Case Report : Clinical Outcome of Surgical Treatment for Periocular

Keratoachantoma: A Case Report

Agenda : 11th Case Report
Day/date : Wednesday / 18th May 2022 (pukul 08.00)
Moderator : dr.Tutty Ariani, Sp.DV
Counsellor : dr. Ennesta Asri, Sp.KK(K), FINSDV
Counsultant : dr. Rina Gustia, Sp.KK(K), FINSDV, FAADV
dr. Irdawaty Izrul, Sp.KK, FINSDV, FAADV

Miranda Ashar
Resident of Dermatology and Venereology Department
Medical Faculty of UNAND / Dr. M.Djamil Hospital Padang

Clinical Outcome of Surgical Treatment for Periocular Keratoachantoma:

A Case Report

Abstract
Background: Keratoachantoma that has a predilection for the periorbital region is a
prominent, cosmetic, and functional area to protect the eyeball. Surgical treatment is often
need a higher-quality reconstructive surgery. Reconstructive surgery needs to be planned
to repair defect after excision tumor.
Case Report: We report of a case on 62 years old woman with a chief complaint lump like
horn with blackish crusts on left lower eyelid that are a little itchy and getting bigger since
2 weeks ago. Patient complained of lump that not feel itchy and not pain with size like a
corn seed appeared on the left lower eyelid since 10 years ago. Patient was exposed to the
sunlight for about 15 to 30 minutes and did not wear sunscreen or hat. Dermatology
examination showed elongated tumor like horn with black crust on left lower eyelid with
size 0,8 cm x 0,5 cm x 0,7 cm. Dermoscopy examination showed yellowish-white keratin,
linear vessel, and whitish area. Histopathological examination showed stratified squamous
epithelium that undergoes hyperplasia, hyperkeratosis, papillomatosis, acanthosis and grew
to form an epidermal lipping resembling a crater. Patient was treated with excision and
rotation flap with tumescent under general anesthesia.
Discussion: The aim of reconstruction is to repair the defect suitable to normal
physiological and anatomical values. The defect width and anatomical localization must be
evaluated before we do surgical treatment. The most suitable reconstruction method must
be identified. The required functional and esthetical results can be obtained with
intraoperative flexible behavior and a change of method when necessary.
Keywords: Keratoachantoma, reconstructive surgery, periorbital

Abstrak
Latar Belakang: Keratoakantoma memiliki predileksi pada daerah periorbital yang
merupakan daerah khusus, menonjol, kosmetik, dan fungsional untuk melindungi bola
mata. Terapi bedah seringkali memerlukan pembedahan rekonstruktif berkualitas tinggi.
Bedah rekonstruktif perlu direncanakan untuk memperbaiki defek setelah eksisi tumor.
Kasus: Kami melaporkan suatu kasus perempuan usia 62 tahun dengan keluhan utama
benjolan seperti tanduk dengan krusta kehitaman pada kelopak mata kiri bawah yang
sedikit terasa gatal dan semakin bertambag besar sejak 2 minggu yang lalu. Pasien
mengeluhkan benjolan yang tidak terasa gatal dan tidak nyeri sebesar biji jagung di kelopak

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mata kiri bawah sejak 10 tahun yang lalu. Pasien sering terpapar sinar matahari selama 15
– 30 menit dan tidak memakai sunscreen atau topi. Pemeriksaan status dermatologikus
menunjukkan tumor yang memanjang seperti tanduk dengan krusta kehitaman pada
kelopak mata kiri bawah dengan ukuran 0,8 cm x 0,5 cm x 0,7 cm. Pemeriksaan
dermoskopi ditemukan yellowish-white keratin, linear vessel, dan whitish area.
Pemeriksaan histopatologi menunjukkan epitel berlapis gepeng yang mengalami
hiperplasia, hiperkeratosis, papilomatosis, akantosis, dan tumbuh membentuk epidermal
lipping menyerupai kawah. Pasien diterapi dengan eksisi dan rotation flap dengan tumesen
dan anestesi umum.
Diskusi: Tujuan rekonstruksi adalah untuk memperbaiki defek yang sesuai dengan nilai
fisiologis dan anatomis yang normal. Luasnya tumor dan lokalisasi anatomi harus
dievaluasi sebelum terapi bedah dilakukan. Metode rekonstruksi yang paling cocok harus
diidentifikasi. Hasil fungsional dan estetika yang diperlukan dapat diperoleh dengan
perilaku fleksibel intraoperatif dan perubahan metode bila diperlukan.
Kata kunci: Keratoakantoma, bedah rekonstruksi, periorbital

