738 Pediatric Dermatology Vol. 31 No. 6 November/December 2014
The importance of understanding how skin care products affect skin barrier function is becoming better recognized (16). Some manufacturers of new products on the market are beginning to evaluate how their products affect pediatric skin (2,3,17). More work is still needed, even regarding some of the most basic questions in skin care, such as how often should we bathe our children, what type of cleanser should be used, how often should we use emollients on our children, what type of emollient is best, and do additives help or hurt the skin? As we better understand the role of the skin barrier in the initiation and persistence of skin disease and as the skin care product market continues to grow, answers to these questions become increasingly important. REFERENCES 1. Mintel Group. Disposable baby products—US— March 2012 [online]. Available at http://oxygen.mintel.com/display/590262/. Accessed on July 11, 2012. 2. Nebus J, Wallo W. Evaluating the tolerance and safety of a colloidal oatmeal cream and cleanser in babies and children with atopic dermatitis. Aveeno Active Naturals Professional Center. Clinical Studies [online]. Available at http://www.aveenoprofessional.com/clinicals. Accessed on January 10, 2014. 3. Simpson E, Trookman NS, Rizer RL et al. Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: results from an open-label study. Pediatr Dermatol 2012;29:590–597. 4. Loden M. Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. Am J Clin Dermatol 2003;4:771–788. 5. Levin J, Miller R. A guide to the ingredients and potential benefits of over-the-counter cleansers and moisturizers for rosacea patients. J Clin Aesthet Dermatol 2011;4:31–49. 6. Danby SG, Al Enezi T, Sultan A et al. Effect of olive and sunflower seed oil on the adult skin barrier: implications for neonatal skin care. Pediatr Dermatol 2013;30:42–50. 7. Cork M, Robinson D, Vasilopoulos Y. The rising prevalence of atopic eczema and environmental trauma to the skin. Dermatol Pract 2002;10:22–26. 8. Kownatzki E. Detergents and atopic dermatitis in children. Pediatr Dermatol 2004;21:179–180. 9. Proksch E, Elias PM. Epidermal barrier in atopic dermatitis. In: Bieber T, Leung DYM, eds. Atopic dermatitis. New York: Marcel Dekker, 2002: 123–143. 10. Blume-Peytavi U, Hauser M, Stamatas GN et al. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol 2012;29:1–14. 11. Lavender T, Bedwell C, O’Brien E et al. Infant skincleansing product versus water: a pilot randomized, assessor-blinded controlled trial. BMC Pediatr 2011;11:35.
12. Garcia Bartels N, Scheufele R, Prosch F et al. Effect of standardized skin care regimens on neonatal skin barrier function in different body areas. Pediatr Dermatol 2010;27:1–8. 13. Rendell ME, Baig-Lewis SF, Berry TM et al. Do early skin care practices alter the risk of atopic dermatitis? A case-control study Pediatr Dermatol 2011;28:593–595. 14. Boyapati A, Tam M, Tate B et al. Allergic contact dermatitis to methylisothiazolinone: exposure from baby wipes causing hand dermatitis. Australas J Dermatol 2013;54:264–267. 15. Walker L, Downe S, Gomez L. Skin care in the well term newborn: two systematic reviews. Birth 2005;32:224–228. 16. Mohammed D, Matts PJ, Hadgraft J et al. Influence of aqueous cream BP on corneocyte size, maturity, skin protease activity, protein content and transepidermal water loss. Br J Dermatol 2011;164:1304–1310. 17. Ehretsmann C, Schaefer P, Adam R. Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin. J Eur Acad Dermatol Venereol 2001;15:16–21. Xiang Gao, B.S. Eric L. Simpson, M.D., M.C.R. Department of Dermatology, Oregon Health & Science University, Portland, Oregon Address correspondence to Eric L. Simpson, M.D., M.C.R., OHSU Dermatology (CH16D), 3303 SW Bond Avenue, Portland, OR 97239, or e-mail: [email protected].
Angiolymphoid Hyperplasia with Eosinophilia: A Previously Unreported Complication of Ear Piercing Abstract: Angiolymphoid hyperplasia with eosinophilia is a rare, benign vascular lesion characterized by discrete, painful papules. Although the exact etiology is unknown, trauma precedes many cases. We present a case of angiolymphoid hyperplasia with eosinophilia in the earlobes of a 15-year-old girl after ear piercing.
A 15-year-old girl was referred to plastic surgery clinic for multiple, painful papules on her earlobes. The lesions appeared several months after ear piercing and had been worsening. Physical examination revealed multiple tan-brown 0.5-cm papules on the anterior and posterior left earlobe (Fig. 1). The right ear lobe also had a palpably thickened area with several papules. The initial clinical impression was that keloids had developed in the areas of trauma after ear piercing.
Brief Reports 739
A
B
C
D
E
F
Figure 1. Multiple papules on the anterior (A) and posterior (B) of the left ear near site of piercing. The right ear and left ear are presented 6 months (C and D) and 11 months (E and F) after treatment with triamcinolone steroid injection and surgical excision, respectively.
740 Pediatric Dermatology Vol. 31 No. 6 November/December 2014
A
B
C
D
Figure 2. Histopathologic images of excised lesion. (A) Dense inflammation with lymphoid follicles present (hematoxylin and eosin [H&E] stain, 950). (B) Medium-power view shows dilated vascular channels with endothelial cells that have a “hobnail” shape that bulge into the lumen (H&E stain, 9200). (C) High-power view shows many eosinophils in the inflammatory infiltrate (H&E stain, 9400). (D) CD21 highlights the follicular dendritic network in the lymphoid follicles (CD21, 9100).
