Keratoacanthoma, Clinical Case, Neoplasm, Squamous Cell Carcinoma, Teledermatology



  1. Polster, Hannah
  2. Tollefson, Christina
  3. Jacob, Sharon E.


ABSTRACT: Teledermatology is a term used to describe how dermatologic medical services are provided via telecommunication technology. This is a case of a rapidly growing skin nodule on sun-exposed skin in a patient with a long history of skin cancers.


Article Content

Teledermatology is a highly relevant modality that has been shown to increase access to dermatology to allow for more efficient patient evaluation and treatment and reduce patient wait times (Roman & Jacob, 2015; Zakaria et al., 2019). According to Whited et al. (2002), "Teledermatology consult systems can result in significantly shorter times to initial definitive intervention for patients compared to traditional consult modalities, and, in some cases, the need for a clinic-based visit can be avoided." Teledermatology is a valued aspect of dermatological clinical practice with proven benefits and endless potential (Roman & Jacob, 2015).


In the store-and-forward teledermatology modality, there is an electronic transfer of a patient's medical information that includes both the history and visual data obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the Teledermatology Viewpoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.




Chief Complaint

Painful nodule on the back of the hand.



A 67-year-old gentleman has developed a painful solitary nodule on the back of his right hand between the thumb and wrist, which he states grew rapidly over the last month (Figure 1). He has a history of multiple precancerous grows and nine nonmelanoma skin cancers. Attempted treatments include triple antibiotic ointment, which provided no relief, and over-the-counter wart removal therapy, which caused the lesion to be more sore. Prior biopsy: none. Other significant laboratory/study findings: none.

Figure 1 - Click to enlarge in new windowFIGURE 1. The image shows a well-differentiated, red, firm-appearing nodule with central keratotic crater and scale located on the dorsal right hand between the thumb and wrist.


Fully satisfactory.



The consult includes one image that shows a solitary, well-circumscribed, erythematous, firm-appearing nodule with a central crater and adherent scale on the dorsal right hand.



Image A


The clinical findings and history of rapid growth of this solitary tumor are highly suggestive of a keratoacanthoma (KA).



Referral for face-to-face evaluation for skin biopsy.



KAs are rapidly growing, cutaneous neoplasms that predominantly present on sun-exposed skin areas. They are most common in fair-skinned, elderly men, and major risk factors include ultraviolet radiation, immunosuppression or immunodeficiency, and trauma (Kwiek & Schwartz, 2016). They routinely exhibit a proliferative (early, rapid growth) stage and may show a stabilization (well-developed) stage and/or a regressive phase (Kwiek & Schwartz, 2016). An article published in The Journal of Dermatology studied the natural course of KAs in more depth. Of 53 KAs in various stages of development, the regression rate was 98.1% after 4-8 weeks of observation (Takai et al., 2015). In every patient, each tumor was diagnosed histopathologically via fusiform partial biopsy of the entire tumor that included its center and both sides (Takai et al., 2015).


KAs are difficult to differentiate clinically from squamous cell carcinoma (SCC), making biopsy an important confirmatory test. Distinguishing KA from SCC is important because the former is generally considered a low-grade tumor in comparison with the latter (Chuang, 2018). Histopathologically, KAs have a characteristic well-defined architecture with a central keratinous plug, lack of nuclear atypia, and minimally infiltrating borders, features that support a benign growth (Takai, 2017). Of note is the "KA-like SCC," a unique type of tumor that has the benign crateriform architecture of a KA but with an asymmetrical outline, a focally prominent infiltrating border, and atypical keratinocytes, characteristics indicating a more malignant tumor, like SCC (Takai, 2017). Because the KA-like SCC subtype exhibits features of malignancy, these lesions are usually removed with a relatively minor surgery (Takai, 2017).


Despite their potential for spontaneous regression, KAs are usually treated rather than observed, unless involution is present (Kwiek & Schwartz, 2016). There are surgical and medical treatment options. Surgical excision is the gold standard, as KAs may grow large and become disfiguring, or there is the potential for transformation into an invasive SCC (Kwiek & Schwartz, 2016). More conservative treatment options include topical fluorouracil, intralesional methotrexate, or electrodesiccation and curettage (Chuang, 2018; Kwiek & Schwartz, 2016). Lasers, cryotherapy, and photodynamic therapy may be used for treatment as well (Kwiek & Schwartz, 2016). Rarely, patients may exhibit one of several syndromes in which they develop multiple KAs. Some of these conditions are the following: multiple familial KAs of Ferguson-Smith, also known as multiple self-healing squamous epithelioma, and generalized eruptive KA of Grzybowski. In addition to the traditional treatments, these patients may be started on systemic retinoids as a preventive measure, as hundreds of lesions may develop and the surgical removal of all lesions is impractical (Kwiek & Schwartz, 2016).



The rapid growth of these lesions often causes concern for both the patient and the evaluating provider. Proper referral to dermatology with biopsy and treatment can provide both the patient and provider reassurance and education. Nurses should use these opportunities as teachable moments for patients to discuss the importance of monthly self-skin checks and to review features that are common to skin cancers. Skin cancers often present as lesions that are asymmetric, with irregular borders and coloring, with dimensions larger than 6 mm, or having evolving features. This is often referred to as the ABCDE (Asymmetry, Border, Color, Diameter, Evolving) rule and can serve as a helpful reminder to patients.




Chuang T. Y. (2018). Keratoacanthoma. Medscape.[Context Link]


Kwiek B., Schwartz R. A. (2016). Keratoacanthoma (KA): An update and review. Journal of the American Academy of Dermatology, 74(6), 1220-1233. [Context Link]


Roman M., Jacob S. E. (2015). Teledermatology; virtual access to quality dermatology care and beyond. Journal of the Dermatology Nurses' Association, 6(6), 285-287. [Context Link]


Takai T. (2017). Advances in histopathological diagnosis of keratoacanthoma. The Journal of Dermatology, 44(3), 304-314. [Context Link]


Takai T., Misago N., Murata Y. (2015). Natural course of keratoacanthoma and related lesions after partial biopsy: Clinical analysis of 66 lesions. The Journal of Dermatology, 42(4), 353-362. [Context Link]


Whited J. D., Hall R. P., Foy M. E., Marbrey L. E., Grambow S. C., Dudley T. K., Datta S., Simel D. L., Oddone E. Z. (2002). Teledermatology's impact on time to intervention among referrals to a dermatology consult service. Telemedicine Journal and E-Health, 8(3), 313-321. [Context Link]


Zakaria A., Maurer T., Su G., Amerson E. (2019). Impact of teledermatology on the accessibility and efficiency of dermatology care in an urban safety-net hospital: A pre-post analysis. Journal of the American Academy of Dermatology, 81(6), 1446-1452. [Context Link]


1The standardized teledermatology reader format is available for authors on the journal's website ( and on the submissions website online at [Context Link]