Profile of Clinical, Dermoscopic, Histopathological Feature

Seborrheic Keratosis in Sanglah General Hospital Period January

2016-December 2017

Putu Indah Andriani

Made Hasri Dewi, Made Swastika Adiguna

Department of Dermatology and Venereology, Faculty of Medicine Udayana University/Sanglah General Hospital,

Denpasar, Indonesia

Keywords: Seborrheic Keratosis, Clinical, Dermoscopic, Histopathological

Abstract: Seborrheic Keratosis (SK) is one of the most common epidermal tumor on the skin.The clinical presentation

can be quite variable. Even though SK is presently one of the most common cosmetic skin problem, there is

lack data relating its clinical, dermoscopic, and histopathologic correlation. The aim of this study to provide

useful information about the clinical profile, dermoscopic, histopathological feature of SK. This retrospective

study obtained data from medical record patients SK at out-patient clinic Sanglah General Hospital during

January 2016 until December 2017. The new SK cases on in January 2016 until December 2017 were 53

cases. There were 21 male and 32 female. SK most commonly occurs at the age over 60 years old (35%). SK

lession commonly found on the sun exposed area like face (47%) and neck (50%). SK most commonly

occured on patients had history of sun exposure more than 2 hours/day (45%). Positive family history was

found on 37 cases (69%). The most common SK subtype was dermatosis papulo nigra (56%), followed by

melanoacanthoma or pigmented SK in 10 subjects (18,8%), common SK in 9 subjects (16,9%), and irritated

SK in 4 subjects (7,54%). In this study only 2 subtype SK done dermoscopic and histopathological

examination (melanoacanthoma and irritated SK). The most common dermoscopic finding seen in

melanoacanthoma SK were millia like cyst in 10 subjects (90%), comedo like opening in 10 subjects (90%),

gyri and sulci in 10 subject (90%). The most common dermoscopic finding seen in irritated SK were millia

like cyst in 3 subjects (100%), comedo like opening in 3 subjects (100%), gyri & sulci in 3 subject (100%),

and also haipin vessel in 1 subject (33,3%). There was correlation between dermoscopy and histopatology

finding in these report.

1 INTRODUCTION

SK is one of the most common epidermal tumor of

the skin that affects both sexes and usually arises in

individual older than 50 years. It present as sharphy

demarcated, slightly raised brownish patches or

plaquae, usually on sun-exposed surface of the skin.

Many individual with SK have a positive familly

history. SK demostrated irregularities in the

expression of the apoptosis markers of p53 and Bcl-

2, though no genetic locul or chromosomal imbalance

has been detected to date (Thomas, Swanson, and

Lee, 2008; Roh et al., 2016). Family history of SKs

should be sought if there are multiple SKs and if

associated with an early age of onset.

The other

possible risk factor for SK is viral infection like

human pappiloma virus (HPV) based on clinical

similarities to warts (Thomas, Swanson, and Lee,

2008; Roh et al., 2016).

Based on the clinical and histopathological SK

can be devided into six mayor subtype: common SK,

reticulated (adenoid) SK, stucco SK, pigmented

(melanoacanthoma) SK, dermatosis papula nigra SK,

clonal SK, and irritated SK (Thomas, Swanson, and

Lee, 2008). Despite the diagnosis is most often

clinically straight-forward, somes SK casess also

need dermoscopic and histophatoloigy examination

besause the tumor can mimic the other premalignant

or malignant lession (Park, Park, and Cho, 2011; Kim

et al., 2013).

Dermoscopic examination reveal

specific criteria according to the particular

histological architecture.

This study describes the clinical, typical

dermoscopic features of Sk along with theirs

histopathological correlations of SK.

Andriani, P., Dewi, M. and Adiguna, M.

Proﬁle of Clinical, Dermoscopic, Histopathological Feature Seborrheic Keratosis in Sanglah General Hospital Period January 2016-December 2017.

DOI: 10.5220/0008149900230027

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 23-27

ISBN: 978-989-758-494-7

2 METHOD

This restrospective study obtained data from medical

record patients SK at out-patient clinic Sanglah

General Hospital during January 2016 until

December 2017. Data got from medical record

patients consits with clinical diagnose of SK,

description of dermoscopic and histopathological

images in these patients. All patients who diagnosed

with SK were subjected to get information from

medical record about the age, gender, history of sun

exposure a day (outdoor occupations and hobbies),

family history of SK, clinical evaluation of the SK

regarding the site and the subtype SK (common SK,

reticulated or adenoid SK, stucco SK, pigmented or

melanoacanthoma SK, dermatosis papula nigra SK,

clonal SK, and irritated SK). Evaluation the spesific

dermoscopic features of SK such as fissure and ridges

or gyri and sulci, haipin vessels, comedo-like

opening, milia-like cyst. Evaluation histopathological

features of SK such as papillomatous surface of the

epidermis, hyperkeratosis or parakeratosis, epidermal

cysts, horn cyst, enlarged cappilaries of dermal

papillae, increased melanin number, squamous edies

and keratin filled invagination. Photographic

documentation of clinical type, dermoscopic and

histophatological features were got from case reports

of SK patients in that period.

