cutaneous horn is an elongated , keratinous projection from the skin , ranging in size from a few millimeters to many centimeters that resembles a miniature horn . its height must be at least one and half times the diameter of the base . the horn is composed of compacted keratin and the base may be flat , nodular , or crateriform . it usually occurs over the sun - exposed areas , that is , upper part of the face , nose , scalp , lips , eyelids , ear cartilage , neck , shoulders , forearms , and back of the hands . it is a clinical diagnosis and may overlap with many benign , premalignant , or malignant conditions . treatment options include wide surgical excision with careful histological examination to exclude a focus of malignancy . herein we report an unusual case of a pyogenic granuloma presenting as cutaneous horn on the lower lip in an 11-year - old boy . an 11-year - old young boy attended skin outpatient department ( opd ) with complaints of growth over lower lip , which was itchy with occasional bleeding . he was relatively asymptomatic 2 months back , when he developed lesion over lower lip , which gradually progressed in size . on examination , single nontender pedunculated blackish cylindrical horny growth , hard in consistency of about 2 cm in length and 1 cm at base was present over left side of lower lip [ figure 1 ] . a clinical diagnosis of cutaneous horn was made and excision was advised , for which his parents were reluctant . after about a month , the patient again visited our opd with complaints of increased episodes of bleeding from the lesion . examination revealed a 3  2 cm pedunculated , erythematous growth over lower lip that was soft to firm in consistency and bled on touch [ figure 2 ] . the underlying stroma showed proliferation of blood vessels separated by edema and chronic inflammatory cells comprising lymphocytes and plasma cells . the patient was followed up for two months with no sign of recurrence [ figure 4 ] . single nontender pedunculated blackish cylindrical horny growth over lower lip pedunculated erythematous growth soft to firm in consistency , after 1 month proliferation of blood vessels separated by edema and chronic inflammatory cells comprising lymphocytes and plasma cells in dermis . h and e stain ( a ) 4 , ( b ) 10 , ( c ) 40 after 1 month of removing the growth a cutaneous horn ( cornu cutaneum ) is a conical protrusion from the skin surface consisting of cornified material organized in the shape of an animal horn , usually affecting the head and neck region . although it derives its name from its resemblance to animal horn , it lacks an axially positioned , well - formed bone characteristic of an animal horn . most cutaneous horns do not project more than 1 cm from the skin surface and are usually shed off due to trauma or are excised before they grow further . the most common sites are on the upper part of the face , nose , scalp , lips , eyelids , ear cartilage , neck , shoulders , forearms , and the back of the hands . they may develop on areas not exposed to sunlight such as the penis , mucosal lower lip , and nasal vestibule . the condition is thought to be more frequent in men , but no consistent gender pattern has been demonstrated . pyogenic granuloma ( pg ) , also referred to as lobular capillary hemangioma , or granuloma pyogenicum , is a benign vascular proliferative lesion of the skin and mucous membrane commonly seen in children . pg usually presents as a solitary , rapidly growing , red papule or nodule , usually painless , with propensity to bleed spontaneously or with manipulation . it is more common in males , whereas mucosal occurrence is more common in females . although the actual mechanism for the development of pg is not known , various factors such as trauma , hormonal influences , viral oncogenes , underlying microscopic arteriovenous malformations play their role . the production of angiogenic factors , cytogenetic abnormalities , and overexpression of transcription factors p - atf2 and stat3 were also found to have a role in its development . pg underlying cutaneous horn is very rare . in our extensive literature search , only two such cases were found . a case of pg clinically diagnosed as cutaneous horn on the chin in a 38-year - old woman and a case of cutaneous horn on vermillion border of lip in a black child proved to be a pg was reported similar to our case . pathogenesis of horn formation in humans has not been fully elucidated , but it has been suggested to be due to abnormal accumulation , excessive adhesiveness , and compaction of keratin . bland - sutton , in 1911 , classified cutaneous horns into four types according to the underlying lesion and the site : 
 sebaceous horns arise from sebaceous cysts , which occur on the scalp;warty horns occur on penis , morphologically resembling sebaceous horns;cicatrix horns are rare , arise from burn scars;nail horns arise from big toe nails in bedridden patients with poor personal hygiene . sebaceous horns arise from sebaceous cysts , which occur on the scalp ; warty horns occur on penis , morphologically resembling sebaceous horns ; cicatrix horns are rare , arise from burn scars ; nail horns arise from big toe nails in bedridden patients with poor personal hygiene . in a large study by yu et al . , out of 643 cases of cutaneous horn studied , the underlying pathology varied from benign , premalignant , to malignant with incidences of 61.1% , 23.2% , and 15.7% , respectively . it can arise from a variety of benign lesions ( angiokeratoma , benign lichenoid keratosis , pyogenic granuloma , dermatofibroma , dle , epidermal nevus , epidermolytic acanthoma , fibroma , granular cell tumour , inverted follicular keratosis , pseudoepitheliomatous balanitis , organoid nevus , prurigo nodularis , sebaceous adenoma , seborrheic keratosis , trichilemmoma , verruca vulgaris ) , premalignant lesions ( adenoacanthoma , actinic keratosis , arsenical keratosis , pagets disease , solar keratosis ) , and malignant lesions ( squamous cell carcinoma , basal cell carcinoma , bowen 's disease , kaposi sarcoma , keratoacanthoma , renal cell carcinoma ) . the horn at the base will display features characteristic of the pathologic process responsible for the development of the horn . it is regarded as reactive phenomenon to the underlying pathology that is usually benign . however , a premalignant or malignant lesion may be associated with or without actinic damage as the underlying pathology . treatment is wide surgical excision with careful histological examination to exclude a focus of malignancy . therefore wide excision with histopathological examination is must . as per our literature search , this is the first such case to be reported from india . cutaneous horns are usually seen in the elderly , whereas our case is a young boy , which make it a rare case .
cutaneous horn is an elongated , keratinous projection that usually occurs over the sun - exposed areas . 
 it is a clinical diagnosis and may overlie any benign , premalignant , or malignant conditions . 
 treatment includes wide surgical excision with careful histological examination to exclude a focus of malignancy . 
 an unusual case of a pyogenic granuloma presenting as cutaneous horn on the lower lip in an 11-year - old boy is presented here .