Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Net Letter
87 (
3
); 455-455
doi:
10.25259/IJDVL_224_20

A rare case of inverted follicular keratosis in an elderly male: Dermoscopic and histopathological overview with therapeutic response to imiquimod

Department of DVL, IMS and SUM Hospital, Siksha O Anusundhan University, Bhubaneshwar, Odisha, India
Department of Ophthalmology IMS and SUM Hospital, Siksha O Anusundhan University, Bhubaneshwar, Odisha, India
Department of Pathology, IMS and SUM Hospital, Siksha O Anusundhan University, Bhubaneshwar, Odisha, India

Corresponding author: Dr. Arunima Ray, Department of DVL, IMS and SUM Hospital, Siksha O Anusundhan University, Bhubaneshwar, Odisha, India. arunima.roma@gmail.com

Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Ray A, Panda M, Samant S, Mohanty P. A rare case of inverted follicular keratosis in an elderly male: Dermoscopic and histopathological overview with therapeutic response to imiquimod. Indian J Dermatol Venereol Leprol 2021;87:455.

Sir,

Inverted follicular keratosis is a benign tumor of the follicular infundibulum, commonly treated with surgical excision. It usually presents as a solitary lesion over the face and neck. The diagnosis is based on histopathological findings and common clinical differentials are squamous cell carcinoma, basal cell carcinoma, keratoacanthoma and warts.1

Due to its predilection for elderly patients and its site, inverted follicular keratosis clinically masquerades as a malignant growth. This makes it diagnostically noteworthy.

We are reporting this case for its rarity, dermoscopic and histopathologically aided conclusive diagnosis and the satisfactory treatment response with topical imiquimod.

A 63-year-old man presented to the dermatology outpatient department (IMS and SUM Hospital, Bhubaneswar) with a single well-defined, painless, skin-colored plaque (1 cm × 0.5 cm) over the margin of his left upper eyelid. The surface was irregular, verrucous with crusting and without any friability [Figure 1]. The plaque was slowly growing over the last three months. No other lesions were present elsewhere and the patient was not on any medications.

Single irregular verrucous plaque (1 cm × 0.5 cm) over the upper left eyelid
Figure 1:
Single irregular verrucous plaque (1 cm × 0.5 cm) over the upper left eyelid

There were no complaints of ocular morbidity except for local conjunctival congestion in the left eye. On slit-lamp examination, there was very mild conjunctival congestion present locally near the eyelid.

On dermoscopy (using DermLite DL3N with iPhone X), yellow-white structureless amorphous areas with central keratinous plugs, white lines, red dots (blood spots), milky red areas and hairpin vessels surrounded by a whitish halo were seen [Figure 2].

Dermoscopy (DermLite DL3N with iPhone X attachment at 10×, polarized mode) showed linear vessels with whitish halo (blue arrow), yellow white structureless areas (red arrow), red dots (yellow arrow), white lines (green arrow) and glomerular vessels (orange arrow)
Figure 2:
Dermoscopy (DermLite DL3N with iPhone X attachment at 10×, polarized mode) showed linear vessels with whitish halo (blue arrow), yellow white structureless areas (red arrow), red dots (yellow arrow), white lines (green arrow) and glomerular vessels (orange arrow)

Histopathological examination revealed a stratified, squamous epithelium with hyperkeratosis, parakeratosis, foci of keratin plugging and dense inflammation with inverted papillomatosis, acanthosis and a number of squamous eddies.. There was no cellular atypia, cell nests or abnormal mitotic figures [Figures 3-5].

Scanner view shows an endo-exophytic growth with features of hyperkeratosis, acanthosis and inverted papillomatosis (H and E stain, 4×)
Figure 3:
Scanner view shows an endo-exophytic growth with features of hyperkeratosis, acanthosis and inverted papillomatosis (H and E stain, 4×)
Numerous squamous eddies are visible (H and E stain 10×)
Figure 4:
Numerous squamous eddies are visible (H and E stain 10×)
H and E stain, 40×), a single squamous eddy is visible (yellow arrow)
Figure 5:
H and E stain, 40×), a single squamous eddy is visible (yellow arrow)

The patient was advised to apply 5% imiquimod cream for three consecutive days a week for four weeks. To avoid any local irritation, strict instructions were given to apply petrolatum jelly around the plaque to avoid any spillover to the normal skin.

After two weeks of commencement of treatment, he had conjunctival congestion and watering of eyes which was treated with mild steroid (loteprednol) eyedrops in tapering doses and lubricant eye drops. Conjunctival congestion subsided within two weeks without any further complaints.

Patient continued to apply imiquimod over the next two weeks and a significant regression in the size of the plaque (more than 80%) was seen [Figure 6].

Significant regression in plaque is seen after 4 weeks of topical imiquimod application
Figure 6:
Significant regression in plaque is seen after 4 weeks of topical imiquimod application

Inverted follicular keratosis usually presents as solitary lesion, principally in elderly men. The classical histopathological sign is squamous eddies which are tight whorls of bland appearing squamous cells which are irritated keratinocytes. It shares a pathogenic consanguinity with irritated seborrheic keratosis.