INTRODUCTION
Keratoacanthoma (KA) is defined as a benign keratinocytic neoplasm which
arises from human’s hair follicle. Keratoachantoma usually erupts rapidly within a
few weeks and has the ability to spontaneously regress. The true incidence of KA
is probably underestimated because of misdiagnosis as a SCC, underreporting KA
by physicians, or spontaneous regression before the diagnosis can be made.1
Keratoachantoma is frequently seen in the elderly people with light skins and in the
areas which are exposed to sun, especially lips, the vermilion border of the lips,
cheeks, nose and the back of the hands.2 In one of the earliest series, Baer and Kopf
reviewed 592 cases of keratoacanthoma, and found that more than 70% of tumours
were located on the face, and 33 cases were periocular (5.6%).3
Keratoacanthoma (KA) is a clinically common, low-grade tumor that
appears to arise from hair follicles. It has several variants, including solitary KA,
KA centrifugum marginatum (characterized by central healing and peripherally
expanding growth), subungual KA (which shows rapid growth with nail dystrophy,
and no tendency to regress), giant KA (with diameter >3 cm), multiple KA
(Ferguson–Smith or Grzybowski types), and a mixed eruptive and self-healing type
(Witten–Zak type).4,5
Controversies remain about the management of the solitary KA. A wait-
and-see strategy for a solitary KA, which assumes spontaneous regression, is
questionable unless clear signs of involution are already present.6 One cannot
predict the final size of a KA that can reach several centimeters before it will regress,

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leaving a potentially disfiguring scar. The potential for transformation into invasive
SCC with metastases is extremely low; however, it has to be considered when
choosing the treatment. Surgical treatment is a gold standard regimen with full-
thickness fusiform excision providing good esthetic outcome and an optimal
specimen for the pathologist. Unfortunately, there are no specific margins
established for KA, but the same as for noninvasive SCC can be advised (5 mm) to
assure 95% chance of complete removal.1
Following tumor removal in the periocular region, reconstruction of the
defect requires understanding of the differences and uses of soft tissue flaps and
skin grafts. Flaps are usually preferred over grafts because homogeneity of skin
color and texture more likely leads to better unification with surrounding tissue.
Because the eyelid is a layered structure, appropriate layered reconstruction is
essential, with the goal towards restoring periocular function and minimizing any
postsurgical complications. Proper eyelid volume and shape should be strived for. 7
The face and eyelids have extensive vascular supply. Because of this, the
design of rotational flaps based on a particular arterial supply is not necessary. The
subdermal vascular plexus can provide adequate blood flow to support random
flaps. Complications are more common in patients with a history of facial surgery,
smoking, vascular disease, and radiation. It is important to minimize horizontal
tension, which is why incisions should be made in conjunction with relaxed skin
tension lines. This promotes proper wound healing and decreases the chances of
tissue necrosis and eyelid malposition. Most of the time, the problem of tension is
lessened due to the fact that many skin cancer patients are elderly with increased
skin elasticity.7

CASE REPORT
Patient identity
Name : Mrs. N
MR : 01.10.54.53
Age : 62 years old
Occupation : Housewife
Sex : Female

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Address : Jl. Berok RT 002, RW 003, Gunung Pangilun
Ethnic : Minang
Religion : Moeslem
Status : Married
Phone number : 08529767xxxx

A 62 years old female patient came to Dermatology and Venereology

Department RSUP Dr. M. Djamil Padang on May 17th, 2021 with:

Chief complaint:

Lump like horn with blackish crusts on left lower eyelid that are a little itchy and
getting bigger since 2 weeks ago.

