INTRODUCTION
Surgical intervention is seen as the gold standard in the treatment of Squamous cell carcinoma. Yet, in cases of recurrence, repeated surgical procedures may unwittingly foment the rise of reactive keratoacanthomas at the surgical margins or edge of a newly placed skin graft.1 These rapidly proliferating epidermal tumors are considered variants of Squamous cell carcinoma. They are theorized to be induced by skin trauma and to become more aggressive with each subsequent recurrence.1 Thus, the establishment of effective non-surgical treatment regimens is paramount. Here we present a case of reactive keratoacanthomas arising at the surgical margins of recurrent Squamous cell carcinoma which had previously been excised four times including most recently via Mohs micrographic surgery. Two reparative skin grafts had also been performed. Treatment of the lesions with oral Acitretin 25 mg BID produced remarkable results with minimal side effects in under two months.
CASE REPORT
A 66-year-old male presented with multiple firm, raised, eroded papules on the dorsum of the left hand consistent with reactive, eruptive keratoacanthomas (Figure 1, 2). Over the course of the last two years, he has had three excisions and one Mohs surgery at the site for biopsy proven Squamous cell carcinomas that have continually recurred. The last excision and Mohs surgery were each followed by skin grafts. Despite successful Mohs surgery, these lesions have now reappeared. They are identical in appearance to his previous lesions and are located at the periphery of the surgical wound. Past medical history was significant for anxiety and depression as well as an appendectomy and surgical repair of a right inguinal hernia. Social and family history were noncontributory. Medications included Aspirin, Ascorbic Acid, Fluticasone Propionate, and Lorazepam.
Given the reappearance of these lesions, despite multiple excisions and a successful Mohs surgery, alternative treatment modalities were considered. After obtaining lab work, the decision was made to start the patient on oral Acitretin (Soriatane) 25 mg BID, a dose equivalent to approximately .5 mg/kg. Over the course of four weeks, the lesions significantly improved and by two months had basically resolved (Figure 3, 4). The patient tolerated the medication well, reporting minor side effects. These included generalized dryness and a resulting rash on his right arm for which he was advised to use Vaseline ointment and Triamcinolone Acetonide .025% ointment BID respectively. The lesions improved and by two months had basically resolved (Figure 3, 4). The patient tolerated the medication well, reporting minor side effects. These included generalized dryness and a resulting rash on his right arm for which he was advised to use Vaseline ointment and Triamcinolone Acetonide .025% ointment BID respectively.
Given the reappearance of these lesions, despite multiple excisions and a successful Mohs surgery, alternative treatment modalities were considered. After obtaining lab work, the decision was made to start the patient on oral Acitretin (Soriatane) 25 mg BID, a dose equivalent to approximately .5 mg/kg. Over the course of four weeks, the lesions significantly improved and by two months had basically resolved (Figure 3, 4). The patient tolerated the medication well, reporting minor side effects. These included generalized dryness and a resulting rash on his right arm for which he was advised to use Vaseline ointment and Triamcinolone Acetonide .025% ointment BID respectively. The lesions improved and by two months had basically resolved (Figure 3, 4). The patient tolerated the medication well, reporting minor side effects. These included generalized dryness and a resulting rash on his right arm for which he was advised to use Vaseline ointment and Triamcinolone Acetonide .025% ointment BID respectively.
DISCUSSION
Keratoacanthomas are rapidly proliferating epidermal tumors, considered to be a form of Squamous cell carcinoma.2 They usually progress through three clinical stages, rapidly growing over the course of 6-8 weeks, followed by a period of relative stability and then regression.3 There are multiple clinical subtypes of keratoacanthomas including solitary or multiple keratoacanthomas that develop as part of a syndrome.1
