The Journal of Dermatology Vol. 17: 260-263, 1990
An Epidermoid Cyst with a Seborrheic Verruca-like Cyst Wall Soo II Chun and Sungbin 1m Abstract
The epidermoid cyst with a seborrheic venuca-like cyst wall is a newly described variant of the epidermoid cyst. The cyst wall of this variant shows changes simulating seborrheic keratosis and verruca, Our case of a subcutaneous mass was shown histopathologically to have this variant.
Key words:
epidermoid cyst; seborrheic venuca-like cyst wall
Introduction In 1982, Rahbari (1) reported five cases of epidermoid cysts with seborrheic verruca-like cyst walls among 122,200 routine dermatopathologic investigations. Recently, we have also found one case of this entity, and we compared the clinical and histopathologic findings of epidermoid cyst, Rahbari's cases, and our case.
Report of a Case A 24-year-old female was seen with an asymptomatic, slowly growing, subcutaneous mass on the left buttock of one year's duration. There was no history of local trauma or irritation. The family history revealed no similar disorder. Physical examination showed a finger-tip sized, flesh-colored, nontender, movable, subcutaneous nodule on the left buttock. Excision biopsy of the subcutaneous mass revealed an oval cyst about 1.2 cm in diameter, containing gray-white friable materials. Histopathologic findings showed an epidermoid cyst with an irregularly thickened cyst wall containing orthokeratotic keratin materials with no apparent relationship to the overlying epidermis (Fig. 1). The surrounding dermis was normal, except for mild cellular infiltrates around the capillary blood vessels and some proliferation of the connective tissue Received October 9, 1989; accepted for publication December 13,1989. Department of Dermatology, Yonsei University College of Medicine, Seoul, Korea. Reprint requests to: Soo II Chun, M.D., Ph.D., Department of Dermatology, Yonsei University Collegeof Medicine, c.p.a. Box 8044, Seoul, Korea.
immediately outside the cyst wall. The wall of the cyst showed marked acanthosis, papillomatosis, pseudohorn cysts, and many squamous eddies (Fig. 2). There were numerous basaloid cells which were small and uniform in appearance and had relatively large nuclei (Fig. 3). In another area of the cyst wall, there were vertical parakeratotic tiers, heavy, irregular clumps ofkeratohyaline granules in the granular cell layers, and numerous vacuolated cells located in the upper and mid layers of the cyst wall (Fig. 4). There was deposition of PAS-positive, diastase-labile materials in the cells of the cyst wall.
Comment An epidermoid cyst usually occurs as a single or a few lesions on the face, scalp, neck and trunk in a young adult. The overlying epidermis is normal (2) with or without a central comedo. The epidermoid cyst with a seborrheic verruca-like cyst wall occurs in persons in their fifth or later decades of life as a single lesion with no predilection area (1). The overlying epidermis is grossly normal. In our case, the cyst occurred as a single lesion on the left buttock of a young female (Table 1). Histopathologically, the cyst wall of an epidermoid cyst is composed of a normal and somewhat flattened epidermis containing basket-weave orthokeratotic keratin (3) which may be connected to the overlying epidermis. There are usually only a few cellular infiltrates in the dermis, but, following the rupture of the cyst, foreign body granulomas may be seen (4). In Rahbari's cases (1), there was a normal to thin overlying epidermis with no apparent
Epidermoid Cyst with a Seborrheic Venuca-like Cyst Wall
261
Fig. 1. The epidermoid cyst had an irregularly thickened cyst wall containing orthokeratotic keratin materials with no apparent relationship to the overlying epidermis (H & E stain, x8).
Fig. 2. The wall of the cyst showed marked acanthosis, papillomatosis, and squamous eddies (H & E stain, x40).
Chun and 1m
262
Fig. 3. There were numerous basaloid cells of small uniform appearance and many squamous eddies (H & E stain, xl00).
Table 1. Clinical information from reported cases of epidermoid cysts with seborrheic verruca-like cyst walls Case
Age (yrs)
Sex
Site
1
68 46 61 58 55 24
M M M
Lt. chest Lt. neck Lt. buttock Upper mid-back Rt. shoulder Lt. buttock
2 3 4 5 6
M
M F
No of lesions
Duration (yrs)
1
?
1
10
1 1 1 1
? ? 10 1
1-5: Rhabari's cases, 6: Our case.