Present Illness history:

• Initially ± 10 years ago, lump that not feel itchy and not pain with size like
a corn seed appeared on the left lower eyelid. Patient did not treat her
complaint. Lump was not getting bigger.
• ± 2 weeks ago, the lump was getting bigger and resembling a horn. The
patient never cut the lump, but sometimes patient often scratches the lump.
• There was no history of taking immunosuppressive drugs for long time
(corticosteroids, leflunomide, anti-tumor necrosis factor alpha,
chemotherapy) before.
• There was no history of lumps in other body parts.
• There was no history of lump that easily blood or ulcers.
• There was no history of suffering from immunodeficiency and chronic
diseases such as leukemia, chronic ulcer, burn scars, and HIV.
• Patient is exposed to the sunlight when drying clothes or cleaning the yard.
Patients are usually exposed to the sunlight between 9 a.m. to 10 a.m. and 4
p.m. to 5 p.m. for about 15 to 30 minutes. The patient does not wear
sunscreen and hat before drying clothes or cleaning the yard.

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 • There was no history of exposure to chemicals agent such as arsenic
(pesticide used) and polycyclic aromatic hydrocarbons (coal-fired power
plants) in longterm.
• There was no history of used tattoos.
• There was no history of warts.

Previous Illness history:

• There was no history of having lump like this before.
• There was no history of diabetes mellitus
• There was no history taking anti-platelet medicine was denied
• There was no history of keloid
• There was no history of bleeding disorder
• There was no history of drug allergy

Family Illness history:

• There was no history of lump or another skin cancer in her family.

Physical Examination:
• Consciousness : Composmentis
• General appearance : Mild illness
• Vital Sign : Blood pressure : 120/80 mmHg
Pulse rate : 86 x/min
Breath rate : 20 x/min
Temperature : 36,80C
• Nutrient state : Body weight : 50 kg
Body lenght : 150 cm
IMT : 22.2 (normoweight)
• Hair : within normal limit
• Eyes : conjungtiva anemis -/-, sclera icteric -/-
• Ear, nose, throat : within normal limit
• Cor :I : ictus cordis not seen

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 Pa : ictus cordis papable at RIC V LMCS
Pe : there is no enlargement
A : regular, murmur (-)
• Pulmo :I : simetris dextra = sinistra
Pa : fremitus dextra = sinistra
Pe : sonor
A : vesikular, Rh -/-, Wh -/-
• Abdomen : Hepar and lien are not palpable, no distension
• Extremitas : Good perfusion, warm acral
• Lymph nodes : Enlarge lymp nodes (-)

Dermatologic state:
• Location : left lower eyelid
• Distribution : localized
• Shape and arrangement : horn / soliter
• Border : defined
• Size : 0,8 cm x 0,5 cm x 0,7 cm
• Efflorescence : elongated tumor with black crust

Figure 1. Lump like horn (red arrow) with blackish crusts (blue arrow) on left
lower eyelid.

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Resume
• A 62 years old female patient with chief complaint there were lump like
horn with blackish crusts on left lower eyelid that are a little itchy and
getting bigger since 2 weeks ago. Initially 10 years ago, the patient
complained of lump that not feel itchy and not pain with size like a corn
seed appeared on the left lower eyelid. ± 2 weeks ago, the lump was getting
bigger and resembling a horn. The patient never cut the lump, but
sometimes patient often scratches the lump. Patient is exposed to the
sunlight when drying clothes or cleaning the yard. Patients are usually
exposed to the sunlight between 9 a.m. to 10 a.m. and 4 p.m. to 5 p.m. for
about 15 to 30 minutes. The patient does not wear sunscreen and hat before
drying clothes or cleaning the yard.
• On dermatologic state there were elongated tumor like horn with black crust
on left lower eyelid with size 0,8 cm x 0,5 cm x 0,7 cm.

Working Diagnosis:
Suspect Keratoachantoma

Differential diagnosis:
Actinic Keratosis type cutaneous horn

Planning:
• Dermoscoy examination
• Routine blood examination, diff.count, PT, APTT, SGOT, SGPT,
electrolyte, blood ureum, blood creatinine, GDS
• Thorax X-ray examination
• Consult to Internal Department for tolerance operation
• Consult to Pulmonology Department for screening COVID-19
• Consult to Anesthetist Department for operation with general anesthesia
• Histopathological examination

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Dermoscopy Examination:

Figure 2. Dermoscopy examination showed yellowish-

white keratin (red arrow).