The subjects demographic data (ie gender, age

range, location, subtye of SK, family history of SK,

and history sun exposure) were presented as number

and pecentage. Statistical significance the frequency

of dermoscopic and histopathologic feature in SK was

assessed using chi-squared. The cutoff for statistical

significance was set at p<0,001. Analyzed using the

SPSS version 21.0 for windows

3 RESULTS

The new SK cases on in January 2016 until December

2017 were 53 cases. There were 21 male and 32

female. The age range from 19-76 years, the mean age

49,75. SK most commonly occurs at the age over 60

years in 19 subjects (35%). SK lession commonly

found on the sun exposed area like face in 25 subjects

(47%) and neck in 27 subjects (50%). The other

location were on the back in 13 subjects (24,5%), on

the chest in 7 subjects (13,2%), on the upper

extremities in 6 subjects (11,3%), on the lower

extremities 4 subjects (7,5%), and there were only 1

subject (1,88%) on each location like abdoment,

symphisis, inguinal and labia majora. The most

common SK subtype was dermatosis papulo nigra in

30 subjects (56%) followed by melanoacanthoma or

pigmented SK in 10 subjects (18,8%), common SK in

9 subjects (16,9%), and irritated SK in 4 subjects

(7,54%). Positive family history was found on 37

subjects (69,8%). SK cases most commony occured

on patients had history of sun exposure more than 2

hours/day in 24 subjects (45,2%). Table 1.

Demostrate the demografic data of subjects.

In this study only 2 subtype SK done dermoscopic

and histopathological examination

(melanoacanthoma and irritated SK). The most

common dermoscopic finding seen in 11 subjects

melanoacanthoma SK were millia like cyst in 10

subjects (90%), comedo like opening in 10 subjects

(90%), and also gyr & sulci in 11 subject (100%).

Only 2 cases of melanoacathoma SK done

histopathology examination. The most common

histopathology finding seen in melanoacanthoma SK

were epidermal cyst or keratin filled invagination in

2 subjects (100%), horn cyst in 2 subjects (100%),

hyperkeratosis, parakerosis, akantosis and

papillomatosis in 2 subjects (100%), and increase of

melanin number in 1 subject (50%). The presence of

millia like cyst was statistically significant with

epidermal cyst, presence of comedo like opening was

statistically significant with horn cyst, presence of

gyri & sulcus was statistically significant with

hyperkeratosis, parakerosis, akantosis and

papillomatosis (p < 0,001). The most common

dermoscopic finding seen in 3 sujects irritated SK

were millia like cyst in 3 subjects (100%), comedo

like opening in 3 subjects (100%), gyri & sulci in 3

subject (100%), and also hairpin vessel in 1 subject

(33,3%). All of the 3 subjects irritated SK done

histopathology examination. The most common

histopathology finding seen in irritated SK were

epidermal cyst or keratin filled invagination in 3

subject (100%), horn cyst in 3 subject (100%),

hyperkeratosis, parakerosis, akantosis and

papillomatosis in 3 subject (100%), enlarge

capillaries in 1 subject (33,3%), inflamation infiltrate

lymphocyte and neutrophil in 1 subject (33,3%), and

squmous edies in 2 subjects (66,6%). The presence of

millia like cyst was statistically significant with

epidermal cyst, presence of comedo like opening was

statistically significant with horn cyst, presence of

gyri & sulcus was statistically significant with

hyperkeratosis, parakerosis, akantosis and

papillomatosis, presence of hairpin vessel was

statistically significant with enlarge capillaries (p <

0,001). Table 2 Demostrate the crosstabulation

frequency dermoscopic and histopathologic feature

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

seen in melanoacanthoma and irritated SK using chai-

squared test.

Table 1: Demographic Data of Subjects.

