scratching behavior and the development of localized or generalized hyperkeratotic pruriginous lesions. Neuronal sensitization and the development of an itch-scratch cycle contribute to the augmentation of pruritus and the chronicity of the disease. We provide here the first international guideline for a rational diagnostic and therapeutic approach for CPG. Recommendations are based on available evidence and expert opinion. The diagnosis of CPG is made clinically. A detailed medical history together with laboratory and radiological examinations are advised in order to determine the severity of CPG, identify the underlying origin of the itch and assist in the elaboration of a treatment plan. Therapeutically, it is advised to adopt a multimodal approach, including general strategies to control itch, treatment of the underlying pruritic conditions, and of the pruriginous lesions. Topical (corticosteroids, calcineurin inhibitors, capsaicin) and systemic antipruritic agents (eg, gabapentinoids, immunosuppressants, and opioid modulators) as well as physical treatment modalities (phototherapy, cryotherapy) should be employed in a step-wise approach. Psychosomatic or psychological interventions may be recommended in CPG patients with signs of psychiatric/psychological comorbidities.

CUTANEOUS HORN VS PYOGENIC GRANULOMA IN LOWER LIPS: A DIAGNOSTIC CHALLENGE

The cutaneous horn is a chronic hyperkeratotic lesion that can associate as both benign and malignant lesions. The differential diagnosis is the pyogenic granuloma, characterized by proliferative non-neoplastic reactive processes, with origin in the connective tissue of the skin or mucous. The objective of this work is relate the case of the pyogenic granuloma with clinical and histopathologic characteristics to similar to cutaneous horn. The 54-year-old female patient was referred to the service of stomatology for evaluation of lesions. The extraoral examination verified nodular lesion, exophytic, pediculate, measuring 2.0 × 2.0 × 10 mm, in lower lip. The diagnostic hypothesis was cutaneous horn. Excisional biopsy was performed, and the histopathologic result was pyogenic granuloma. Although the clinical characteristics are not determined for diagnosis for this lesion, it is important to note the differences that may occur in these aspects because a wrong interpretation can lead to a hasty diagnosis as well as incorrect therapeutic behavior.

Dermatosis neglecta: a case report

&lt;p&gt;Dermatosis neglecta or dermatitis neglecta is a condition which occurs due to inadequate cleansing of a localised area of skin resulting in the accumulation of dirt, sebum, sweat, corneocytes and bacteria. These patients do not clean the area due to various reasons like pain at the site, prior surgery, physical disability, neurological deficit, or psychiatric illness. Vigorous rubbing of the lesion with alcohol soaked gauze results in removal of the lesion. We report a case of dermatosis neglecta in a 50 year old lady with carcinoma breast following mastectomy on the right side. She did not clean the area adequately as she was scared that the area of suture after mastectomy would give way, thus resulting in hyperkeratotic lesions.&lt;/p&gt;

Toe Absence Related to Verrucous Carcinoma

Abstract Introduction: Verrucous carcinoma is a rare variant of squamous cell carcinoma. It generally grows exogenously and bone erosion is rare. Here we present a case of verrucous carcinoma on the foot with toe absence. Case presentation: A 64-year-old man presented with a 6-year history of a slowly growing exogenous hyperkeratotic verrucous lesion on the right fifth toe, which had been absent for 1 year. Before the lesion appeared, he had undergone nail extraction on this toe. The culture of fungi and mycobacteria were negative. Three-dimensional computed tomography showed that the fifth toe of the right foot was absent. Histopathological examination showed that the lesion was exogenous and verrucous and exhibited moderate keratinocyte hyperplasia. Combined with clinical manifestation and histopathological examination, verrucous carcinoma is suggested. The lesion was surgically excised, and the patient was followed up for more than 6 months without recurrence. Discussion: Verrucous carcinoma is an exophytic tumor with verrucous growth at the beginning, which can invade deep tissues and even cause limb mutilation. When encountering a patient with a wart-like plaque on the foot that responds poorly to conventional treatments, clinicians should maintain a high degree of clinical vigilance and a low threshold for biopsy. Conclusion: We observed a rare outcome of toe absence associated with verrucous carcinoma. Therefore, early diagnosis of verrucous carcinoma is very important. Surgical excision is an effective treatment at present. Extensive resection is usually required to avoid recurrence.

Immunohistochemical Assessment of Immune Response in the Dermis of Sarcoptes scabiei-Infested Wild Carnivores (Wolf and Fox) and Ruminants (Chamois and Red Deer).

