Giant Cutaneous Horn

Giant cutaneous horns are rare and only few cases have been reported in the literature. This paper reports the case of 65 year old female who presented with the giant cutaneous horn on the dorsum of her left hand which was completely excised and primary closure was done under local anaesthesia.


Introduction
Cutaneous horn or cornucutaneum is a conical lesion with dense, hyperkeratotic protrusion, resembling an animal horn.They occur most commonly at the sun exposed area of body like scalp, upper part of face.Other uncommon locations are forearm, ear, leg, shoulder and back of hand [1].Although majority are benign lesions, many premalignant and malignant skin lesion may be found at the base of cutaneous horn.These lesion should be completely excised and subjected to biopsy [1].We report a case of benign giant cutaneous horn on the dorsum of the left hand.

Case report
A 65-year-old female presented with the chief complaint of slowly growing hard skin lesion on dorsum of her left hand for last three years.She complained that it was cosmetically disfiguring and pruritic, adding to her discomfort.There was no history of ulceration, bleeding, trauma, pain or discharge.There was no past history of skin cancer.Patient was taking some ayurvedic treatment for osteoarthritis of bilateral knee.
Clinical examination revealed a keratinous conical mass arising from the dorsum of the left hand with the base measuring 4.0cm X 3.0 cm and projecting 3.0 cm above skin surface (Figure 1).There was no cervical or axillary lymphadenopathy.Systemic examination was normal.Routine blood investigations were within normal limits.

Discussion
Cutaneous horn is hard conical and circumscribed projection from the skin, made of compact keratin with a height of at least half the widest diameter of its base [2].They arise mostly from benign and about 38.9% from pre-malignant or malignant skin lesion [1].The size of the horn may vary from a few millimetres to several centimetres.A giant cutaneous horn is a horn of more than 1cm in height [3].They are more common in white older male population with a peak incidence in those between 60 and 70 years [1].Majority of the cutaneous horns involve sun exposed areas of the head especially the scalp, lip and cheek and rarely they affect the limbsas in our case but can occur on any body part and are also found to be associated with HPV-2infection [4], radiation, chronic irritation.
The duration of growth of cutaneous horn has been reported from six weeks to seventy-five years.The largest horn was reported by Michal M et al (2002) had a length of 25 cm [5].
A GCH often occurs in isolation as in our case.Farris from Italy reported the first case of a giant cutaneous horn in a man with adequate histology in 1953 [6].
Cutaneous horns are often asymptomatic although patients experience psychological stress and itching with these disfiguringlesions [7].In our case the lesion in hand caused difficulty in day to day activity like wearing clothes and also caused itching.
Paper ID: ART20175052 Cutaneous horns are treated by surgical excision, a full thickness wide local excision with an adequate margin should be obtained and sent for histological examination to exclude a focus of malignancy.If malignancy is present, margins should be reassessed for complete excision otherwise a re-excision may be required.Other options for treatment include electro cautery, cryotherapy, carbon dioxide and Nd YAG laser and are used when there is low index of suspicion for malignancy [8].
The most cutaneous horns have benign pathology at the base, such as seborrhoeic keratosis, viral wart or trichilemmal cysts orkeratoacanthoma.However, just under 40% have pre-malignant or malignant change, usually a SCC, at the base [2].When these present in multiples, the histopathological diagnosis is often verruca vulgaris.

Conclusion
Giant cutaneous horns are uncommon skin lesion.GCH are mostly benign lesion but possibility of underlying premalignant or malignant skin condition should always be kept in mind .They should be completely excised and subjected to histopathological examination to rule out malignancy.Cutaneous horn can also be prevented by use of photoprotectors which could help to prevent the disease by minimizing the action of ultraviolet radiation that is widely known as an important factor in the genesis of skin cancers.

Figure 1 :
Figure 1: Giant cutaneous horn on the dorsum of left hand A clinical diagnosis of giant cutaneous horn (GCH) was made and lesion was completely excisedwith primary closure of skin under local anaesthesia and specimen was Figure a

a)
Consent: written informed consent was obtained from patient for publication of images after hiding her identity.b) Conflict of Interest: The authors have no conflicts of interest to declare.c) Source of Funding: None.d) Author Contribution: All the authors have contributed significantly for the article.e) Guarantor: R.K Soni f) Ethical Approval: Not required g) Acknowledgement: None