Figure 3. Dermoscopy examination showed linear vessel

(black arrow), whitish area (blue arrow).

Laboratory Finding:
• Hemoglobin : 12,6 g/dl (N = 12 – 14)

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 • Hematokrit : 39 % (N = 37 – 43)
• Leucocyte : 7.180/mm3 (N = 5000 – 10000)
• Trombocyte : 236.000/mm3 (N = 150.000 – 400.000)
• Diff.count :
Basophils :0 (N = 0-1)
Eosinophils :1 (N = 1-3)
Stem neutrophils :4 (N = 2.0-6.0)
Segmented neutrophils: 60 (N = 50-70)
Limphocytes : 20 (N = 20.0-40.0)
Monocytes :5 (N = 2.0-8.0)
• Blood Ureum : 38 mg/dl (N = 10 – 50)
• Blood Creatinin : 0,8 mg/dl (N = 0,6 – 1,2)
• Natrium : 140 Mmol/L (N = 136 – 145)
• Kalium : 3,9 Mmol/L (N = 3,5 – 5,1)
• Clorida : 102 Mmol/L (N = 97 – 111)
• SGOT : 27 u/l (N = < 32)
• SGPT : 23 u/l (N = < 31)

Result of Thorax X-ray examination:

No pulmonary abnormalities and cardiomegaly were found.

Result of Consult to Pediatric Department:

PCR swab results of Covid-19 : negative.

There are no contraindications to electrosurgery under general anesthesia.

Result of Consult to Anesthetist Department:

There are no contraindications to do general anesthesia.

Result of Histopathologic Examination (PJ 1276-2021)

Macroscopic
A piece of brownish white skin tissue, chewy dense with a size of 1 x 0.8 x 0.5 cm
Microscopic

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The surface is covered with stratified squamous epithelium that undergoes
hyperplasia, hyperkeratosis, papillomatosis, acanthosis and grows to form a crater-
like epidermal lipping.

Figure 4. The microscopic view showed skin tissue with keratinized stratified
squamous epithelium that protrude to form "epidermal lipping" (blue arrow)
resembling a crater containing keratin pearls (black arrow). (H&E, 4x)

Figure 4. The microscopic view showed papillomatosis

(black arrow). (H&E, 4x)

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 Figure 5. The microscopic view showed
achantosis (black square) and no mitotic cells and
invagination at the lower border of the tumor
(blue circle). (H&E, 40x)

Diagnosis
Keratoachantoma

Treatment:
Excision + flap with tumescent under general anesthesia

Prognosis:
• Quo ad vitam : bonam
• Quo ad sanationam : bonam
• Quo ad cosmeticum : bonam
• Quo ad functionam : bonam

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Surgical Treatment:
• Before the patient enters the operating room: making a rotation flap.

Figure 6. Design of flap

• In operation room:
After excision of the tumor, simple closure turned out to be feasible because
the elasticity of the skin on the patient's lower eyelid had decreased, so that
reconstruction using a flap was not performed.

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Follow up:
June 8th 2021
Anamnesis • No new lumps appear
• Post-excision wound still wet, no pus, and no pain
• Patient has no fever
Physical Consciousness : composmentis
examination Blood pressure: 120/70 mmHg
Pulse rate : 92 x/min
Breath rate : 20 x/min
Temperature : 36,6C

Suture wound : still wet, no erythema and edema around suture

wound, no pus
Diagnosis Diagnosis :
Post-excision keratoachantoma with general anesthesia
Treatment Topical therapy:
• Fusilex cream 2% twice daily on erotion

Figure 4. Suture wound was stiil wet, no

erythema and edema around suture wound, no
pus.

