Eyelid Cutaneous Horn

Sir,

We read with great interest the article by Oludiran et al., “Cutaneous horns in an African population”, reporting their experiences with six patients who had cutaneous horns on scalp and extremities.[1] In this article we want to present a patient with an eyelid cutaneous horn.

Cutaneous horn is a relatively rare tumor, most often arising on sun-exposed skin in elderly men.[2] The important issue is not the horn itself, which is dead keratin, but rather the underlying condition, which may be benign, premalignant, or malignant.[3] Our patient, a 78-year-old farmer, presented with a 3-year history of a slowly growing lesion on his left lower eyelid. Physical examination revealed a solitary firm horn like projection, 5 cm in height with a hyperkeratotic surface without associated lymphadenopathy [Figure 1]. The lesion was completely excised surgically. Histology was reported as well-differentiated squamous cell carcinoma [Figure 2]. Investigations showed no metastases. The patient underwent two additional operations to achieve free surgical margins. On follow up, patient had an uneventful course with no clinical relapse [Figure 3].

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Figure 1

Left lower eyelid cutaneous horn

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Figure 2

Hematoxylin and eosin-stained sections showing well-differentiated squamous cell carcinoma

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Figure 3

Post-op appearance, after one year

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Various types of associated lesions may be found at the base of a cutaneous horn, including viral warts, actinic keratosis, keratoacanthoma, seborrheic keratosis, pyogenic granuloma, discoid lupus erythermatosus, verruca vulgaris, Bowen's disease, basal cell carcinoma, and squamous cell carcinoma.[4–7] In a study performed on 48 cases with eyelid horns, by Mencía-Gutiérrez et al., 23% of them were premalignant and malignant.[8] Although it is very difficult to distinguish between benign, premalignant, and malignant lesions, larger size of lesions and tenderness at base of lesions are signs in favor of malignancy. Treatment depends on the type of lesion and its malignant potential.[3] Therefore, prompt diagnosis of the underlying lesion by appropriate biopsy is mandatory. In cases of benign lesions, the biopsy may be both diagnostic and therapeutic, while for malignant tumors, complete surgical excision with appropriate margin is usually required.[3] So, in every patient with cutaneous horn, an underlying disease must be looked for.