Case and Research Letters
Subungual Keratoacanthoma: The Importance of Distinguishing it From Subungual Squamous Cell Carcinoma
Queratoacantoma digital distal: importancia del diagnóstico diferencial con el carcinoma escamoso subungueal
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Pliable, erythematous-violaceous plaques with poorly defined borders are shown. B, Lesion on the forearm during the fourth recurrence 3 years before development of the most recent lesion. This lesion is indurated and brownish, and the borders of the erythematous plaque are poorly defined. C, Lesion on the right thigh during the recurrence 6 months before the most recently developed lesion. The multinodular tumor is superficial and ulcerated and has a fleshy appearance.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Agustí-Mejias, F. Messeguer, A. Pérez, V. Alegre de Miquel" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Agustí-Mejias" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Messeguer" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Pérez" ] 3 => array:2 [ "nombre" => "V." 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González-Rodríguez, E.M. Gutiérrez-Paredes, E. Montesinos-Villaescusa, O. Burgués Gasión, E. Jordá-Cuevas" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A.J." "apellidos" => "González-Rodríguez" "email" => array:1 [ 0 => "ajavigo@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E.M." "apellidos" => "Gutiérrez-Paredes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Montesinos-Villaescusa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "O." "apellidos" => "Burgués Gasión" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Jordá-Cuevas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Queratoacantoma digital distal: importancia del diagnóstico diferencial con el carcinoma escamoso subungueal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 348 "Ancho" => 900 "Tamanyo" => 63603 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nodular lesion in the distal subungual region of the fourth finger of the left hand.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Subungual keratoacanthoma is a rare, destructive variant of keratoacanthoma that seldom regresses spontaneously. It may involve the distal tissue under the nail or the proximal nail fold and sometimes also affects the underlying bone. Histopathology is similar to that of other solitary keratoacanthomas but the subungual form shows more pronounced dyskeratosis with little or no nuclear atypia.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 39-year-old Caucasian woman with no relevant past medical history who presented with a very painful hyperkeratotic nodular lesion under the distal portion of the nail of the fourth finger of her left hand; the lesion had grown rapidly during the previous month (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). A radiograph of the left hand revealed an osteolytic lesion in the phalanx underlying the nodule. On the basis of these findings we carried out a complete excision of the lesion, adopting a conservative approach with regard to the underlying bone.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology using hematoxylin-eosin staining revealed epidermal hyperkeratosis, parakeratotic foci, and a central crater filled with amorphous keratin. Other findings were dyskeratotic cells, a small number of intraepithelial neutrophils and eosinophils, little nuclear atypia, patchy infiltrates of lymphocytes and plasma cells, and little or no fibrosis at the bases of the lesions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a-c). Staining for Ki-67 only revealed positivity in the stratum basale (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>d). All these findings were consistent with subungual keratoacanthoma.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The differential diagnosis of a painful nodular lesion on the distal phalanx includes dermoid cyst, subungual fibroma, glomus tumor, giant cell tumor of the tendon sheath, digital mucoid cyst, common wart, subungual exostosis, amelanotic melanoma, subungual squamous cell carcinoma (SCC), and subungual keratoacanthoma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Subungual keratoacanthoma is a rare, aggressive variant of this tumor which has a higher prevalence in men and a tendency to appear on the first 3 fingers of the hand, particularly the thumb. It consists of a painful, localized endo-exophytic nodular lesion that has a characteristic central keratin-filled crater. Subungual keratoacanthomas differ from typical forms of this tumor in their appearance on hairless skin and the absence of characteristic epithelial cords.