DISCUSSION
Keratoacanthoma based on the competence of the dermatology and
venereology collegium is the competence of the 4 divisions of skin surgery tumors.
Keratoachantoma commonly is regarded as a subtype of highly
differentiated SCC with typical clinical and histopathologic features.8 Most cases
develop in older persons, particularly in the sixth and seventh decades. There is a

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male preponderance. Keratoacanthomas are more frequent in subtropical areas.9
The annual incidence of cutaneous keratoacanthoma varies according to
geographical location. It was estimated to be 104 cases per 100 000 in Hawai and
as high as 150 cases per 100.000 in the northern areas of Australia.
Keratoachantoma usually erupts rapidly within a few weeks and has the ability to
spontaneously regress. KA is reported to be a lesion which rapidly grows during 6
to 8 weeks. The growth phase is followed by a growth-stop period and then by a
four-to six-week period of impulsive regression. After the lesion is resolved, an
atrophic and hypopigmented scar is left.3 In this patient, patient was a 62 years old
female that diagnosed with keratoachantoma. One of the factors that influence
patients to experience keratoacanthoma is that the patient lives in the tropics and is
often exposed to the sun without using sunscreen.
Keratoachantoma clinically presents as a sharply circumscribed firm nodule
with a central horn-filled crater that commonly arises on sun exposed and hair
bearing areas of elderly patients, mainly on the face, forearms, and hands.5 Boniuk
and Zimmerman reported a large series of 44 patients with periocular
keratoacanthoma that 58% were located on the lower lid, 35% on the upper lid, and
7% on the medial or lateral canthi. In a recent report, Donaldson et al reported
another 10 patients with periocular keratoacanthoma that 50% of the lesions were
located on the lower lid, 20% on the upper lid, 20% on the medial canthus, and 10%
on the lateral canthus.10 Similar distribution was found in this patient. This
distribution correlates with the degree of sun exposure and it located in left lower
eyelid.
Keratoachantoma has several variants, including solitary KA, KA
centrifugum marginatum, subungual KA, giant KA (with diameter >3 cm), multiple
KA (Ferguson–Smith or Grzybowski types), and a mixed eruptive and self-healing
type (Witten–Zak type).1 The solitary form KA is the most common of these
variants. Its clinical presentations are characterized by a flesh to pinkcolored crater-
like nodule with a central keratotic plug. An essential clinical characteristic of
solitary KA is its self-limiting course, with rapid enlargement and spontaneous
regression. However, some authors suggest that it be classified as a low-grade type
of squamous cell carcinoma (SCC), based on cases with clinical and

14
histopathological features of solitary KA that show malignant biological behavior
such as metastasis or tumor related death.9,11 Giant keratoacanthoma was a lesion
greater than 2-3 cm in diameter. Keratoacanthoma centrifugum marginatum which
undergoes progressive peripheral growth with coincident central healing. Multiple
keratoacanthomas, which may be eruptive (Grzybowski type), self-healing (the
Ferguson Smith type, which is autosomal dominant in inheritance and caused by an
abnormality on chromosome 9q22-q31), a mixed eruptive and self-healing type
(Witten and Zak type).9 In this patient, patient was diagnosed with keratoacanthoma
and included in variant of solitary keratoacanthoma.
Actinic keratoses (also known as solar keratoses or senile keratoses) are
cutaneous lesions that consist of proliferations of atypical epidermal keratinocytes
that may progress to invasive squamous cell carcinoma (SCC). The typical AK
lesion, sometimes called the erythematous AK, presents most commonly as a 2- to
6-mm, erythematous, flat, rough, gritty or scaly papule. Beside that, there are
several subtypes of AK such as cutaneous horn. cutaneous horn is a type of
hypertrophic AK that presents with a conical hypertrophic protuberance emanating
from a skin-colored to erythematous popular base. Classical definitions of a
cutaneous horn maintain that the height is at least one-half of the largest diameter.
Approximately 21% of all cutaneous horns represent AK.12
Thong et al reported a 55-year-old Indian male with a complaint of a slow
progressing growth on his left ear pinna, which was occasionally painful and itchy
but without any episodes of bleeding or discharges. The lesion had appeared one
year prior and it occurred spontaneously, unrelated to any event of trauma or insect
bites. Examination of the left ear revealed a blackish hard curved mass, hard in
consistency, arising from the antihelix of the left ear pinna measuring 5 cm in length
and 2 cm in width at its base like a horn. Patient was diagnosed with actinic
keratoses.13 In this patient, patient complaint about lump like horn with blackish
crusts on left lower eyelid that are a little itchy and getting bigger that appeared
spontaneously. On dermatologic state there were elongated tumor like horn with
black crust on left lower eyelid with size 0,8 cm x 0,5 cm x 0,7 cm.
Dermoscopy usually helps in identifying keratoachantoma and establishing
the diagnosis. Typically, dermoscopy of KA appears as concentric circles of central