Variable Subject

(n)

Percenta

Gender

Male

Female

39,6%

60,3%

Age Range (years)

10-20 years

21-30 years

31-40 years

41-50 years

51-60 years

>60 years

3,7%

1,8%

28,3%

15,1%

35,8%

Location

Face

Neck

Back

Chest

Abdoment

Upper extremities

Lower extremities

Symphisis

Inguinal

Labia majora

47,1%

50,9%

13,2%

24,5%

1,8%

11,3%

7,5%

1,8%

Subtype SK

Dermatosis papulo

nigra

Irritated

Melanoacanthoma or

pigmented

Common

56,6%

7,5%

18,8%

16,9%

Family History of SK

Positive

Negative

69,8%

30,1%

History of Sun

Exposure

<1 hour/day

1-2 hours/day

>2 hours/day

18,8%

35,8%

45,2%

Table 2: Crosstabulation Frequency Dermoscopic*Histopathologic Feature in Melanoacanthoma & Irritated SK using Chi-

Squared Test.

Dermoscopic

Melanoacan-

thom SK

(2 subjects)

Histopathologic

Melanoacanthoma SK

(2 subjects)

value

Dermoscop

ic Irritated

(3 subjects)

Histopathologic Irritated

(3 subjects)

value

EC HC HP EC EC HC HP EC

ML 2 0 0 0 <0.00

ML 3 0 0 0 <0.00

CL 0 2 0 0 <0.00

CL 0 3 0 0 <0.00

GS 0 0 2 0 <0.00

GS 0 0 3 0 <0.00

HV 0 0 0 0 HV 0 0 0 1 <0.00

Total 2 2 2 0 Total 3 3 3 1

ML : Millia Like Cyst, CL : Comedo Like Opening, GS: Gyri & Sulcus, HV: Hairpin Vessel, EC: Epidermal Cyst, HC:

Horn Cyst, HP: Hyperkeratosis, Papilomatosis, EC: Enlarge Capillaries

Proﬁle of Clinical, Dermoscopic, Histopathological Feature Seborrheic Keratosis in Sanglah General Hospital Period January

2016-December 2017

Figure 1: Dermoscopic image of irriated SK presenting

milia like cysts, hyperkeratosis, comedo like openings,

fissures, ridges, gyri and sulcus.

Figure 2: Histopatologic image of irritated SK presenting

keratin filled invagination or epidermal cyst, horn cyst, and

squmous eddies.

4 DISCUSSION

A study conducted by Alapatt et al on 50 participants

reported the peak incidence of SK was 31-50 years

(Alpatt, Sukumar, and Bhat, 2016). A Korean study

by Kwon et al, has reported that 88,1% of Korean

male aged 40-70 years had at least one lession (Kwon

et al., 2003).

SK in this study mostly occur in middle-

aged individuals, the peak incidence in this study was

over 60 years.

Gender distribution of SK in this study more

common in female than male with ratio 1.5:1. In some

study slight female preponderance of SK was seen. A

study conducted by Alapatt et al show that female

preponderance of 76% SK cases (Alapatt, Sukumar,

and Bhat, 2016). This condition could be due to the

fact that women usually seek dermatological advice

due to cosmetic concern more than man.

There are many risk factors have been implicated

in the etiology of SK. Many inidividual of SKs have

a positive family for the condition. SKs demostrate

irregularities in the expressions in the apoptosis

markers p53 and Bcl-2, though no genetic locus or

chromosomal imbalance has been detected (Thomas,

Swanson, and Lee, 2008).

Family history associated

with multiple seborrhoeic keratoses on early age of

onset. Genetic predisposition inherited SK associated

with an autosomal dominant trait. Activating

mutations in FGFR3 which provide proliferative

signals to keratinocytes, increased expression of Bcl2

and Ki-67, increased DNp63a expression and

activating PIK3CA mutations has been noted in the

pathogenesis of SK. Increased expression of

keratinocyte derived Endothelin I mediated by TNF α

and Endothelin Converting Enzyme 1α (ECE 1α) is

linked to pigmentation seen in SK (Shariff,

Balamurugan, and Saravanan, 2017). In this study

positive family history was found on 37 cases (69%).

From 37 cases who had postive family history only 2

subjects (5,4%) occured on early age onset at age

range 10-20 years, 7 subjects (18,9%) occured at age

range 31-40 years, and the other occured at age more

than 40 years.

Sunlight and Human Papilloma Virus (HPV) has

been implicated in the risk factors of seborrhoeic

keratosis (Shariff, Balamurugan, and Saravanan,

2017). Hafner et al, reported that UV-light-induced

mutations of the gene encoding FGFR3 may

contribute to formation of SK (Roh et al., 2016).

this study only investigate the riks factor of sun

exposore. The most common location of SK lession

in this study on the sun exposed area like face (47%)

and neck (50%). SK cases most commony occured on

patients had history of sun expose more than 2

hours/day (45%). This result simillar with study

conducted on Korea males by Kwon et al on 303

volunteers aged 40-70 years, which showed

cumulative sunlight exposure to be a contributing

factor (Alapatt, Sukumar, and Bhat, 2016).

Our study showed the highest incidence of SK

was dermatosis papulo nigra (56%), followed by

melanoacanthoma or pigmented SK in 10 subjects

(18,8%), common SK in 9 subjects (16,9%), and

irritated SK in 4 subjects (7,54%). In this study only

2 subtype SK done dermoscopic and

histopathological examination (melanoacanthoma

and irritated SK) because this type of SK usally

mimic the other pigmented lesion like

nevomelanocytic nevus and melanoma.

Melanoacanthoma is a heavily pigmented variant

of SK, histopathologically characterized by increased

large, dendritic, melanin-rich melnocyte throuhout

the tumor. The heavy pigmentation of

melanoachantoma masks dermoscopic finding,

rendering it almost impossible to differentiate this

condition from melanoma and other pigmented skin

lesions like melanoma (Minagawa, 2017). The most

common dermoscopic finding seen in

melanoacanthoma SK were millia like cyst in 10

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

subjects (90%), comedo like opening in 10 subjects

(90%), and also gyr & sulci in 10 subject (90%). Only

2 cases of melanoacathoma SK done histopathology

examination. The most common histopathology

finding seen in melanoacanthoma SK were epidermal

cyst or keratin filled invagination in 2 subjects

(100%), horn cyst in 2 subjects (100%),

hyperkeratosis, parakerosis, akantosis and

papillomatosis in 2 subjects (100%), and increase of

melanin number in 1 subject (50%).The presence of

millia like cyst was statistically significant with

epidermal cyst (100%), presence of comedo like

opening was statistically significant with horn cyst

(100%), presence of gyri & sulcus was statistically

significant with hyperkeratosis, parakerosis,

akantosis and papillomatosis (100%) with p < 0,001.

These finding simillar with the previous study by

Alapatt et al showed that milia like cysts in

dermoscopy corespond to epidermal cyst (100%),

presence of gyri & sulcus corespond to papillomatosis

(89%), and the other features of histopathologic were

horn cyst in 32,30% of the cases, pigmentation in

74,20% of the cases, acanthosis in 18% of the cases,

and hyperkeratosis in 58,10% of cases (Alapatt,

Sukumar, and Bhat, 2016).

The most common dermoscopic finding seen in

irritated SK in this study were millia like cyst in 3

subjects (100%), comedo like opening in 3 subjects

(100%), gyri & sulci in 3 subject (100%), and also

haipin vessel in 1 subject (33,3%). The most common

histopathology finding seen in irritated SK in this

study were epidermal cyst or keratin filled

invagination in 3 subject (100%), horn cyst in 3

subject (100%), hyperkeratosis, parakerosis,

akantosis and papillomatosis in 3 subject (100%),

enlarge capillaries in 1 subject (33,3%), inflamation

infiltrate lymphocyte and neutrophil in 1 subject

(33,3%), and squmous edies in 2 subjects (66,6%).

The presence of millia like cyst was statistically

significant with epidermal cyst (100%), presence of

comedo like opening was statistically significant with

horn cyst (100%), presence of gyri & sulcus was

statistically significant with hyperkeratosis,

parakerosis, akantosis and papillomatosis (100%),

presence of hairpin vessel was statistically significant

with enlarge capillaries (100%) with p < 0,001.

Irritated SK have two histopathological

characteristic, numerous squmous eddies and

downward ploriferation of the epidermis.

Dermoscopic finding of irritated SK usually not only

typical demoscopic image like the other type SK but

also can found pinkish structures on white

background (Minagawa, 2017).

5 CONCLUSIONS

Clinical profile SK in this study most commonly

occured on age over 60 years, female subjects,

location on sun exposed area like face and neck, in

subjects who had history of sun exposured more than

2 hous/day. Highest incidence of SK was dermatosis

papulo nigra (56%), followed by melanoacanthoma

or pigmented SK in 10 subjects (18,8%), common SK

in 9 subjects (16,9%), and irritated SK in 4 subjects

(7,54%). There was correlation between dermoscopy

and histopatology finding of SK in these study.

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Proﬁle of Clinical, Dermoscopic, Histopathological Feature Seborrheic Keratosis in Sanglah General Hospital Period January

2016-December 2017