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> They tend to be associated less with inflammation and more with deep invasion and a greater number of eosinophilic dyskeratotic cells. The diagnosis should be based on the correlation of clinical, radiologic, and histologic findings.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Subungual keratoacanthoma should be considered in the differential diagnosis of subungual tumors, especially SCCs (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Radiologically, a subungual keratoacanthoma is almost indistinguishable from a subungual SCC. However, a keratoacanthoma causes a phalangeal lesion with a well-defined border as it expands but does not infiltrate the bone; in addition, keratoacanthomas usually occur in the fifth decade of life, whereas SCCs usually occur in the seventh decade of life. SCCs grow slowly, whereas keratoacanthomas grow rapidly for a few weeks or months before they stabilize and regress spontaneously. If a subungual keratoacanthoma does not regress spontaneously, it can become locally destructive, making differential diagnosis difficult, and cases of malignant transformation to SCC have been reported. The differential diagnosis is currently subject to debate. Some authors believe that these keratoacanthomas are SCCs of low-grade malignancy that can be locally invasive and spread to the underlying bone; however, keratoacanthomas often involute spontaneously.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> Recent studies of differences in the expression of certain markers between these 2 tumors (higher expression of Ki-67 and p53 proteins in SCC) that help to establish the diagnosis have concluded that they are separate lesions that behave differently.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, although subungual keratoacanthoma is a rare clinical entity, it is a destructive variant and its differential diagnosis with respect to subungual SCC is essential. Both can present as a painful nodular lesion associated with inflammation and can affect the distal subungual tissue and underlying bone.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–10</span></a> Although the 2 conditions can be almost indistinguishable, their prognosis and treatment are different. Subungual keratoacanthoma is treated conservatively, whereas Mohs micrographic surgery is indicated for SCCs that are noninvasive (without bone involvement) and amputation is performed when an SCC has invaded the bone (in cases of rapid growth or delayed diagnosis).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, we have reported an unusual case of subungual keratoacanthoma on the fourth finger of a 39-year-old woman, highlighting the importance of considering this diagnosis when SCC is suspected, in the interest of avoiding mutilating treatments.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: A.J. González-Rodríguez, E.M. Gutiérrez-Paredes, E. Montesinos-Villaescusa, O. Burgués Gasión, E. Jordá-Cuevas. Queratoacantoma digital distal: importancia del diagnóstico diferencial con el carcinoma escamoso subungueal. Actas Dermosifiliogr. 2012;103:549-51.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 348 "Ancho" => 900 "Tamanyo" => 63603 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Nodular lesion in the distal subungual region of the fourth finger of the left hand.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 963 "Ancho" => 1300 "Tamanyo" => 391057 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Crater filled with amorphous keratin (hematoxylin-eosin, original magnification ×40). B, Epidermal hyperkeratosis, foci of parakeratosis (hematoxylin-eosin, original magnification ×100). C, Dyskeratotic cells with little nuclear atypia (hematoxylin-eosin, original magnification ×400). D, Positive staining for Ki-67 in the stratum basale.