15
crater, surrounded by an ivorywhitish area and adjacent peripheral vessels and the
most outer circle of whitish halo.14 Selmer et al. in 2016 conducted a dermoscopy
features study on keratoacanthoma with the results of central keratin, blood spots,
and centred vessels were the most frequent dermatoscopic findings of KA.15
Only a few reports so far have described the dermoscopic features of AK,
and studies of specific or highly suggestive diagnostic criteria have usually focused
on AK lesions located on the face. Lesions located on the face are dermoscopically
characterized by the presence of the so-called pseudonetwork which results from
the unique anatomy of the facial skin that is devoid of rete ridges and contains
abundant, closely located follicular infundibula. In AK located on the face and in
hyperkeratotic AK, the yellowish keratotic plugs within the hair follicles have a
targetoid appearance.16 In this patient, dermoscopy examinations showed yellowish-
white keratin, linear vessel, and whitish area (blue arrow).
Keratoacanthoma is histopathologically characterized by the following
findings: (i) a tumor with exoendophytic architecture, (ii) a relatively well-defined,
almost symmetrical outline, (iii) a multilobular lesion with a central keratinous
plug, and (iv) overhanging epithelial lips covered with normal epidermis. 17
Schwartz et al. advocated three clinical stages – proliferative, mature and resolving
– based on experimental observations of its similarity to the hair cycle. This
triphasic concept is widely accepted and currently called the early proliferative,
fully developed and regressing stages. Histopathological examination at an early
proliferative stage was characterized by a few to several keratin-filled invaginations
of the infundibulocystic structures, which anastomose or merge with each other, but
do not form the central keratotic horn yet. These invaginations show the laminated
keratinization often with prominent keratohyaline granules and tend to have so-
called pale pink cells with glassy, abundant cytoplasm only in the deeper portions
(Figure 7). In fact, the well-differentiated infundibulocystic SCC reported by
Kossard et al. has been suggested to be early or proliferative stage KA. To
accurately diagnose early/proliferative stage KA, a histopathological assessment
should confirm the virtual absence of nuclear atypia in the proliferating cells of the
invaginated epidermal or infundibular structures. However, an infiltrating border is

16
an expected finding, and nuclear atypia or mitosis would likely be detectable in the
infiltrating border of the tumors.5
At the well-developed stage, KA shows: (i) a characteristic crateriform
architecture (an exoendophytic lesion with a central large keratotic plug formed by
merged, dilated infundibula located in the multilobular fashion); (ii) overhanging
epithelial lips covered with a normal epidermis; and (iii) neoplastic lobules with a
proliferation of large pale pink cells with a glassy eosinophilic cytoplasm that show
compact keratinization in most parts. Regressing stage KA is histopathologically
characterized by one or two keratin filled, shallow, cup-shaped structures formed
by the thinner epithelium, associated with dermal inflammation and fibrosis. The
keratin-filled, shallow, cupshaped structures again show infundibular
characteristics, with laminated keratinization, with a few pale pink keratinocytes
with a glassy appearance.5 In this patient, histopathology examination was found
stratified squamous epithelium that undergoes hyperplasia, hyperkeratosis,
papillomatosis, acanthosis and grows to form a crater-like epidermal lipping. Based
on the histopathological examination, the patient is included in the well
differentiated stage.
Literature Patient

Figure 5. Histopathological features of early or

proliferative stage keratoacanthoma. (a) Lesion is
Figure 6. The microscopic view showed skin
composed of the invaginated infundibular structures,
tissue with keratinized stratified squamous
which anastomose or merge, but do not yet form a
epithelium that protrude to form "epidermal
definite crater or central keratotic plug. (b) Invaginated
lipping" (blue arrow) resembling a crater
epidermal/infundibular structures show lamellar
containing keratin pearls (black arrow). (H&E,
keratinization and exhibit no nuclear atypia. (c) Deep
4x).
area shows growth of large pale pink cells in addition

17
 to the infundibular structures. (d) Infiltrating border
and nuclear atypia are seen in periphery of the lobules.

