ARTICLE
A 55-year-old man presented with a nodular lesion on the right nasal
ala. Medical history revealed that the lesion had appeared two months
earlier and it grew quickly to about 2 cm in size. The patient had been
on anticlotting drugs for ischemic cardiomyopathy for several years. Otherwise
the patient's history, physical examination and laboratory investigations
were unremarkable.
Clinical examination showed a pinkish-red, dome-shaped nodule with a
central keratotic plug. Consistency was hard-elastic and the mass was
mobile on the underlying layers (Fig.
1). Although the patient did not report any subjective symptoms,
there was an evident alteration of the anatomical proportions in the nose
area.
Keratoacanthoma treated
with intralesional bleomycin
Diagnosis of keratoacanthoma was made based on the clinical appearance,
on the time scale of the onset of the lesion and on the histological examination
of a full-thickness fusiform biopsy specimen excised from the center of
the lesion. We therefore opted for intralesional bleomycin therapy. Bleomycin
was dissolved in normal saline solution to a concentration of 1 mg/ml
and further diluted with an equal amount of 0.5% marcaine to attenuate
the pain caused by the bleomycin injection; 0.4 ml of the solution was
injected with 30-gauge needles inserted tangentially into the slopes of
the lesion. The injection was repeated one week later. A week after the
first injection the lesion became fluctuant and on removal of the central
plug a whitish, necrotic mass was discharged, leaving an elevated peripheral
border, which became completely flat a week after the second injection.
Eighteen months after the first injection, no recurrence was observed
and the aesthetic results were excellent. Only a small unpigmented depression
remained (Fig. 2). The
patient's compliance was very good.
Comments
Keratoacanthoma is a common, rapidly growing squamous tumour of unknown
etiology, developing from a hair follicle. It shows a histological similarity
to squamous cell carcinoma. Many forms of this benign epithelial tumor
have been described, but the usual clinical findings are a single lesion
on sun-exposed skin, particularly on the face and backs of the hands.
The growth normally reaches full size in a few weeks and involutes spontaneously
within several months [1-4]. Altough the malignant potential of keratoacanthoma
is still unclear, the vast majority of keratoacanthomas seem to be benign
and do not metastasize. Keratoacanthomas are often known to undergo spontaneous
involution, the result of which may be a depressed, hypopigmented, pitted
or puckered scar [1, 3-5]. In areas such as the ears, nose, lips and fingers
the scar may cause considerable deformity. In fact, even the most common
and conservative surgical techniques may have unsightly results in these
sensitive areas. In such cases, especially when there are technical contra-indications
to surgery, alternative therapies that give good results are to be preferred.
Since keratoacanthoma itself is self-healing, treatments that cause scarring
are to be avoided [3-5].
Several types of treatment have been used for
keratoacanthoma, all with beneficial effects. They include surgical excision,
electrocoagulation and curettage, cryosurgery, fractioned soft X-rays
(20-40 Gy), intralesional steroids, topical or intralesional 5-fluorouracil,
intralesional bleomycin, systemic isotretinoin or etretinate and intralesional
interferon. In choosing the type of treatment, the following factors need
to be considered: site, size and number of lesions, recurrence, age and
general condition of the patient, competence of the clinician with various
therapeutic techniques, aesthetic considerations compatible with complete
removal of the growth, and patient compliance [1, 5].
Bleomycin is an antineoplastic agent isolated
from Streptomyces verticillus. In dermatology it is mainly used
in the therapy of tumors of epithelial origin and common disseminated
warts [6-9]. Intralesional administration of bleomycin is a codified therapy
for keratoacanthoma. It gives good aesthetic results because it does not
cause scarring. Complete resolution of the lesion takes from two to six
weeks [6, 7]. In the present case, the tumor resolved quickly, with minimum
discomfort for the patient. The aesthetic and functional outcome was excellent.
REFERENCES
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