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Keratoacanthoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Squamous Cell Carcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fifth decadeRapid growthSpontaneous regression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seventh decadeSlow growthNo regression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radiologic findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteolytic lesion with well-defined borders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Poorly-defined borders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Histopathologic findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symmetric exophytic lesionEpidermal hyperkeratosisCentral crater filled with keratinDyskeratotic eosinophilic cellsLittle nuclear atypiaPatchy dermal infiltration of lymphocytes and plasma cells \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proliferation of epidermal cells with marked cellular and nuclear atypiaAbnormal mitotic figuresInvasion of the dermis and underlying tissues \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunohistochemical characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No increase in Ki-67/p53 expression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elevated Ki-67/p53 expression \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab182241.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Keys to Differential Diagnosis Between Subungual Keratoacanthoma and Squamous Cell Carcinoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subungual keratoacanthoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.W. 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| año/Mes | Html | Total | |
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| 2020 Noviembre | 53 | 32 | 85 |
| 2020 Octubre | 89 | 24 | 113 |
| 2020 Septiembre | 64 | 23 | 87 |
| 2020 Agosto | 73 | 22 | 95 |
| 2020 Julio | 64 | 30 | 94 |
| 2020 Junio | 58 | 31 | 89 |
| 2020 Mayo | 60 | 29 | 89 |
| 2020 Abril | 43 | 31 | 74 |
| 2020 Marzo | 40 | 30 | 70 |
| 2020 Febrero | 5 | 10 | 15 |
| 2020 Enero | 4 | 6 | 10 |
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| 2019 Noviembre | 4 | 8 | 12 |
| 2019 Octubre | 0 | 6 | 6 |
| 2019 Septiembre | 4 | 10 | 14 |
| 2019 Agosto | 4 | 6 | 10 |
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| 2019 Junio | 4 | 21 | 25 |
| 2019 Mayo | 2 | 31 | 33 |
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| 2019 Marzo | 2 | 11 | 13 |
| 2019 Febrero | 0 | 4 | 4 |
| 2019 Enero | 4 | 4 | 8 |
| 2018 Diciembre | 0 | 10 | 10 |
| 2018 Noviembre | 2 | 1 | 3 |
| 2018 Septiembre | 6 | 1 | 7 |
| 2018 Agosto | 0 | 4 | 4 |
| 2018 Julio | 0 | 6 | 6 |
| 2018 Junio | 0 | 2 | 2 |
| 2018 Mayo | 0 | 8 | 8 |
| 2018 Abril | 0 | 2 | 2 |
| 2018 Marzo | 8 | 5 | 13 |
| 2018 Febrero | 103 | 15 | 118 |
| 2018 Enero | 118 | 18 | 136 |
| 2017 Diciembre | 93 | 12 | 105 |
| 2017 Noviembre | 137 | 27 | 164 |
| 2017 Octubre | 113 | 16 | 129 |
| 2017 Septiembre | 129 | 28 | 157 |
| 2017 Agosto | 116 | 56 | 172 |
| 2017 Julio | 105 | 33 | 138 |
| 2017 Junio | 113 | 41 | 154 |
| 2017 Mayo | 129 | 37 | 166 |
| 2017 Abril | 95 | 29 | 124 |
| 2017 Marzo | 107 | 31 | 138 |
| 2017 Febrero | 93 | 15 | 108 |
| 2017 Enero | 94 | 30 | 124 |
| 2016 Diciembre | 123 | 19 | 142 |
| 2016 Noviembre | 147 | 22 | 169 |
| 2016 Octubre | 138 | 23 | 161 |
| 2016 Septiembre | 263 | 25 | 288 |
| 2016 Agosto | 155 | 30 | 185 |
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| 2016 Junio | 8 | 20 | 28 |
| 2016 Mayo | 3 | 20 | 23 |
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| 2015 Diciembre | 13 | 1 | 14 |
| 2015 Noviembre | 15 | 1 | 16 |
| 2015 Octubre | 16 | 4 | 20 |
| 2015 Septiembre | 11 | 5 | 16 |
| 2015 Agosto | 12 | 1 | 13 |
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| 2015 Junio | 123 | 9 | 132 |
| 2015 Mayo | 153 | 15 | 168 |
| 2015 Abril | 141 | 14 | 155 |
| 2015 Marzo | 133 | 6 | 139 |
| 2015 Febrero | 131 | 5 | 136 |
| 2015 Enero | 107 | 13 | 120 |
| 2014 Diciembre | 95 | 9 | 104 |
| 2014 Noviembre | 82 | 12 | 94 |
| 2014 Octubre | 107 | 18 | 125 |
| 2014 Septiembre | 89 | 13 | 102 |
| 2014 Agosto | 110 | 15 | 125 |
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| 2014 Junio | 63 | 5 | 68 |
| 2014 Mayo | 92 | 11 | 103 |
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| 2014 Marzo | 57 | 13 | 70 |
| 2014 Febrero | 51 | 21 | 72 |
| 2014 Enero | 35 | 15 | 50 |
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| 2013 Noviembre | 35 | 16 | 51 |
| 2013 Octubre | 46 | 16 | 62 |
| 2013 Septiembre | 27 | 16 | 43 |
| 2013 Agosto | 21 | 22 | 43 |
| 2013 Julio | 9 | 34 | 43 |
| 2013 Junio | 14 | 32 | 46 |
| 2013 Mayo | 11 | 28 | 39 |
| 2013 Abril | 13 | 41 | 54 |
| 2013 Marzo | 16 | 14 | 30 |
| 2013 Febrero | 29 | 8 | 37 |
| 2013 Enero | 54 | 11 | 65 |
| 2012 Diciembre | 21 | 7 | 28 |
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