Table 2. Histopathologic patterns of epidermoid cysts with seborrheic verruca-like cyst walls Case Case Case Case Case Case
1 2 3 4 5 6
Many pseudohorn cysts in the wall Clefting in the wall Thick and smooth surfaced wall Church spire-like cyst wall Verruca-like cyst wall Many squamous eddies in the wall
Case 1-5: Rhabari's cases, Case 6: Our case.
relationship to the cysts. In the dennis, there were mild perivascular infiltrates and some proliferations of the connective tissue around the cyst walls, which were acanthotic and papillomatous, strongly resembling seborrheic verruca. Individual cysts seemed to simulate distinctive varieties of seborrheic verruca. There were many pseudohom cysts in the wall of case 1, some areas of suprabasal cleft formation in the wall of case 2, a thick and
Epidermoid Cyst with a Seborrheic Verruca-like Cyst Wall
263
Fig. 4. In another area of the wall, there were vertical parakeratotic tiers, hypergranulosis, and numerous vacuolated cells in the upper and mid layers of the cyst wall (H & E stain, xlOO).
smooth surfaced wall in case 3, a church spirelike wall in case 4, and an area of wart-like wall in case 5. Our case showed the irregularly thickened cyst wall of acanthosis, papillomatosis, and several pseudohorn cysts with many squamous eddies in the wall of the cyst. In addition, vertical parakeratotic tiers, vacuolated cells in the upper layer, and heavy, irregular clumps of keratohyaline granules in the granular cell layers and horny cell layers were also seen in our case, as in the verruca. However, no suprabasal cleft formation was seen. PAS-positive, diastase-labile materials, which may have been derived from follicular infundibulum, were also found in our case (Table 2). Rahbari (1) suggested that a seborrheic verruca-like cyst wall might be an acanthotic and papillomatous outgrowth of the follicular infundibulum with aging, because most patients
were in the fifth or later decades of life. However, our case occurred in a young adult female on the buttock; therefore we suggest that the seborrheic verruca-like cyst wall may have been a nevoid change or had a mechanical factor.
References 1) Rahbari H: Epidermoid cysts with seborrheic verruca-like cyst walls, ArchDermatol, 118: 326-328, 1982. 2) MacKie RM: Cysts of the skin, in Rook A, Wilkinson DS, Ebling FJG, Champion RH (eds): Textbook of Dermatology, Blackwell Scientific Publications, Oxford, 1986, pp 2404-2407. 3) Caro WA, Bronstein BR: Epithelial cysts, in Moschella SL, Hurley HJ (eds): Dermatology, WB Saunders Company, Philadelphia, 1985, pp 15401542. 4) Lever WF, Schaumberg-Lever G: Tumors and cysts of the epidermis, in Lever WF, Schaumberg-Lever G (eds): Histopathology of the Skin, JB Lippincott Company, Philadelphia, 1983, pp 482-484.
An Epidermoid Cyst with a Seborrheic Verruca-like Cyst Wall Soo II Chun and Sungbin 1m Abstract
The epidermoid cyst with a seborrheic venuca-like cyst wall is a newly described variant of the epidermoid cyst. The cyst wall of this variant shows changes simulating seborrheic keratosis and verruca, Our case of a subcutaneous mass was shown histopathologically to have this variant.
Key words:
epidermoid cyst; seborrheic venuca-like cyst wall
Introduction In 1982, Rahbari (1) reported five cases of epidermoid cysts with seborrheic verruca-like cyst walls among 122,200 routine dermatopathologic investigations. Recently, we have also found one case of this entity, and we compared the clinical and histopathologic findings of epidermoid cyst, Rahbari's cases, and our case.
Report of a Case A 24-year-old female was seen with an asymptomatic, slowly growing, subcutaneous mass on the left buttock of one year's duration. There was no history of local trauma or irritation. The family history revealed no similar disorder. Physical examination showed a finger-tip sized, flesh-colored, nontender, movable, subcutaneous nodule on the left buttock. Excision biopsy of the subcutaneous mass revealed an oval cyst about 1.2 cm in diameter, containing gray-white friable materials. Histopathologic findings showed an epidermoid cyst with an irregularly thickened cyst wall containing orthokeratotic keratin materials with no apparent relationship to the overlying epidermis (Fig. 1). The surrounding dermis was normal, except for mild cellular infiltrates around the capillary blood vessels and some proliferation of the connective tissue Received October 9, 1989; accepted for publication December 13,1989. Department of Dermatology, Yonsei University College of Medicine, Seoul, Korea. Reprint requests to: Soo II Chun, M.D., Ph.D., Department of Dermatology, Yonsei University Collegeof Medicine, c.p.a. Box 8044, Seoul, Korea.
immediately outside the cyst wall. The wall of the cyst showed marked acanthosis, papillomatosis, pseudohorn cysts, and many squamous eddies (Fig. 2). There were numerous basaloid cells which were small and uniform in appearance and had relatively large nuclei (Fig. 3). In another area of the cyst wall, there were vertical parakeratotic tiers, heavy, irregular clumps ofkeratohyaline granules in the granular cell layers, and numerous vacuolated cells located in the upper and mid layers of the cyst wall (Fig. 4). There was deposition of PAS-positive, diastase-labile materials in the cells of the cyst wall.
