Are You Confident of the Diagnosis?
What you should be alert for in the history
Acanthoma fissuratum cutis (AFc), originally named granuloma fissuratum, is a relatively common, although not widely recognized, cutaneous lesion induced by minor, but constant mechanical trauma. Cutaneous lesions occur typically on the lateral edges of the nasal root or on top of or behind the auricle (Figure 1). AFc is a reactive process of the skin usually caused by chronic point pressure and rubbing of either the interconnecting bridge, foot rests or arms of eyeglasses.Its clinical resemblance to malignant tumors makes it important to recognize this benign condition.
A similar appearing lesion has been described as occurring in the alveolar recess of the buccal mucosa. This was the first lesion of this type to be described. It was originally identified by Sutton., who mistook it for an epithelial tumor and called it a fissured granulomatous lesion of the upper labio-alveolar fold. He subsequently identified it as granuloma fissuratum and believed it to be a variant of granuloma pyogenicum whose existence was due to minute particles of food trapped in the oral vestibule. Eventually, even this particular lesion was attributed to a minor disturbance caused by ill-fitting prostheses, such as dentures, that caused some form of constant mechanical trauma to the mucosal site (Figure 2).The term “granuloma” for this particular lesion is a misnomer. Acanthoma fissuratum of the mucosa (AFm) is a more accurate and appropriate term.
Characteristic findings on physical examination
Characteristically, all lesions, whether they are cutaneous or mucosal, appear on physical examination as a papule or an elongated disc of tissue with a pathognomonic longitudinal fissure down its center. Cutaneous lesions appear as firm, flesh-colored to slightly erythematous and pigmented nodules at the site of focal pressure and rubbing (see Figure 1). Mucosal nodules appear similarly, except they are on mucous membranes making them moist and more supple but always displaying a central fissure (see Figure 2).
Expected results of diagnostic studies
The histology of these lesions is nonspecific, manifesting overall irregular acanthosis with a focus of central epidermal thinning or separation, representing the fissure seen clinically. Also seen are areas of compact orthokeratosis, patchy parakeratosis near the central groove, prominent stratum granulosum, superficial and mid dermal fibrosis, granulation tissue with a patchy mixed inflammatory infiltrate of lymphocytes, histiocytes, plasma cells and occasional neutrophils. Gomori elasic tissue staining has shown no significant increase in elastin within the nodule. These findings are interpreted as the end stage of an inflammatory process that commonly results in scarring (see Figure 3).
Acanthoma fissuratum has been attributed to various causes, including metal sensitivity from dental and eyeware prostheses, chronic skin infections, and seborrheic dermatitis. More importantly, when first observed, these lesions are consistantly thought to be an epithelial cancer, in particular basal cell carcinoma. It is important to recognize the clinical appearance of AF and understand its pathophysiology so that excessive diagnostic and therapeutic procedures are avoided. However, a simple biopsy of the lesion will confirm the diagnosis. Keloids can also be considered as part of the differential diagnosis.
Considering its origins and histology, treating AF with intralesional corticosteroids can also be a viable adjunctive alternative when simply eliminating the source of the persistent trauma does not cause the lesions to remit completely. Chondrodermatitis nodularis helicis should also be considered in the differential diagnoses of AF.However, the common location of chondrodermatitis nodularis helicis on the anterior surface of the pinna, and its exquisite painfulness, along with the histology, will readily differentiate these lesions from AF. Solitary prurigo nodules in an atypical location may also be confused with AF, although the histology is slightly different and there is usually a circular ulcer in its center rather than a fissure. This acanthomatous lesion is usually created by its host and additional evidence of excoriations nearby and elsewhere should be evident.
Other types of individual acanthomatous papules and nodules should be included in the list of differential diagnoses but can be distinguished by their characteristic histology.
Who is at risk for Developing Acanthoma Fissuratum?
The individuals most at risk for developing AF are those who persist in wearing ill-fitting prostheses of some sort, be it eyeware or a dental apparatus. Age or gender is not a factor in the etiology or epidemiology of AF. Only consistent point pressure, rubbing, or some form of frictional trauma to skin or mucosa will eventually develop into a nodule with a pathognomonic central fissure where the inciting prosthetic device is placed.
What is the Cause of Acanthoma Fissuratum?
AF are simple cutaneous and mucosal lesions created induced by minor, but constant mechanical trauma because of improperly fitting prosthetic devices such as eyeware and dental apparatus. The persistent mechanical trauma causes a build up of epithelium focally, which is seen as a nodule with a central depression or fissure.This central depression is located usually in the exact location where the problematic prosthetic device exerts most of its insidious trauma.
