Dirk M Elston, MD

Benign acanthomas
Acanthomas are benign cutaneous neoplasms
characterized by an expansion of the epidermis.
The acanthoma may be composed of clones of
cells that displace or compress the preexisting
epidermis. In contrast to the reactive acanthosis
seen in inflammatory disorders, the rete ridge pattern is commonly ablated by the neoplastic tissue
of an acanthoma.

Seborrheic keratoses
Seborrheic keratoses are acanthomas composed
of small polygonal keratinocytes about the size of
acrosyryngeal keratinocytes (the cells that make
up the intraepidermal portion of the eccrine
duct). The cells are typically smaller than the
cells of the surrounding epidermis, and they are
commonly pigmented. Architectural subtypes of
seborrheic keratoses include acanthotic, hyperkeratotic, reticulated, and clonal. Any of these subtypes may be pigmented, irritated (spindling of
cells and squamous eddy formation), or inflamed
(usually lymphoid inflammation). Melanoacanthoma is a distinct subtype of seborrheic keratosis
composed of small keratinocytes and dendritic
melanocytes.
Seborrheic keratoses produce a characteristic
loose lamellar shredded-wheat stratum corneum. Exceptions include irritated or inflamed
seborrheic keratosis. Instead of the characteristic
loose lamellar horn, irritated or inflamed seborrheic keratoses produce a compact brightly eosinophilic parakeratotic stratum corneum. Adjacent
unaffected areas of the seborrheic keratosis still
produce the characteristic loose lamellar stratum
corneum, and it is common to see remnants of
loose stratum corneum above areas of compact
stratum corneum. Melanoacanthomas produce
a deeply eosinophilic compact parakeratotic

Chapter

Benign tumors and cysts

of the epidermis

stratum corneum, even when they are not irritated or inflamed.

Seborrheic keratoses may express BCL-2, a
marker associated with resistance to programmed
cell death (apoptosis). Activating point mutations
in the gene encoding fibroblast growth factor receptor 3, a tyrosine kinase receptor, are also common in seborrheic keratoses.

Acanthotic seborrheic keratosis

Key features
Broad sheets of small polygonal keratinocytes
with intervening horn cysts

Loose lamellar shredded-wheat or onion-skin

keratin

Commonly pigmented
Acanthotic seborrheic keratoses are composed of
broad sheets of cells with intervening horn cysts
or pseudo horn cysts. Horn cysts are completely
encased within the acanthoma, whereas pseudohorn cysts open to the surface. Like other seborrheic keratoses, they may become irritated or
inflamed.

Figure 2-1 Acanthotic seborrheic keratosis