Treatment options
Cryosurgery
Some textbooks list cryosurgical therapy as an option.8 If there were a clearly benign pre-existing underlying dermopathy, such as verruca vulgaris or molluscum contagiosum, cryosurgery might be considered. However, cryosurgery is destructive; it does not preserve a specimen for pathologic examination. Because cutaneous horns have a 15% to 40% chance of underlying malignancy,1,4 it is difficult to recommend cryosurgical destruction without an initial biopsy-proven diagnosis.
Punch biopsy
In this patient, a 3-mm excisional punch biopsy was performed using a punch-to-ellipse technique. The skin is stretched parallel to the skin lines as the punch biopsy is performed. As the skin relaxes after removal of the punch instrument, an elliptical defect remains, enhancing cosmesis of the repair. Especially for a convex facial surface (which heals less well cosmetically than concave facial surfaces), this technique was believed to offer the potential for a better long-term cosmetic result.
In this case, a shave biopsy would have been a good option for both diagnosis and treatment. If the pathology from a punch biopsy or shave biopsy turned out to demonstrate an underlying skin cancer, then a fusiform excision would be needed to provide adequate surgical margins for the definitive treatment.
Results of histologic exam
With this patient, histologic examination revealed that the underlying condition was verruca vulgaris, or the common wart. Several months after removal of the cutaneous horn, the patient could not locate the surgical site, a cosmetically acceptable result to her and her physician ( Figure 3).
FIGURE 3
After successful treatment
Acknowledgments
The author would like to acknowledge the unfailing cooperation and expert assistance of the St. Vincent Mercy Medical Center library staff.
Correspondence
Gary N. Fox, MD, 2200 Jefferson Avenue, Toledo, OH 43624. E- mail: foxgary@yahoo.com.