Systemic Implications and Complications
Because AF is a localized reactive process, there are no reported systemic complications or implications.
Nonsurgical treatments include readjustment of the prosthetic device and topical or intralesional corticosteroids. The surgical treatment of choice is superficial excision.
Optimal Therapeutic Approach for Acanthoma Fissuratum
Readjustment of the inciting ill-fitting prosthetic device is the sine qua non for successful treatment and may be the only therapeutic maneuver necessary. However, at times this cannot be readily accomplished, so adjunctive antiinflammatory treatment with mid- to high-potency topical corticosteroids such as triamcinolone acetonide 0.1% ointment or betamethasone diproprionate 0.05%, respectively. Intralesional triamcinolone acetonide 20 to 40 mg/ml may be required to completely reduce the nodule of AF.A shave or excisional biopsy may be mistakenly performed when AF is not recognized and an epithelial neoplasm is assumed to be the diagnosis. This simple excision will also be therapeutic, provided the causative prostheic device is readjusted or eliminated. Otherwise, AF will certainly recur.
The patient should be monitored to confirm that the ill-fitting prosthetic device was adjusted so that the causative trauma no longer exists. Once the inciting trauma has been eliminated, the area will gradually heal and the patient does not need to be seen again for this problem.
Unusual Clinical Scenarios to Consider in Patient Management
Any focal rubbing, scratching or shearing of the skin will build up an acanthomatous, nodular lesion. What differentiates one from another is how gentle the minor trauma may be. In the case of AF, the trauma is pinpoint and mostly pressure, without much shearing of the surface of the skin. A similar scenario may develop in someone who has difficulty with neurotic excoriations, neurodermatitis and prurgo nodules. In this situation, the shearing forces are extreme on the surface of the skin, which will create a characteristic clinical presentation and histology.
In an interesting report of a different type of benign reactive hyperplasia, nodular lesions of the hip were analogously identifed as acanthoma supratrochantericum.Five patients were described with well-circumscribed nodules in the area of the trochanteric prominence of the hip. The lesions were attributed to the protuberant bony anatomy and constant pressure created over the area while the patients sat or rested in bed. The contributory pressure was mostly focal and constant and no additional shearing or rubbing motion over the area could be identified.
The histology resembled that of AF, but it also was difficult to differentiate the clinical and histologic changes from an incipient decubitus ulcer. The patients were quite mobile and did not have a previous or present history of a decubitus ulcer nor did they ever develop one . Because of the distinct history, clinical picture, and histopathology of the lesions, the authors likened these nodular formations to AF and termed this relatively common entity acanthoma supratrochantericum.
What is the Evidence?
Dorn, M, Plewig, G. “Acanthoma fissuratum cutis”. Hautarzt. vol. 32. 1981 Mar. pp. 145-8. (Clinical features of AF, which occasionally may be mistaken for basal cell epitheliomas, are presented.)
Farrell, WJ, Wilson, JW. “Granuloma fissuratum of the nose”. Arch Dermatol. vol. 97. 1968 Jan. pp. 34-7. (This is the first case report and dicussion of a typical case of AF on the nose and how AF was understood in its earlier years of recognition.)
Benedetto, AV, Bergfeld, WF. “Acanthoma fissuratum. Histopathology and review of the literature”. Cutis. vol. 24. 1979 Aug. pp. 225-9. (A thorough review of the history and pathophysiology with a complete summary of all cases of AF reported up to that time.It includes the first case report describing perhaps the youngest and first African-American patient recorded in whom bilateral lesions of acanthoma fissuratum developed and were misdiagnosed as keloids but successfully treated with intralesional corticosteroids.)
Cerroni, L, Soyer, HP, Chimenti, S. “Acanthoma fissuratum”. J Dermatol Surg Oncol. vol. 14. 1988 Sep. pp. 1003-5. (Five cases of acanthoma fissuratum located along the retroauricular fold and on the nasal bridge, caused by ill-fitting eyeglasses. AF is often mistaken for a basal cell carcinoma. The definitive diagnosis can be confirmed by characteristic histology in association with the patient's history and clinical presentation.)
MacDonald, DM, Martin, SJ. “Acanthoma fissuratum–spectacle frame acanthoma”. Acta Derm Venereol. vol. 55. 1975. pp. 485-8. (The original report that renamed this entity as Acanthoma fissuratum.)
Frey, T, Barták, P. “Acanthoma supratrochantericum”. Cutis. vol. 49. 1992 Jun. pp. 412-6. (The original account of this entity.)
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