Early excision of periocular keratoacanthoma is essential, not only to

maintain normal eyelid function, but also to prevent further tissue destruction and
invasion into deeper tissues. Surgical excision with margin control is the most
appropriate method for solitary tumours, with recurrence rates of 4–8% for
cutaneous keratoacanthomas. Conventional standard excision with 4-to 6-mm
margins may be acceptable as primary treatment of local keratoachantoma. Boniuk
and Zimmerman treated most of their 44 periocular keratoacanthomas with surgical
excision (margin control was not specified), and had no cases of recurrence during
a follow up period ranging from 8 months to 11 years.10 In this patient,patient
underwent surgical excision with a margin of 5 mm because keratoacanthoma is
one of the pre-cancerous lesions.
Donaldson et al. reported 10 cases of periocular keratoachantoma. The
lesion was found on the lower lid in five patient (50%), the upper lid in two patient
(20%), the medial canthus in two patient (20%), and the lateral canthus in one
patient (10%). The maximum diameter of the lesion varied from 2 to 25 mm, with
a mean of 7.2 mm and median of 4.0 mm. Most lesions were small and well
circumscribed at presentation. All lesions were treated by surgical excision, with
frozensection control of margins in five patients (50%). Lesions in this series were
small (< 4 mm) at presentation in most cases. Because of the small size, most
defects were closed directly with good cosmetic outcome.10 In this patient, the size
of tumor was 0,8 cm x 0,5 cm x 0,7 cm and less than 4 mm. Patient was planed to
do a flap, but after excision tumor, the wound can closure with simple closure.
Kakudo et al. analyze the surgical outcomes of treatment for 49 patient with
periorbital BCC, and evaluate reconstruction method after resection. BCC was most
frequently occurred in the lower lid (55%), followed by inner canthus (19%), upper
lid (17%), and outer canthus (9%). The reconstruction methods applied in 4
different locations: upper lid, inner canthus, lower lid, and outer canthus, are
presented in figure 7.18 In this patient, patient was planed to used rotation flap.

18
 Figure 7. Reconstructive methods after periorbital BCC
removal.

The aims of the ideal reconstruction of the periorbital region are: (1) to
provide ocular surface lubricity and form an internal layer in the smooth mucus
membrane structure, protecting against corneal irritation, (2) to form tars that
imitates the shape and hardness of the lid, (3) to form fixed lid edges with the lashes
out of corneal contact, (4) to obtain medial and lateral ligaments for stability and
movement of the lid, (5) to provide enough muscles for the necessary tonus for the
movement of the lid, (6) to form a thin skin, allowing for lid movement, (7) to
provide enough levator movement to lift the upper lid, and (8) to obtain an esthetical
image. Due to these reasons, the construction of this region still includes some
difficulties for reconstructive surgeons.19
Despite the surgeon’s best effort, occasional complications may occur (see
Table 1). Approximately 10 percent of cases may require additional surgery to
correct lid malposition. This rate may be higher in patients with a history of
radiation, smoking, and previous surgery. Patients with large tumors or perineural
invasion are at a particular risk for recurrence and the index of suspicion should
remain high in patients with keratoachantoma. 7

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Table 1. Complications of eyelid reconstruction.

CONCLUSION
Periocular keratoacanthoma is a tumour that can be locally destructive and
invasive. Although the clinical and morphological presentation is characteristic in
most cases, it cannot always be differentiated from other pre-cancerous lesions.
Gold standar for treatment keratoachantoma requires complete tumour excision.
Reconstruction of periorbital defects requires special attention to both aspects of
aesthetic appearance and eyelid function. Many different techniques of
reconstructive surgery and the surgeon has some latitude to achieve the best result
and prevent complication of patient.

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 References

1. Kwiek B, Schwartz RA. Keratoachantoma: an update and review. Journal of

American Academy of Dermatology.2016;1-14.
2. Zargaran M, Baghaei F. A clinical, histopathological and
immunohistochemical approach to the bewildering diagnosis of
keratoachantoma. Journal of Dermatology Shiraz University Medical
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