Multiple keratoacanthomas in a young woman: report of a case emphasizing medical management and a review of the spectrum of multiple keratoacanthomas

Abstract

A 27-year-old white woman was referred for consultation with regard to the presence of extensive multiple keratotic lesions. She began to develop these lesions at the age of 9 years, with healing of the lesions resulting in scar formation. A biopsy was performed at the age of 16 years, but the patient was unsure of the results. Since then, she had not had any treatment or biopsies, and stated that she had not suffered from any health problems during the intervening period. She was most concerned about the tumors on her heels and soles, which caused difficulty with ambulation. The family history was negative for skin diseases, including melanoma, nonmelanoma skin cancer, psoriasis, and eczema, and positive for Type II diabetes mellitus. A relative reported that the patient's grandfather had similar lesions, but the patient's parents and siblings were healthy. She was married and had one child, a 9-year-old daughter. Her child had no skin lesions. The patient's only medication was Ortho-Tricyclene birth control pills. She had no known drug allergies. Physical examination revealed the presence of multiple lesions on her body (Fig. 1). Her left superior helix contained a well-demarcated, dome-shaped nodule with a rolled, mildly erythematous border with a central hyperkeratotic plug. A similar lesion was present in the scaphoid fossa of the left ear and smaller lesions were scattered on her face. Numerous lesions were present on the arms and legs bilaterally, with the majority of lesions being located on the anterior lower legs. There were also lesions present on the palms and soles. The lesions ranged in size from 5 mm to 3 cm, the largest being a verrucous exophytic nodule on the anterior aspect of her left leg. Overall, there appeared to be two distinct types of lesion. One type appeared round, oval, and symmetric with a central keratotic plug, similar to that on the ear. The other type was larger, more exophytic, and verrucous, including the lesions on the volar surfaces. Also present were numerous, irregularly shaped atrophic scars where previous lesions had healed spontaneously. There were no oral lesions or lesions on her fingernails or toenails, and her teeth and hair were normal. A biopsy was obtained from an early lesion on the right dorsal forearm. Histology revealed an exo-/endophytic growth having a central crater containing keratinous material (Fig. 2). The crater was surrounded by markedly hyperplastic squamous epithelium with large squamous epithelial cells having abundant glassy cytoplasm. Some cells were dyskeratotic. Within the dermis was a dense, chiefly mononuclear inflammatory infiltrate. A buttress of epidermis surrounded the crater. The clinical and pathologic data were consistent with keratoacanthomas. Initial laboratory screenings revealed elevated triglycerides and total cholesterol, 537 mg/dL (normal, < 150 mg/dL) and 225 mg/dL (normal, < 200 mg/dL), respectively, with all other laboratory results within normal limits. In anticipation of starting oral retinoid therapy for her multiple kerat...

Recurrent keratoacanthoma with vascular invasion: A diagnostic and management dilemma

“…13 Feldman and Maize used acitretin at a dose of 35 mg daily tapered to 25 mg daily and topical tazarotene in a young woman with multiple KA, with good effect. 14 A case of a 46-year-old man with the Ferguson-Smith type of multiple KA with KA centrifugum marginatum responding to acitretin at 0.7 mg/kg has been reported. 1 Rosenblum reported a 62-year-old woman with palmar KA who was initially treated with 1 mg/kg of acitretin for a 30-day period and subsequently maintained on 25 mg daily following resolution of lesions.…”

Eruptive keratoacanthoma and squamous cell carcinoma complicating imiquimod therapy: Response to oral acitretin

“…In our patient, oral acitretin was given in an effort to hasten the resolution of 1 year have all been documented as efficacious in the treatment of multiple KA, as was the case in our experience. 29 In summary, we report a case of eruptive KA and SCC complicating topical imiquimod therapy at both the treatment and distant sites. Resolution of KA was promoted by oral acitretin.…”

“…[27][28][29][30][31][32][33][34] Watchful waiting is a potential alternative, given lesions typically regress and uncommonly behave in a malignant manner. 35 Unfortunately, it is sometimes difficult to distinguish KA from SCC; therefore, surgical excision with clear histological margins is the gold standard.…”

Treatment of multiple keratoacanthomas with erlotinib

“…Treatment of multiple keratoacanthomas is more problematic, as the number of lesions makes surgical or destructive techniques impractical, and recurrence is frequent [10]. We hypothesized that keratoacanthomas would exhibit increased activation of EGFR, making them a target for therapy with an EGFR tyrosine kinase inhibitor.…”