Simple SummaryThis article studies the local immune processes in dermis underlying the macroscopical differences (hyperkeratotic or alopecic) in mangy lesions from wolves (Canis lupus), foxes (Vulpes vulpes), chamois (Rupicapra rupicapra) and red deer (Cervus elaphus) naturally infested with Sarcoptes scabiei. Skin sections were immuno-stained to detect macrophages, plasma cells, T lymphocytes and B lymphocytes. Skin lesions contained significantly more inflammatory cells in fox than in wolf and chamois. Macrophages were the most abundant inflammatory cells in the lesions of all the species studied, suggesting a predominantly innate, non-specific immune response. Lesions from wolf contained higher proportions of macrophages than the other species, which may reflect a more effective response, leading to alopecic lesions. Fox and chamois may also mount substantial humoral and cellular immune responses with apparently scarce effectiveness that lead to hyperkeratotic lesions.Sarcoptic mange is caused by the mite Sarcoptes scabiei and has been described in several species of domestic and wild mammals. Macroscopic lesions are predominantly hyperkeratotic (type I hypersensitivity) in fox, chamois and deer, but alopecic (type IV hypersensitivity) in wolf and some fox populations. To begin to understand the immune processes underlying these species differences in lesions, we examined skin biopsies from wolves (Canis lupus), foxes (Vulpes vulpes), chamois (Rupicapra rupicapra) and red deer (Cervus elaphus) naturally infested with S. scabiei. Twenty skin samples from five animals per species were used. Sections were immuno-stained with primary antibodies against Iba1 to detect macrophages, lambda chain to detect plasma cells, CD3 to detect T lymphocytes and CD20 to detect B lymphocytes. Skin lesions contained significantly more inflammatory cells in the fox than in the wolf and chamois. Macrophages were the most abundant inflammatory cells in the lesions of all the species studied, suggesting a predominantly innate, non-specific immune response. Lesions from the wolf contained higher proportions of macrophages than the other species, which may reflect a more effective response, leading to alopecic lesions. In red deer, macrophages were significantly more abundant than plasma cells, T lymphocytes and B lymphocytes, which were similarly abundant. The fox proportion of plasma cells was significantly higher than those of T and B lymphocytes. In chamois, T lymphocytes were more abundant than B lymphocytes and plasma cells, although the differences were significant only in the case of macrophages. These results suggest that all the species examined mount a predominantly innate immune response against S. scabiei infestation, while fox and chamois may also mount substantial humoral and cellular immune responses, respectively, with apparently scarce effectiveness that lead to hyperkeratotic lesions.

Unilateral Dyshidrosiform Pemphigus Vulgaris

AbstarctPemphigus vulgaris is an autoimmune disease characterized by fluid-filled blisters over body and mucosal surfaces. Localized pemphigus is a rare presentation of the disease. There are few reports of localized pemphigus in literature presenting as esophageal involvement, recurrent paronychia, conjunctival mass, foot ulcers, discoloration of toes with hyperkeratotic skin lesions, verrucous lesions, and dyshidrosiform pemphigus vulgaris. We present a case of dyshidrosiform pemphigus involving a foot following trauma. Histopathology and direct immunofluorescence confirmed our diagnosis. In our patient, the disease started as localized dyshidrosiform pemphigus and later became generalized. This unusual presentation led to a delay in diagnosis and proper treatment in this patient. Physicians should be aware of such rare presentations to aid in the timely diagnosis and management of such patients.

Photodynamic therapy and laser‐assisted drug delivery and R0 excision in the treatment of an immunosuppressed patient showing multiple actinic keratosis and recurrent squamous cell carcinoma: A case report

AbstractWe report on a 73‐year‐old male patient with granulomatosis with polyangiitis (Wegener's granulomatosis) who developed increasingly growing lesions of actinic keratosis (AK) and squamous cell carcinoma (SCC) of the scalp under systemic immunomodulatory therapy with azathioprine for more than 8 years. The patient underwent a first‐line surgical therapy resulting in histologically confirmed R0 resection status followed by topical imiquimod treatment and cryotherapy. However, recurrence of AK/SCC progression could not be stopped sufficiently. Therefore, due to the difficult localization of the lesions at the head and the limitation of further surgical procedures, the patient was presented to our laser medicine department in order to consider complementary therapy options. The therapy approach was combining photodynamic therapy (PDT) with laser‐assisted drug delivery (LADD). PDT has been successful in treating field cancerization for decades, but it has limitations in the treatment of hyperkeratotic lesions. Pre‐treatment with LADD can be used to optimize the penetration depth of the prodrug 5‐aminolevulinic acid (BF‐200 ALA, Ameluz) and significantly increase the bioavailability as well as inducing an inflammatoric reaction. Following this therapeutic approach, we were able to achieve a stable disease over a follow‐up period of 2 years after six sessions of combined LADD + PDT.