Comment An epidermoid cyst usually occurs as a single or a few lesions on the face, scalp, neck and trunk in a young adult. The overlying epidermis is normal (2) with or without a central comedo. The epidermoid cyst with a seborrheic verruca-like cyst wall occurs in persons in their fifth or later decades of life as a single lesion with no predilection area (1). The overlying epidermis is grossly normal. In our case, the cyst occurred as a single lesion on the left buttock of a young female (Table 1). Histopathologically, the cyst wall of an epidermoid cyst is composed of a normal and somewhat flattened epidermis containing basket-weave orthokeratotic keratin (3) which may be connected to the overlying epidermis. There are usually only a few cellular infiltrates in the dermis, but, following the rupture of the cyst, foreign body granulomas may be seen (4). In Rahbari's cases (1), there was a normal to thin overlying epidermis with no apparent
Epidermoid Cyst with a Seborrheic Venuca-like Cyst Wall
261
Fig. 1. The epidermoid cyst had an irregularly thickened cyst wall containing orthokeratotic keratin materials with no apparent relationship to the overlying epidermis (H & E stain, x8).
Fig. 2. The wall of the cyst showed marked acanthosis, papillomatosis, and squamous eddies (H & E stain, x40).
Chun and 1m
262
Fig. 3. There were numerous basaloid cells of small uniform appearance and many squamous eddies (H & E stain, xl00).
Table 1. Clinical information from reported cases of epidermoid cysts with seborrheic verruca-like cyst walls Case
Age (yrs)
Sex
Site
1
68 46 61 58 55 24
M M M
Lt. chest Lt. neck Lt. buttock Upper mid-back Rt. shoulder Lt. buttock
2 3 4 5 6
M
M F
No of lesions
Duration (yrs)
1
?
1
10
1 1 1 1
? ? 10 1
1-5: Rhabari's cases, 6: Our case.
Table 2. Histopathologic patterns of epidermoid cysts with seborrheic verruca-like cyst walls Case Case Case Case Case Case
1 2 3 4 5 6
Many pseudohorn cysts in the wall Clefting in the wall Thick and smooth surfaced wall Church spire-like cyst wall Verruca-like cyst wall Many squamous eddies in the wall
Case 1-5: Rhabari's cases, Case 6: Our case.
relationship to the cysts. In the dennis, there were mild perivascular infiltrates and some proliferations of the connective tissue around the cyst walls, which were acanthotic and papillomatous, strongly resembling seborrheic verruca. Individual cysts seemed to simulate distinctive varieties of seborrheic verruca. There were many pseudohom cysts in the wall of case 1, some areas of suprabasal cleft formation in the wall of case 2, a thick and
Epidermoid Cyst with a Seborrheic Verruca-like Cyst Wall
263
Fig. 4. In another area of the wall, there were vertical parakeratotic tiers, hypergranulosis, and numerous vacuolated cells in the upper and mid layers of the cyst wall (H & E stain, xlOO).
smooth surfaced wall in case 3, a church spirelike wall in case 4, and an area of wart-like wall in case 5. Our case showed the irregularly thickened cyst wall of acanthosis, papillomatosis, and several pseudohorn cysts with many squamous eddies in the wall of the cyst. In addition, vertical parakeratotic tiers, vacuolated cells in the upper layer, and heavy, irregular clumps of keratohyaline granules in the granular cell layers and horny cell layers were also seen in our case, as in the verruca. However, no suprabasal cleft formation was seen. PAS-positive, diastase-labile materials, which may have been derived from follicular infundibulum, were also found in our case (Table 2). Rahbari (1) suggested that a seborrheic verruca-like cyst wall might be an acanthotic and papillomatous outgrowth of the follicular infundibulum with aging, because most patients
were in the fifth or later decades of life. However, our case occurred in a young adult female on the buttock; therefore we suggest that the seborrheic verruca-like cyst wall may have been a nevoid change or had a mechanical factor.
References 1) Rahbari H: Epidermoid cysts with seborrheic verruca-like cyst walls, ArchDermatol, 118: 326-328, 1982. 2) MacKie RM: Cysts of the skin, in Rook A, Wilkinson DS, Ebling FJG, Champion RH (eds): Textbook of Dermatology, Blackwell Scientific Publications, Oxford, 1986, pp 2404-2407. 3) Caro WA, Bronstein BR: Epithelial cysts, in Moschella SL, Hurley HJ (eds): Dermatology, WB Saunders Company, Philadelphia, 1985, pp 15401542. 4) Lever WF, Schaumberg-Lever G: Tumors and cysts of the epidermis, in Lever WF, Schaumberg-Lever G (eds): Histopathology of the Skin, JB Lippincott Company, Philadelphia, 1983, pp 482-484.
