Penile Cutaneous Horn in a 22-month-old Child: A Rare Case Report.

Cutaneous horn is a horn-like hyperkeratotic lesion. Its presence over penis is unusual and rare. Herein, we report a case of horn of penis in a 22-month-old child.

INTRODUCTION

Cutaneous horn is a clinical diagnosis referring to a conical projection of cornified material above the surface of the skin that resembles a miniature horn. Historically, it is also called by its Latin name, cornu cutaneum, and less commonly, as cornu cutaneum of Rokitansky, after the German pathologist Baron Carl von Rokitansky who reported it for the first time.[1]

The horn is composed of compacted keratin. The base of the horn may be flat, nodular, or crateriform. On histology, various lesions have been documented at the base of the keratin mound, and histologic confirmation is often necessary to rule out malignant changes.

Cutaneous horn occurs mainly in individuals who are above 50 years of age and penile horns are no exception to this rule. They are common in males after 50 years and probably coincide with the age group of occurrence of penile cancer. To date, a little more than 150 cases have been reported in the literature. Lowe and Mc Cullogh reported that penile horn may be benign in 42%–56% of cases, premalignant in 22%–37%, or frankly malignant in 20%–22%.[2] Cutaneous penile horn in pediatric age group is extremely rare.

CASE REPORT

We report a case of a 22-month-old male child who presented to the outpatient department for religious circumcision. On examination, the patient had a protruding mass on dorsolateral aspect of preputial skin around 2.5 cm × 1 cm × 0.5 cm extending perpendicularly from the shaft of penis. Another small swelling was present proximal to this protuberance around 0.5 cm × 0.5 cm in line with the protuberance as depicted in Figure 1. The first swelling was hard in consistency, whitish, with its maximum dimension perpendicular to skin surface, while the second swelling was soft, had a normal skin covering, and was more in width than height.

Figure 1

Preoperative picture

Patient's relatives gave a history of the presence of a small cyst-like swelling which eventually grew perpendicularly and became hard in consistency over a period of few months. The second swelling developed around a month ago. Both swellings were painless and had no associated complaints.

Circumcision was done in this patient with excision of both swellings. Histopathological study of the first mass revealed hyperkeratosis. The second swelling had features of a sebaceous cyst.

The patient was discharged on the next day. On follow-up, the patient had a complete recovery with no complications.

DISCUSSION

London surgeon Everard Home (1791) is credited with the earliest descriptions of cutaneous horns. However, cases from as early as the 16th and 17th centuries have been described in the medical literature.

These usually arise on sun-exposed skin but can occur even in sun-protected areas. The hyperkeratosis that results in horn formation develops over the surface of a hyperproliferative lesion. While the protruding, compact keratin may be the most prominent clinical feature, it is the process at the base of the lesion that is of most importance.

Most often, this is a benign verruca or seborrheic keratosis; however, cutaneous horns complicate a number of conditions, including premalignant actinic keratoses and frank malignancy. More than half of all of the inciting lesions at the base of these horns are benign, and a further 23%–37% are derived from actinic keratoses. Malignancy has been reported at the base in up to 20% of lesions.

Penile cutaneous horns are even rarer and have been reported mostly in old age patients. Most of them have been reported as malignant and premalignant lesions.

In younger age group, a case of a 20-year-old male with a penile horn over the ventral surface of penis has been reported.[3] He developed the lesion 2 months postcircumcision done for phimosis. Histopathology of tissue at base showed hyperplastic squamous epithelium with marked hyperkeratosis. There was no evidence of malignancy. In our case, the swelling was present over the preputial skin contrary to this case where the swelling was present directly on the penis just below the glans. Histopathology was similar to our case.

Another case of a 30-year-old married Hindu male with a 3-month history of a horn-like growth over the penis has been reported.[4] His only significant medical history was a circumcision for warty swellings over the prepuce about 1 year back, which on histopathological evaluation revealed condylomata acuminata. Histopathological features were suggestive of condylomata acuminata. In this case too, the swelling was present directly on the penis.

The present case of benign hyperkeratotic penile lesion was just a 22-month-old child. Diagnosis was based on clinical findings and postoperative histopathological features. The possible reason for the development of cutaneous horn in this patient was chronic irritation, along with poor hygiene, wherein a burst sebaceous cyst was the predisposing condition.

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.