Clinical characteristics and prognosis of acquired perforating dermatosis: A case report.

Acquired perforating dermatosis (APD) is an uncommon skin disease characterized by umbilicated hyperkeratotic lesions, and involves the transepidermal elimination of dermal components, including collagen and elastic fibers. The disease can affect patients with systemic disorders, especially those with chronic renal failure or diabetes mellitus. The current paper described four cases of patients with APD and investigated the clinical characteristics and prognosis of APD, as well as its possible link with systemic disorders. In each of the four cases, the patient had systemic disorders before the onset of APD, three had concomitant renal and thyroid disorders and one had hepatocirrhosis secondary to chronic hepatitis C. The results of the present study showed that APD occurred after the transient worsening of the original systemic disease. Furthermore, it was revealed that dermatosis symptoms were alleviated upon remission of the original systemic disorder, without specific dermatological treatment. Dermatosis symptoms improved in all four patients, indicating that the management of the associated systematic diseases was essential for the successful clinical outcomes of APD.

Disseminated superficial actinic porokeratosis, Bowen's disease and basal cell carcinoma. Coincidence or rare double malignant transformation?

Disseminated superficial actinic porokeratosis (DSAP) is a skin condition that consist of multiple annular, hyperkeratotic lesions. They are usually distributed bilaterally and mostly affect the extremities. DSAPs have a wider distribution than the porokeratosis of Mibelli and usually appears between the age of 40 and 50. Squamous cell carcinoma, Bowen’s disease, and basal cell carcinoma that arises in the classical type of porokeratosis of Mibelli is well-documented, but there are not many reported cases of Bowen’s disease and basal cell carcinoma arising in DSAP. We present a 77-year-old woman in whom the two– Bowen’s disease and Basal cell carcinoma develop in a histologically proven DSAP.

Pruritic dermatitis in two stray pups due to mixed Demodex and Sarcoptes mite infestations

Two stray pups in the Jabalpur were having the history of severe itching, hyperkeratotic skin lesions, alopecia involving face, head, ears, dorsal parts of body and on the leg region. Skin scrapping examination from the infested parts revealed mixed infestation of Demodex spp. and Sarcoptes spp. mites. The animals were treated with injectable ivermectin, multivitamins and topically amitraz. Marked clinical improvement was observed after fourteen day post treatment and complete healing with disappearance of crusts and scabs leading to normal skin was recorded on 28th day post treatment.

Hypertrophic Lichen Planus with Histological Features of Squamous Cell Carcinoma Associated with Immune Checkpoint Blockade Therapy.

Immune checkpoint blockade (ICB) is highly effective for the treatment of metastatic cancers, but its side effects are incompletely understood. The objective of this article is to highlight hypertrophic lichen planus (HLP) with histological features diagnosed as squamous cell carcinoma (SCC), which is a potential cutaneous reaction to ICB. Two patients (75 and 69 years) presented with lesions diagnosed as SCC on biopsy, which developed after 3-9 months on ICB therapy. Biopsies demonstrated endophytic, atypical, or cystic squamous proliferations consistent with cutaneous SCC. However, the clinical presentation including monomorphic nature of the lesions and lichenoid inflammation in the background were consistent with HLP. Patients initially received topical 5-fluorouracil (5-FU) to reduce the hyperkeratotic lesions followed by topical steroids. The eruptions readily responded to this treatment regimen. Dermatologic immune-related adverse events (irAEs) are the most common irAEs associated with ICB therapy. Our findings indicate that HLP resembling SCC on biopsy is a potential side effect of ICB that can be correctly diagnosed on careful clinical exam and is responsive to ICB cessation and topical steroid with or without 5-FU treatment. KEY POINTS: Immune checkpoint blockade is associated with cutaneous immune-related adverse events including lichen planus. Hypertrophic lichen planus can appear as squamous cell carcinoma histologically and clinical context is key for the proper diagnosis. Hypertrophic lichen planus can be safely treated with topical steroids with or without topical 5-fluorouracil in cases with severe hyperkeratotic lesions. Immune checkpoint blockade may be safely continued if clinical presentation is consistent with hypertrophic lichen planus.

