Jpn J Ophthalmol 2004;48:497–498 © Japanese Ophthalmological Society 2004
DOI 10.1007/s10384-004-0099-2
BRIEF COMMUNICATION
Conjunctival Inverted Follicular Keratosis: A Case Report Sevin Soker Cakmak1, M. Kaan Unlu1, Bagdagul Bilek1, Huseyin Buyukbayram2, and Yildirim Bayezit Sakalar1 1
Department of Ophthalmology, Dicle University Faculty of Medicine, Diyarbakır, Turkey; 2 Department of Pathology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
Abstract Background: We report a case of inverted follicular keratosis (IFK) on the conjunctiva. A few cases of IFK have been reported in the literature, but it appears that IFK on the conjunctiva has never been reported. Case: A 21-year-old man was referred for evaluation of a conjunctival mass. Observations: By slit-lamp biomicroscopy, an 8 5 3 mm mass was observed over the nasal conjunctiva adjacent to the limbus in the left eye. An excisional biopsy of the lesion was carried out. The results of a pathologic examination showed IFK. During the 9-month follow-up period, the patient had no recurrence of the lesion. Conclusion: IFK can be considered in the differential diagnosis of conjunctival masses as a rare specific lesion. Jpn J Ophthalmol 2004;48:497–498 © Japanese Ophthalmological Society 2004 Key Words:
conjunctiva, inverted follicular keratosis
Introduction Inverted follicular keratosis (IFK) occurs as a benign, solitary nodule, predominantly on the skin of the face. The patient is most often white, usually a man, middle-aged or older (median: 45–70 years).1 IFK may mimic malignant lesions, especially squamous cell carcinoma, both clinically and pathologically.2 IFK may occur on any skin surface, the most common being the upper lid and the cheek. Typically, the lesion has been present for several weeks or months before treatment is sought.1 Controversy exists as to whether inverted follicular keratosis is a distinct hair follicle lesion, an old lesion of verruca vulgaris, or an irritated seborrheic keratosis.3
Received: September 30, 2003 / Accepted: January 19, 2004 Correspondence and reprint requests to: Sevin Soker Cakmak, Department of Ophthalmlogy, Dicle University Faculty of Medicine, TR-21280 Diyarbakir, Turkey e-mail:
[email protected]
We report a 21-year-old man with IFK on the nasal bulbar conjunctiva of his left eye and present its pathological features.
Case Report A 21-year-old man was referred for evaluation of a conjunctival mass in the left eye. The patient had first noticed the lesion 2 months previously. The tumor was not growing rapidly. The patient was in excellent health and took no medications. On examination, visual acuity was 2/20 in each eye without correction. By slit-lamp biomicroscopy, the lesion was determined to be 8 5 3 mm and yellowish with a hard surface. No adherence to scleral vessels was visible, and no lobular mass was present over the nasal conjunctiva adjacent to the limbus in the left eye (Fig. 1). The remainder of the ocular examination showed normal results. An excisional biopsy of the lesion was carried out. Results of the pathologic examination showed an inverted, cup-shaped lesion composed of multiple downward invaginations of acanthotic epithelium that were
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Jpn J Ophthalmol Vol 48: 497–498, 2004
Figure 1. The appearance of the conjunctival lesion in the left eye of a 21-year-old man when first examined.
Figure 2. Extensive keratotic and acanthotic epithelium is undergoing acantholysis and contains squamous eddies. H&E; bar 50 µm.
continuous with the markedly hyperkeratotic lesion in which the height of the keratotic mass amounted to at least half of its width. Part of the acanthotic epithelium was composed of typical acantholytic basal cells surrounding squamous eddies. Tumor cells did not show mitosis or atypia indicating malignancy. The adjacent lobules of the acanthotic epithelium were crowded together at the margins (Fig. 2). During the 9-month follow-up period the patient had no recurrence of the lesion.
Discussion IKF is a rarely occurring lesion found on the eyelids or face of middle-aged or elderly persons. Clinically, frequent diag-
nostic confusion exists between inverted follicular keratosis and actinic keratosis, seborrheic keratosis, verruca vulgaris, keratoacanthoma, and basal or squamous cell carcinoma.1 IFK can occur on the conjunctiva, although it is uncommon. IFK can be mistaken clinically for squamous cell carcinoma and a variety of benign conjunctival lesions. Sasani et al.4 reviewed 17 cases of inverted follicular keratosis. The median age of the patients at the time of surgery was 69 years. Follow-up in 14 cases showed no recurrences of IFK, which is a benign skin lesion often mistaken clinically and pathologically for a malignancy. IFK is characterized histologically by the presence of squamous eddies, acantholysis, acanthosis, and hyperkeratosis. IFK is always benign. However, some cases of IFK have been histopathologically diagnosed incorrectly as squamous cell carcinoma.1 Histopathologically, IFK resembles seborrheic keratosis. Both lesions are benign papillomatous proliferations of basaloid cells and contain horn cysts. Some researchers consider IFK to be an irritated variant of seborrheic keratosis, whereas other favor verruca vulgaris.1 However, there is a limit to the alterations in histologic appearance in response to irritation. Seborrheic keratosis following croton oil irritation or surgical trauma shows an increased rate of focal maturation; however, the characteristics of IFK, such as squamous eddies and follicular changes, are not observed.5 Diagnosis of our case was confirmed histopathologically. Schweitzer and Yanoff1 reported two cases of IFK that recurred within weeks of primary excision. Lesions were present on the lower and upper eyelids. They recommended careful excision of the primary lesion, attempting to remove all of the lesion, excisional biopsy of any secondary lesion before contemplating more drastic surgery, and careful review of the original specimen to determine the initial diagnosis of IFK or a malignant tumor. IFK may be considered in the differential diagnosis of conjunctival masses as a rare specific lesion.
References 1. Schweitzer JG, Yanoff M. Inverted follicular keratosis. A report of two recurrent cases. Ophthalmology 1987;94:1465–1468. 2. Shih CC, Yu HS, Tung YC, Tsai KB, Cheng ST. Inverted follicular keratosis. Kaohsiung J Med Sci 2001;17:40–54. 3. Ackerman AB, editor. Controversies in dermatopathology. Am J Dermatopathol 1983;5:427–475. 4. Sassani JW, Yanoff M. Inverted follicular keratosis. Am J Ophthalmol 1979;87:810–813. 5. Hori K. Inverted follicular keratosis and papillomavirus infection. Am J Dermatopathol 1991;13:45–151.
