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 Table of Contents  
LETTER TO EDITOR
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 113-115

Solitary keratoacanthoma resolved after a single intralesional 5-fluorouracil therapy


Department of Dermatology, NMMC General Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication16-Dec-2019

Correspondence Address:
Dr. Hari Shivaram Pathave
Department of Dermatology, NMMC General Hospital, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_32_19

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How to cite this article:
Mhatre A, Pathave HS. Solitary keratoacanthoma resolved after a single intralesional 5-fluorouracil therapy. Indian J Drugs Dermatol 2019;5:113-5

How to cite this URL:
Mhatre A, Pathave HS. Solitary keratoacanthoma resolved after a single intralesional 5-fluorouracil therapy. Indian J Drugs Dermatol [serial online] 2019 [cited 2020 Jan 18];5:113-5. Available from: http://www.ijdd.in/text.asp?2019/5/2/113/272959



Sir,

Keratoacanthoma (KA) is a rapidly growing neoplasm of the skin with no potential for metastatic spread and may involute spontaneously in most of the cases.[1] Majority of the KA affects the sun-exposed sites in fair individuals in the age group of 40–70 years. The clinical presentation is as a solitary, pink- or flesh-colored, dome-shaped nodule with a central keratin plug and histopathological appearance aids the diagnosis. Although spontaneous regression occurs, therapy is indicated to prevent local tissue destruction and cosmetic purpose. We present a 63-year-old male with solitary KA on the dorsum of the left hand, which completely resolved with a single dose of 0.5 ml intralesional 5-fluorouracil (5-FU).

A 63-year-old fair skin male presented with solitary, dome-shaped, asymptomatic lesion over the dorsum of the left hand. The lesion had grown to the present size over a period of 2 months. The patient denied any history of trauma or any previous skin lesion on the affected area.

The cutaneous examination revealed a solitary, well-circumscribed, firm, skin-colored to erythematous dome-shaped nodule measuring 3 cm × 3 cm, over the dorsum of the left hand [Figure 1]. Its surface was smooth, shiny, and showed crateriform central area with keratin plug. The lesion was slightly mobile and not attached to the underlying structure. No regional adenopathy noted, and the patient was otherwise healthy.
Figure 1: A solitary, well-circumscribed, firm, skin-colored to erythematous dome-shaped nodule with central crateriform keratin plug over the dorsum of the left hand

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Skin biopsy showed pseudoepitheliomatous hyperplasia which did not extend below the level of the sweat glands, large cup-like crater filled with keratin with adjacent epidermis extending such as a buttress, multiple keratin pearls, and eosinophilic glassy keratinocytes around keratin pearls showing the shell of proliferations at center [Figure 2]. There were no atypical keratinocytes or abnormal mitotic figures. On the basis of clinical presentation and histopathological findings, we diagnosed a case of KA.
Figure 2: Biopsy showing pseudoepitheliomatous hyperplasia, large cup-like crater filled with keratin with adjacent epidermis extending such as a buttress, multiple keratin pearls, and eosinophilic glassy keratinocytes around keratin pearls showing the shell of proliferations at center (H and E, ×10)

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We injected 0.5 ml of 5-FU (50 mg/ml) into the lesion, circumferentially at three to four sites and at the base. The patient was followed weekly; within 2 weeks of therapy, the tumor size was reduced by 50% [Figure 3]. Within the next 7 days, the lesion had almost completely resolved with residual slight hyperpigmentation [Figure 4].
Figure 3: After 2 weeks of therapy, the tumor size was reduced by 50%

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Figure 4: After 3 weeks of therapy, nodule completely resolved with slight residual hyperpigmentation

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KA is a benign tumor derived from a hair follicle and is more common in males over sun-damaged skin of face, dorsum of hand and forearm. It was first described by Sir Jonathan Hutchinson in the year 1888.[2] KA usually arises de novo but has been reported in association with inflammatory dermatosis, congenital skin lesions, and scars.

The clinical appearance may be confused with that of squamous cell carcinoma, molluscum contagiosum, or sebaceous carcinoma.

Histologically, KA is characterized by central-keratin filled depression surrounded by pseudoepitheliomatous hyperplasia. The epidermal strands show few atypical cells with nuclear atypia, atypical mitoses, and dyskeratotic cells.[3]

Solitary KA is usually treated by surgical excision. Other treatment modalities include electrosurgery, cryotherapy, radiotherapy, systemic chemotherapy, and topical cytotoxic agent.

Intralesional 5-FU is found to be safe, effective, inexpensive treatment with excellent patient acceptance, ease of administration, and good cosmetic results.[3],[4],[5] It has shown to produce an accelerated regression of KA. Mild pain or irritation may be expected at the site of injection. It interferes with DNA synthesis resulting in unbalanced cell growth and death of cells that are proliferating more rapidly. It is ideal for patients with multiple lesions of KA or surgically contraindicated patients.

In prior studies,[3],[4],[5],[6] the investigators did not perform pre-injection histopathology of lesions in all cases, and also lesions had cleared after multiple weekly intralesional 5-FU sessions (minimum 2–3 weekly sessions). They injected single KA lesion at multiple sites circumferentially. Allergic reactions from 5-FU as described by Goette and Odom [6] were not observed in our patient.

This is the first-ever case of KA from Indian population which completely regressed after single intralesional 5 FU (0.5 ml) session and without circumferential multiple site injections.

There was no recurrence of lesion after 12 months of follow-up; hence, besides its high efficacy and no recurrence, 5-FU therapy has good cosmetic results, excellent patient acceptance, and low cost which is undoubtedly important in developing countries. However, this is a single-case study; hence, multiple such studies are required to validate the result.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kingman J, Callen JP. Keratoacanthoma. A clinical study. Arch Dermatol 1984;120:736-40.  Back to cited text no. 1
    
2.
Schwartz RA. Keratoacanthoma. J Am Acad Dermatol 1994;30:1-9.  Back to cited text no. 2
    
3.
Bergin DJ, Lapins NA, Deffer TA. Intralesional 5-fluorouracil for keratoacanthoma of the eyelid. Ophthalmic Plast Reconstr Surg 1986;2:201-4.  Back to cited text no. 3
    
4.
Goette DK, Odom RB. Successful treatment of keratoacanthoma with intralesional fluorouracil. J Am Acad Dermatol 1980;2:212-6.  Back to cited text no. 4
    
5.
Odom RB, Goette DK. Treatment of keratoacanthomas with intralesional fluorouracil. Arch Dermatol 1978;114:1779-83.  Back to cited text no. 5
    
6.
Goette DK, Odom RB. Allergic contact dermatitis to topical fluorouracil. Arch Dermatol 1977;113:1058-61.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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