Reverse Sural Flap for Repair of Foot and Ankle Defects: Our Cases, Modifications, and a Literature Review

Introduction: Reverse-flow sural flap is a valuable option in cases of lower extremity repair. In this study, we aimed to present our sural flap applications and modifications for the treatment of ankle and foot defects and to evaluate our results in the light of historical process and current literature. Materials and Methods: A reverse-flow fasciocutaneous flap was performed in 14 patients to repair foot and ankle defects. In 6 cases (42.86%), we chose to perform interpolation sural flaps where we aimed to repair the distal defects of the foot and/or in order to prevent patients from having trouble wearing shoes due to bulkiness of the flap pedicle at the ankle. In other cases (tunnel flap group, 57.14%), the pedicle of the flap was passed through the subcutaneous tunnel. Wide and meticulous dissection of the tunnel, nitroglycerine application on the flap, and close flap monitoring were our protective measures. Our results were analyzed statistically. The literature review was performed from Medline and PubMed. Results: Sural flap repair was performed in 14 patients. The mean age was 32.75 years. Etiologic factors were traffic accidents, spinal cord injuries, and hyperkeratotic lesions. The defects were localized in the ankle or proximal foot in 12 (85.71%) patients and the distal foot in the remaining patients (14.29%). The mean area of the defects was 46.75 cm2. Partial necrosis at the distal flap developed in 2 (25%) cases in the tunnel group and in 1 (16.67%) in the interpolation group (3 cases in total, 21.43% in the study population). No statistical difference was found between the flap groups in terms of patient distribution and complications. Conclusion: Wide dissection of the subcutaneous tunnel through which the pedicle is passed (in the tunnel group), application of nitroglycerin, meticulous hemostasis, and postoperative follow-ups are important factors for a successful reverse sural flap application. Sural interpolation modification is advantageous in several cases as the flap can reach farther and does not cause bulkiness in the ankle that would impair shoe wear. However, the disadvantage is that it requires 2 sessions.

Cutaneous Horn of Prepucial Skin on Pre-existing Lichen Sclerosus in a Young Male: A Rare Presentation

Cutaneous horn of penis is rare. Cutaneous horns are generally found over sun exposed areas of body after fifth decade of life. Penile horns are hyperkeratotic lesions which are secondary to chronic irritation. Hereby,the author reports a case of a young male with cutaneous horn over phimotic prepucial skin with lichen sclerosus which was successfully treated by circumcision.

Malignant transformation of oral lichen planus: where are we now?

Oral lichen planus (OLP) is a very prevalent disease whose main clinical feature is the appearance of white hyperkeratotic reticular lesions, which may or may not be accompanied by erosive and/or atrophic lesions, among others. One of the most relevant aspects of the process is its current consideration as an oral potentially malignant disorder (OPMD), although this is currently the subject of considerable controversy. A review of the literature was carried out in order to critically analyze the controversies surrounding the consideration of OLP as an OPMD, where they originate from and the available evidence that has led to the conclusion that OLP patients are at risk of developing oral cancer. The controversies over the definitive acceptance of OLP as an OPMD were classified as controversies related to the lack of widely accepted diagnostic criteria for OLP; controversies related to histopathological aspects of OLP and the presence of epithelial dysplasia as a diagnostic exclusion criterion; and controversies related to clinical aspects of OLP (which in turn were subclassified into: controversies on how to interpret reticular lesions in OLP, on the nature of the white plaques that appear in OLP; on the changing character of reticular lesions in OLP; and on the criteria for accepting a case as a true malignant OLP). Furthermore, evidence to justify the acceptance of OLP as an OPMD was in depth reviewed, including the molecular evidence, evidence from research studies with the highest evidence design -systematic reviews and meta-analyses-, and evidence from case series reporting strong results. This paper presents the reasons for the controversies as well as the evidence that allows us to accept that OLP behaves as an OPMD.

Effectiveness of Three Scalpel Debridement Techniques on Painful Callus in Older People.

