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E-IJD® - QUIZ |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 839 |
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| Dermoscopy to the rescue |
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Dharmesh G Parmar, Trisha B Patel, Pragya A Nair
Department of Dermatology, Shree Krishna Hospital, Karamsad, Gujarat, India
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Pragya A Nair
Department of Dermatology, Shree Krishna Hospital, Pramukhswami Medical College, Karamsad - 388 325, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_905_21
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How to cite this article:
Parmar DG, Patel TB, Nair PA. Dermoscopy to the rescue. Indian J Dermatol 2022;67:839 |
A 12-year-old boy presented with asymptomatic lesion over left cheek which was gradually increasing in size since 1 year. He has no previous history of any skin lesions, application of medications, food/drug allergy, or systemic complaints. Cutaneous examination revealed single well-defined skin colored nodule of size 2 × 3 cm, firm to soft in consistency, over left side of angle of mandible [Figure 1]a. | Figure 1: (a) Single well-defined skin colored firm to soft in consistency, nodule of size 2 × 3 cm over left side angle of mandible. (b) Dermatoscopy showed ivory-white background (blue arrow), punctum/pore sign (yellow arrow), branched irregular linear vessels (red arrows)
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Dermatoscopy done with handheld polarized LED ILLUCO dermoscope IDS-1100 with 10× magnification showed peripheral linear branched vessels, white structureless background, and a punctum. [Figure 1]b
Excisional biopsy was done after parent's consent. Histopathological section showed hyperplastic and acanthotic epidermis. A single focus of epidermis shows cyst formation lined by hyperplastic epithelium containing lamellated keratin. The underlying superficial dermis was partially separated from epidermis and contain mild perivascular polymorphonuclear inflammatory infiltrate. Occasional hair follicles were noted. [Figure 2]. | Figure 2: A single focus of epidermis shows cyst formation lined by hyperplastic epithelium containing lamellated keratin with polymorphonuclear inflammatory infilterate in dermis. (H and E stain 10×)
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Diagnosis-Unruptured epidermal inclusion cyst.
 Discussion | |  |
Epidermal inclusion cysts (EIC) are the most common benign, noncontagious cutaneous cysts, also called as epidermoid, epidermal, infundibular, inclusion, or keratin cyst. They are more common in men than women, with a ratio of 2:1 in their 20s to 40s. It occurs commonly on face, neck or trunk presenting as nodules with visible central punctum. The size ranges from a few millimeters to several centimeters in diameter and is freely moveable. Lesions may remain stable or progressively enlarge over time.[1]
Human papilloma virus and exposure to ultraviolet light play a role in the formation of EIC. Patients on BRAF inhibitors such as imiquimod and cyclosporine have a higher incidence of epidermoid cysts of the face.[2]
Primary or unruptured epidermal cyst arise directly from the infundibulum of the hair follicle. Plugging of the follicular orifice leads to cyst formation which communicates with the surface of the skin through visible central punctum. Patients of acne vulgaris have hair follicle disruption and pore blockages leading to a higher rate of epidermal inclusion cyst formation from preexisting comedones.[2] Secondary or ruptured epidermoid cysts can arise after the implantation of the follicular epithelium in the dermis due to trauma or comedone formation.
Dermoscopy shows an ivory-white background, punctum/pore sign, as well as peripheral-branched irregular linear vessels. Ivory-white background is known to be a dermoscopic clue implying a tumor originating from the hair follicle and correspond to keratin mass histologically. Punctum/pore sign is plugged pilosebaceous unit which represent a circular orifice filled with keratin on the surface of the lesion. In unruptured-cyst, vascular structure of the peripheral linear-branched vessels (with an erythematous rim) arborizing telangiectasia was found in the central or peripheral portion. It is due to congestion of the blood flow pressed by the surrounding tissues due to the mass effect caused by the increase in the size of the epidermal cyst. Ruptured epidermal cysts may contain red blood cell components due to bleeding, which may appear as red lacunae in dermoscopy but, does not show arborizing telangiectasia as blood congestion occurs relatively less frequently.[3]
Elmas OF[4] reported 'Mobility sign' in his study which corresponds to mobile cystic nodule relatively free from the overlying epidermis observed more clearly and accurately with dermatoscope. Author also reported polychromatic structures known as “rainbow pattern” as several different colors juxtaposed next to each other.
The cyst wall is usually derived from the infundibular portion of the hair follicle. The cystic cavity is filled with laminated keratinous material and a granular layer is filled with keratohyalin granules. Infected cysts microscopically can show disruption of the cyst wall, acute inflammation or neutrophil invasion, or intense foreign body giant cell reaction.[5]
Choosing a treatment for EIC is not easy as it is difficult to determine whether it is ruptured or not with the naked eye, particularly in Asians as inflammation cannot be appreciated easily.
Complete surgical excision of the cyst with its walls intact will prevent reoccurrence. Excision is best accomplished when the lesion is not acutely inflamed.[6]
| Learning points | | |
- Epidermal inclusion cysts are common benign epidermal cyst occurring on face, neck, or trunk presenting as nodules with visible central punctum.
- Dermatoscopy of primary or unruptured epidermal inclusion cyst shows arborizing telangiectasia in the central or peripheral portion.
- Dermatoscopy helps in differentiating ruptured and unruptured cyst, thereby increase diagnostic accuracy and help in deciding the treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Zito PM, Scharf R. Epidermoid Cyst. StatPearls. Stat Pearls Publishing; Treasure Island (FL); 2020.  |
| 2. | Boussemart L, Routier E, Mateus C, Opletalova K, Sebille G, Kamsu-Kom N, et al. Prospective study of cutaneous side-effects associated with the BRAF inhibitor vemurafenib: A study of 42 patients. Ann Oncol 2013;24:1691-7. |
| 3. | Suh KS, Kang DY, Park JB, Yang MH, Kim JH, Lee KH, et al. Usefulness of dermoscopy in the differential diagnosis of ruptured and unruptured epidermal cysts. Ann Dermatol 2017;29:33-8. |
| 4. | Elmas OF. Dermoscopic diagnosis of epidermal cyst. Ann Med Res 2019;26:1249-52. |
| 5. | Apollos JR, Ekatah GE, Ng GS, McFadyen AK, Whitelaw SC. Routine histological examination of epidermoid cysts; to send or not to send? Ann Med Surg (Lond) 2017;13:24-8. |
| 6. | Lee HE, Yang CH, Chen CH, Hong HS, Kuan YZ. Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: A prospective, randomized study. Dermatol Surg 2006;32:520-5. |
[Figure 1], [Figure 2] |
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