Warty dyskeratoma

Warty dyskeratoma (WD) is a benign epidermal proliferation^[1] with distinctive histological findings that may mimic invasive squamous cell carcinoma^[2] and commonly manifests as an umbilicated (having a central mark or depression resembling a navel) lesion with a keratotic plug.^[3]

Warty dyskeratoma was first described by Graham and Helwig as isolated Darier’s disease in 1954. The name warty dyskeratoma was first coined by Szymanski in 1957 after his review of the cases.

The etiology of warty dyskeratoma is unclear, but a viral infection, smoking, autoimmunity, and ultraviolet light have been postulated to play a role. Several hypothesis reveal histopathologic similarities to viral warts but it’s not caused by HPV and the majority of these lesions display overall histopathologic features consistent with a follicular adnexal neoplasm.^[4]

• Warty dyskeratoma can also be thought of as one of the manifestations of focal acantholytic dyskeratosis, an epidermal reaction pattern that can be seen in several disorders, including Darier’s disease and Grover’s disease.^[5] But the main difference between Darier disease and warty dyskeratoma, is that Darier’s disease inherited dermatosis (autosomal dominant) consisting of multiple keratotic papules on the face, trunk, and extremities, while WD occurs as an isolated, noninherited, single keratotic nodule mainly confined to the head and neck as mentioned earlier.^[6]
• Warty dyskeratoma must be differentiated from viral-induced squamous lesions.

• Actinic keratosis
• Basal cell carcinoma
• Bowenoid papulosis
• Condyloma
• Darier’s disease
• Grover’s disease
• Squamous carcinoma
• Vulvar dysplasia^[6]

Warty dyskeratoma is a rare epidermal tumor that frequently arises as a papule or nodule on the head or neck of middle-aged or older persons.

• The patient usally comes complaing of pruritus that is usually limited to the head, neck,^[6] scalp^[7] or face and vulva.^[6]
• Lesions are generally solitary and sporadic and may be associated with a follicular unit.
• Oral involvement, particularly the hard palate, and genital involvement have been reported. They may also complain of recurrent foul-smelling cheesy drainage from the lesions.^[3]
• There may be central bleeding associated with trauma to the lesion.

• Hisotopathological examination of the lesions may reveal a cup-shaped invagination filled with a keratotic plug.
• The invagination contains numerous acantholytic dyskeratotic cells and typical corps ronds can be seen at the entrance to the invagination.
• The lower portion of the invagination may show the presence of many villi that are often covered by a single layer of basaloid cells and these villi protrude upward.

• 
  Warty dyskeratoma. Adapted from Dermatology Atlas.^[8]
• 
  Warty dyskeratoma. Adapted from Dermatology Atlas.^[8]
• 
  Warty dyskeratoma. Adapted from Dermatology Atlas.^[8]
• 
  Warty dyskeratoma. Adapted from Dermatology Atlas.^[8]

• The treatment of choice of WD is surgical excision.
• Other possible modalities of treatment are available but they are frequently associated with recurrences. These modalities include:
  • Curettement with electro-desiccation
  • Irradiation with X-ray ^[9]
  • Tazarotenic acid gel ^[10]

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