Plantar hyperkeratotic lesions are prevalent foot problems in the older population, affecting 30% to 65% of people older than 65 years. Their onset is a common cause of foot pain due to the release of inflammatory mediators. Because of its simplicity, scalpel debridement is the most common treatment. We assessed how the degree of plantar hyperkeratosis debridement affects self-perception of pain in older people. Three hundred older participants (mean ± SD age, 76.3 ± 7.4 years) were randomly allocated to receive full debridement (FD) of plantar hyperkeratoses, partial debridement (PD) of plantar hyperkeratoses, or debridement simulation (control group). Plantar hyperkeratotic pain was measured on a visual analog scale before treatment, just after treatment, 24 hours after treatment, and 7 days after treatment. Both FD and PD of plantar hyperkeratoses of the forefoot generate similar levels of self-perception of pain just after treatment (P = .32), 24 hours after treatment (P = .15), and 7 days after treatment (P = .22). Significant differences were found between the groups treated using a scalpel (FD and PD) and the control group just after treatment (P = .04 for FD; P = .05 for PD), 24 hours after treatment (P = .03 for FD; P = .04 for PD), and 7 days after treatment (P = .04 for FD and PD). The results of this trial suggest that there are no significant differences in pain reduction between PD and FD of forefoot plantar hyperkeratoses in older people.

Reflectance confocal microscopy for noninvasive examination of nonmelanocytic tumors and virus-associated skin lesions in organ transplant recipients.

Drug-induced immunosuppression is necessary to prevent rejection of the foreign organ in transplanted patients, but neoplastic and virus-associated skin diseases are frequent complications. Reflectance confocal microscopy (RCM) recently emerged as a promising tool for the early diagnosis of skin lesions. A total of 61 skin lesions, among them 20 basal cell carcinomas, six Bowen's diseases, 23 actinic keratoses, and 12 verrucae, were analyzed. All lesions were clinically evaluated followed by RCM evaluation by two independent dermatologists and histological examination. For the diagnosis of basal cell carcinoma, a sensitivity of 100% by both investigators (INV I+II) and a specificity of 100% by INV I and 80% by INV II were achieved. The sensitivity average rate for RCM features reached by both investigators ranged between 60% and 100%, and the specificity between 55% and 90%. For the diagnosis of actinic keratosis, a concordant sensitivity of 94.4% and a specificity of 80% (INV I) and 60% (INV II) were detected. The sensitivity average rate of specific RCM criteria ranged between 72.3% and 97.2%, whereas specificity ranged between 20% and 90%. Regarding verrucae, RCM confirmed the histological diagnosis with a sensitivity of 85.7% (INV I) and 100% (INV II), while specificity was 100% and 80%, respectively. Reflectance confocal microscopy resulted to be a reliable tool for the noninvasive diagnosis of neoplastic and virus-associated skin changes in organ transplant recipients. Nevertheless, given the frequency and diagnostic complexity of the hyperkeratotic lesions occurring post-transplantation, larger cohorts of patients are required to confirm and consolidate these findings.

A precancerous skin lesion that is often misdiagnosed.

Disseminated superficial actinic porokeratosis (DSAP) is a precancerous skin condition often seen by dermatologists that is characterised bymultiple annular hyperkeratotic lesions on sun-exposed areas. In Australia, DSAP is not a rare condition, possibly owing to Australia's high levels of sun exposure, and patients with DSAP often initially present to general practitioners (GPs). Alack of awareness about DSAP may result in misdiagnosis and inappropriate management of the condition. The aim of this article is to provide an overview of DSAP relevant to GPs to better facilitate diagnosis, management and referral to a dermatologist. The underlying pathophysiological mechanism of DSAP is unknown. Although there is currently no effective standardised treatment, ongoing management is warranted, given the potential for malignant transformation. Suggested strategies include frequent full skin checks, patient education about sun protection and ablative treatment (such as cryotherapy) if indicated. Suspicious lesions require excision and histopathology.

Dermatologic and Dermatopathologic Features of Monogenic Autoinflammatory Diseases.

Autoinflammatory diseases include disorders with a monogenic cause and also complex conditions associated to polygenic or multifactorial factors. An increased number of both monogenic and polygenic autoinflammatory conditions have been identified during the last years. Although skin manifestations are often predominant in monogenic autoinflammatory diseases, clinical and histopathological information regarding their dermatological involvement is still scarce. Monogenic autoinflammatory diseases with cutaneous expression can be classified based on the predominant lesion: (1) maculopapular rashes or inflammatory plaques; (2) urticarial rashes; (3) pustular, pyogenic or neutrophilic dermatosis-like rashes; (4) panniculitis or subcutaneous nodules; (5) vasculitis or vasculopathy; (6) hyperkeratotic lesions; (7) hyperpigmented lesions; (8) bullous lesions; and (9) aphthous lesions. By using this classification, this review intends to provide clinical and histopathological knowledge about cutaneous involvement in monogenic autoinflammatory diseases.