Case for Diagnosis
Crateriform Tumor of 2 Years’ Duration
Tumor crateriforme de dos años de evolución
P.J. Gómez Arias
, R. Salido Vallejo
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UGC de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario Reina Sofía, Córdoba, Spain
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The lesion was asymptomatic and had not increased in size or shown other changes, although the patient reported discomfort caused by rubbing, and for this reason requested excision of the lesion.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a solitary tumor of 15 mm in diameter located on the chest. The lesion was similar in color to the surrounding skin, and had a firm consistency with a keratotic, crateriform center (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology showed a branched, endophytic tumor of epithelial origin that had neat borders and a follicular appearance, contained clear cells without atypia, and did not reach the resection margin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Dermoscopy revealed a tumor with a keratinized center and irregular yellowish areas. Fine radial vessels and some poorly focused fine telangiectasias were visible in the periphery (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">What is Your Diagnosis?</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Inverted follicular keratosis.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Course</span><p id="par0030" class="elsevierStylePara elsevierViewall">Complete excision of the lesion was carried out, without having confirmed recurrence during follow-up.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall">Inverted follicular keratosis is a rare benign tumor originating in the follicular infundibulum. It typically presents as a single nodule or papule, usually located on the face (mainly the eyelid, nose, upper lip, and cheek) and is more common in elderly men.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Histology reveals an endophytic tumor in the form of an inverted cone that originates from the infundibular portion of the hair follicle and forms a lobulated mass of follicular sheath epithelium that extends into the dermis. The peripheral portion is composed of several rows of cells with a basaloid appearance. The center contains smaller basaloid cells mixed with keratinizing cells and keratin pearls. The lesion may be accompanied by fibrosis, a chronic inflammatory infiltrate, or increased vascularity.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Some authors consider it a variant of seborrheic keratosis or the common wart, while others classify it as an independent entity owing to its follicular origin.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has been speculated that inverted follicular keratosis is a lesion caused by human papillomavirus (HPV).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The presence of this lesion could constitute a marker of Cowden syndrome, especially in patients with multiple lesions.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The differential diagnosis includes keratinizing tumors, such as cutaneous squamous carcinoma and keratoacanthoma, as well as other variants of pigmented keratosis pilaris, including pigmented basal cell carcinoma, seborrheic keratosis, common warts, and even melanoma.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Diagnosis is usually established based on histology of the excised lesion.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The most common dermoscopic finding in patients with inverted follicular keratosis is a keratoacanthoma-like pattern, with a central keratinized area surrounded by radially arranged hairpin vessels. The presence of a whitish-yellowish central area with radially arranged peripheral vessels and/or whitish or red blood cells has also been described.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The most common treatment is surgical excision, although complete resolution has been reported after treatment with 5% imiquimod. Recurrence after complete excision is very rare.</p></span></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This work has not received any type of funding.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Histopathology" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "What is Your Diagnosis?" 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Actas Dermosifiliogr. 2021;112:915–916.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 78371 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Macroscopic appearance of the lesion.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 98948 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×40.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 563 "Ancho" => 750 "Tamanyo" => 50770 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic image of the lesion.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inverted follicular keratosis successfully treated with imiquimod" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.S. 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Pizarro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ced.12832" "Revista" => array:7 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2016" "volumen" => "41" "numero" => "July" "paginaInicial" => "468" "paginaFinal" => "473" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27018237" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack566197" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The authors thank Dr. José Luis Rodríguez Peralto for his essential assistance with the histopathological diagnosis and description of the case.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011200000010/v1_202111080506/S157821902100264X/v1_202111080506/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000011200000010/v1_202111080506/S157821902100264X/v1_202111080506/en/main.pdf?idApp=UINPBA000044&text.app=https://www.actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821902100264X?idApp=UINPBA000044" ]
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