Seborrheic keratosis has a predominantly exophytic component, and inverted follicular keratosis has a downward growing component characterized by endo-exophytic growth.2 Some consider inverted follicular keratosis as a rare variant of seborrheic keratosis while some others consider it as a distinct entity.

Llambrich et al. in one of the largest dermoscopic series on inverted follicular keratosis found that 83.3% of patients showed hairpin vessels, 75% showed white structureless areas and scales, 66.6% showed keratin, and 33.3% had blood spots.3 Hairpin vessels along with white structureless areas, which is the keratoacanthoma like pattern, was seen in 58.3% of their patients. All these findings were seen in our patient also. Other dermoscopic studies on inverted follicular keratosis also show such findings.4

The exact etiopathogenesis of this entity is unknown. Association with human papillomavirus infection, seborrheic keratosis, viral warts and Cowden Syndrome has been seen.5 Surgical excision is the preferred treatment. However, due to the delicate site over the eyelid, imiquimod cream was preferred in this patient. Karadag et al. has reported successful treatment of inverted follicular keratosis with topical 5% imiquimod cream.In our patient, 5% imiquimod cream applied three times per week for four weeks produced significant regression by over 80% [Figure 6].

Imiquimod has both antitumor and antiviral activity, with antiangiogenic properties, which upregulates the endogenous antiangiogenic mediators like tissue inhibitor of matrix metalloproteinase and downregulates proangiogenic molecules like basic fibroblast growth factor and matrix metalloproteinase.

Owing to its site, morphological ambiguity and predilection for elderly, inverted follicular keratosis may be mistaken as a malignant growth. This is a cause for concern in the patient and adequate counselling regarding the benign nature of the lesion must be done with histopathological evidence. Even though rare, inverted follicular keratosis should be considered as a differential among conditions like squamous cell carcinoma, basal cell carcinoma, seborrheic keratosis, keratoacanthoma and verruca [Table 1].

Table 1: Clinical, dermoscopic and histopathological comparison of differentials of inverted follicular keratosis
Differential diagnoses Inverted follicular keratosis Viral warts Seborrheic keratosis Actinic keratosis BCC Squamous cell carcinoma
Clinical feature Solitary papule with irregular surface and crusting Firm papules with rough horny surface Verrucous plaques in stuck-on appearance Erythematous papules or plaques, adherent dry scales. With varying degrees of hyperkeratosis Prominent surface telangiectasia. Nodular BCC is pink or red colored. Cystic center gives a translucent appearance Verrucous or ulcerated plaque with an ill-defined base extending beyond tumor margins
Dermoscopic feature Yellow-white structureless areas, keratin plugs, red dots, hairpin vessels with white halo Lobular, frog spawn structure, red dots, and loss of dermatoglyphics Cerebriform pattern, comedo-like openings, milia-like cysts, moth eaten border and hairpin vessels Erythema in reddish vascular pseudo network, yellow-white scales, thin and wavy vessels, follicular openings with keratotic plugs5 Arborizing vessels or surface telangiectasia over milky red background (vascular blush). Blue gray nests and spoke wheel pattern also White structureless area, white perifollicular areas, blood spots, polymorphic vessels3
Histopathological feature Hyperkeratosis, inverted papillomatosis, acanthosis and squamous eddies with endo exophytic growth Acanthosis, hyperkeratosis, koilocytosis, papillomatosis Hyperkeratosis, irregular acanthosis, keratin filled invaginations, marked papillomatosis, squamous eddies in irritated variant with exophytic growth Hyperkeratosis, parakeratosis, loss of polarity, nuclear crowding, nuclear hyperchromatism, hypogranulosis, nuclear pleomorphism, increased epidermal mitotic activity Marginal palisading pattern with well-organized stroma. Mitotic figures are seen. Tumor buds appear from the epidermis Atypical keratinocytes breach epidermal basement membrane, and invade the dermis. Pleomorphic cells are seen

BCC = basal cell carcinoma

Surgical excision ensuring complete removal can be difficult in delicate areas. Topical 5% imiquimod cream has been used only rarely for this condition so far. Our experience shows that application of topical imiquimod is safe and effective even in such delicate areas if used judiciously.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , , , . Inverted follicular keratosis successfully treated with imiquimod. Indian Dermatol Online J. 2016;7:177-9.
    [CrossRef] [PubMed] [Google Scholar]
  2. , . Inverted follicular keratosis. J Clin Pathol. 1975;28:465-71.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , , , , , et al. Dermoscopy of inverted follicular keratosis: Study of 12 cases. Clin Exp Dermatol. 2016;41:468-73.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , , , et al. Inverted follicular keratosis: Dermoscopic and reflectance confocal microscopic features. Dermatology. 2013;227:62-6.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , . Multiple inverted follicular keratoses as a presenting sign of Cowden's syndrome: Case report with human papillomavirus studies. J Am Acad Dermatol. 2004;51:411-5.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
7,232

PDF downloads
3,097
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections