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A 64-year-old man with a history of numerous nonmelanoma skin cancers presents with a lesion on the left side of his nose that was first noticed about 6 months ago and is slowly growing. The lesion is not painful or itchy. The patient has not tried any medications on the lesion. The patient wears eyeglasses and the nose pad of his eyeglasses rubs on the lesion. On physical examination, an erythematous papule is found on the left superior nasal sidewall with a central depression.
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Acanthoma fissuratum (AF), synonymous with granulosum fissuratum, is a relatively rare, benign skin lesion caused by chronic abrasive trauma to the affected area.1 In 1932, Sutton first described 2 cases of fissured, granulomatous lesions in the superior labioalveolar folds caused by stubbornly lodged food particles and poor-fitting dentures.2 Subsequent reports of AF of the ears and nose were attributed to chronic rubbing from eyeglasses.3,4 Although AF more commonly involves the retroauricular area or the nasal bridge, it has also been described on the external auditory meatus, oral cavity, posterior fourchette of the vulva, and penis.5-8
The development of AF is not associated with age or sex. The incidence of AF is unclear, as many patients do not seek medical treatment.8 Individuals wearing ill-fitting or heavy spectacles and other prosthetic devices in constant, direct contact with skin are at risk of developing AF. The persistent pressure and irritation from such devices may lead to frictional injury to the skin and formation of a bumpy lesion with a central depression.3,4 Additional risk factors for AF include local abnormalities such as hyperhidrosis, contact dermatitis, and seborrheic dermatitis.9
In cases of AF of the external genitalia, the etiology similarly appears to be continuous, mechanical trauma to the affected region. Acanthoma fissuratum of the posterior fourchette is often caused by repeated friction with vaginal penetration during sexual intercourse, tampon insertion, and vaginal examination.6 Likewise, in a case study of penile AF, the patient had a history of wearing tight-fitting underwear and increased pain with sexual intercourse, suggesting frictional trauma as the main cause.7
Clinically, AF presents as a firm, skin-colored to erythematous papule, plaque, or nodule with variably raised edges and a characteristic central, vertical fissure at the point of friction.8,9 Most cases are unilateral, asymptomatic, and focal without systemic involvement. The condition may present initially with an inflammatory halo.9 The most commonly affected areas of the ear are the retroauricular sulcus and superior auricular sulcus. In cases caused by spectacle frames, the lateral aspect of the nasal bridge near the inner canthus of the eye is commonly affected.8
Histologic examination demonstrates that granuloma fissuratum is a misnomer, as AF does not present with a granulomatous inflammatory response.8 Rather, histopathology shows irregular acanthosis, which is most prominent at the lesion’s periphery, compact orthokeratosis, and focal parakeratosis adjacent to the central fissure. The central fissure is marked by epidermal thinning and may be filled with the debris of inflammatory cells or keratin.9 The papillary dermis displays dilated blood vessels and moderate perivascular inflammatory infiltrate composed primarily of plasma cells, histiocytes, and lymphocytes.8,9 Mild dermal fibrosis is possible.9
Diagnosis of AF is largely made clinically. A skin biopsy may be performed if the clinician is unable to differentiate AF from conditions with similar appearance upon physical examination.8 Clinically, AF is most frequently confused with basal cell carcinoma but can be distinguished by its unique vertical depression in the lesion’s midline and by the absence of a pearly border seen in basal cell carcinoma.1 Acanthoma fissuratum of the oral mucosa may be mistaken for squamous cell carcinoma.1,8
A feasible method of confirming the diagnosis is by observing the therapeutic effect of removing the irritating stimulus; for instance, the adjustment of ill-fitting glasses or dentures will typically resolve AF.1 Since many cases of AF are associated with poor-fitting eye or dental ware, a thorough patient history is important to prevent misdiagnosis of a malignant cutaneous condition.8
Chondrodermatitis nodularis helicis and lichen simplex chronicus constitute 2 other conditions that mimic AF.8 Chondrodermatitis nodularis helicis may be distinguished histologically by an abundance of neutrophilic infiltrate and inflammatory changes extending into cartilage.9 Lichen simplex chronicus may also be differentiated histologically as this entity presents with vertically oriented collagen fibers in the papillary dermis, which are not characteristic of AF.10
The mainstay of treatment of AF is the aforementioned removal of the irritating medical device or skin stimulus. Correction of ill-fitting spectacles usually results in spontaneous resolution of the lesion within 1 to 6 months.9 In addition, intralesional triamcinolone acetonide has been reported as an effective treatment for AF.11 In cases where the lesion persists, surgical excision is recommended.8
In the case presented, a diagnosis of AF was suspected clinically and we discussed the treatment option of discontinuing or replacing his eyeglasses. The patient was concerned about the lesion and after discussing the risks and benefits of shave biopsy, the patient opted for shave biopsy to rule out basal cell carcinoma. The biopsy results showed AF and the biopsy site healed well, effectively removing and thereby treating the lesion.
Yuli Lim, BA, is a medical student at Baylor College of Medicine in Houston, Texas; Tara Braun MD, is a resident physician at Baylor College of Medicine.
References
1. Wilkin JK. Acanthoma fissuratum cutis: report of a case and a review of previous cases. J Dermatol Surg Oncol. 1977;3(5):531-532. doi:10.1111/j.1524-4725.1977.tb00348.x
2. Sutton RL Jr. A fissured, granulomatous lesion of the upper labio-alveolar fold. Arch Derm Syphilol. 1932;26(3):425-427. doi:10.1001/archderm.1932.01450030423004
3. Epstein E. Granuloma fissuratum of the ears. Arch Dermatol. 1965;91(6):621-622. doi:10.1001/archderm.1965.01600120053012
4. Farrell WJ, Wilson JW. Granuloma fissuratum of the nose. Arch Dermatol. 1968;97(1):34-37. doi:10.1001/archderm.1968.01610070040006
5. Gonzalez SA, Moore AGN. Acanthoma fissuratum of the outer auditory canal from a hearing aid. J Cutan Pathol, 1989;16(5);304.
6. Kennedy CM, Dewdney S, Galask RP. Vulvar granuloma fissuratum: a description of fissuring of the posterior fourchette and the repair. Obstet Gynecol. 2005;105(5 Pt 1):1018-1023. doi:10.1097/01.AOG.0000158863.70819.53
7. Lee JI, Young BK, Cho BK, Park HJ. Acanthoma fissuratum on the penis. Int J Dermatol. 2013;52(3):382-384. doi: 10.1111/j.1365-4632.2011.04903.x
8. Deshpande NS, Sen A, Vasudevan B, Neema S. Acanthoma fissuratum: lest we forget. Indian Dermatol Online J. 2017;8(2):141-143. doi:10.4103/2229-5178.202267
9. Cerroni L, Soyer HP, Chimenti S. Acanthoma fissuratum. J Dermatol Surg Oncol. 1988;14(9):1003-1005. doi:10.1111/j.1524-4725.1988.tb03738.x
10. Fernandez-Flores A. Lesions with an epidermal hyperplastic pattern: morphologic clues in the differential diagnosis. Am J Dermatopathol. 2016;38(1):1-16; quiz 17-19. doi:10.1097/DAD.0000000000000324
11. Ramroop S. Successful treatment of acanthoma fissuratum with intralesional triamcinolone acetonide. Clin Case Rep. 2020;8:702–703.
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