Lesions on the left earlobe were excised and sent for histopathologic examination. The right ear lobe was injected with intralesional triamcinolone. The histologic sections showed a nodular proliferation of chronic inflammatory cells including mature lymphocytes and focally forming germinal centers with histiocytes and numerous eosinophils within the superficial and deep dermis. The inflammatory infiltrate also incorporated a proliferation of small vascular structures that focally demonstrated prominent endothelial cells with a “hobnail” appearance (Fig. 2). CD3 and CD20 stains demonstrated a mixture of T- and B-cells, consistent with a reactive process, with an intact dendritic cell network highlighted by CD21. These findings were consistent with angiolymphoid hyperplasia with eosinophilia (ALHE). The final diagnosis of ALHE secondary to ear piercing was made. Six months after treatment, lesions were absent. Papules re-appeared on the right earlobe 11 months after steroid injection and were surgically excised (Fig. 1). Pathologic findings were again consistent with ALHE. DISCUSSION ALHE, also known as epithelioid hemangioma, is an uncommon, benign vascular proliferation that usually
presents as a single or multiple purple or brown papules. Approximately 85% present in the head and neck and commonly affect the periauricular and scalp areas (1,2). Histopathologically, ALHE shows proliferation of thick-walled and irregular blood vessels that are often lined by enlarged epithelioid- or histiocyctic-appearing ‘hobnail’ endothelial cells with ovoid nuclei and intracytoplasmic vacuoles protruding into the lumen of vessels. A perivascular inflammatory infiltrate accompanies the vascular findings, with eosinophils accounting for 5–15%. The vascular proliferations accumulate in loosely lobular patterns with surrounding fibrous stroma and occasional lymphoid follicles (1,3,4). Thought to be part of the Kimura disease spectrum that Wells and Whimster first described in 1969, ALHE has since been determined to be a separate entity (4). Confusion surrounding its pathology, etiology, and classification has led to many names through the years, including histiocytoid hemangioma, pseudo or atypical pyogenic granuloma, and inflammatory angiomatous nodules (1,3). Multiple studies, including the most comprehensive analysis of 116 histologically confirmed cases, show that approximately 10% are associated with previous trauma (1,3). Case reports have also described ALHE after local trauma, including a
Brief Reports 741
recent report that found it to be secondary to venipuncture (2,3). ALHE and common traumatic lesions share similar findings, including elastic tissue alteration, mucosaccharide elaboration, and reactive vessel formation, although multiple factors found in lesions may drive the unique pathologic vascular and inflammatory proliferation seen in ALHE: large numbers of mast cells that release histamine, interleukin-5, and vascular endothelial growth factor; high renin and angiotensin II levels; and a lack of periendothelial cells (1,3,5,6). To our knowledge, this is the first reported case of ALHE secondary to ear piercing. Although lesions can regress spontaneously, various treatments are used to speed resolution (2,5). Simple surgical excision, Mohs surgery, intralesional steroid injections, laser therapy, retinoids, cyro- and radiotherapy, and electrodesiccation have all been successful, with varying rates of recurrence. Therefore, regardless of the modality of treatment, followup is required (1–3,5). It is important for clinicians to consider the diagnosis of ALHE after ear piercing, especially because the lesions can clinically mimic keloids. REFERENCES 1. Olsen TG, Helwig EB. Angiolymphoid hyperplasia with eosinophilia: a clinicopatholgic study of 116 patients. J Am Acad Dermatol 1985;12(5 pt. 1):781–796. 2. Stewart N, Zagarella S, Mann S. Angiolyphoid hyperplasia with eosinophilia occurring after venipuncture trauma. J Dermatol 2013;40:393–395. 3. Vadlamudi G, Schinella R. Traumatic pseudoaneurysm: a possible early lesion in the spectrum of epithelioid hemangioma/angiolymphoid hyperplasia with eosinophilia. Am J Dermatopathol 1998;20:113–117. 4. Chun SI, Ji HG. Kimura’s disease and angiolymphoid hyperplasia with eosinophilia: clinical and histopathologic differences. J Am Acad Dermatol 1992;27(6 Pt 1):954–958. 5. Trindade F, Haro R, Requena L. Giant angiolymphoid hyperplasia with eosinophilia on the chest. J Cutan Pathol 2009;36:493–496. 6. Busquets AC, Sanchez JL. Angiolymphoid hyperplasia with eosinophilia induced by trauma. Int J Dermatol 2006;45:1211–1214. Jonathan S. Okman, M.D., M.B.A.* Tricia R. Bhatti, M.D.† Oksana A. Jackson, M.D.à Adam I. Rubin, M.D.¶ *Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, †Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, àDivision of Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, ¶Department of Dermatology, Division of Dermatopathology, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Address correspondence to Adam I. Rubin, M.D., Department of Dermatology, Division of Dermatopathology, University of Pennsylvania Health System, 2 Maloney, 3600 Spruce Street, Philadelphia, PA 19104, or e-mail: [email protected].
Utility of the “Magnet Sign” in the Differential Diagnosis of a Firm Papule in the Skin Abstract: A symptomatic retained foreign body can be frustrating to physicians and patients alike. Herein we present a case of a retained metal ball bearing from an air gun injury. This brief communication highlights an innovative “bedside” technique that helped to confirm the diagnosis and allow for immediate and definitive management.
A 17-year-old boy presented to the department of pediatric and adolescent dermatology for evaluation of a persistent “hard bump” within his right medial eyebrow. He noted the lesion was “pretty close” to where, 2 years before, he had been accidentally shot by a ball bearing (BB) air gun. The patient had thought that the BB had “bounced off” of his skin after the injury, so he did not sought medical care at that time. Other than frequent, focal headaches emanating from the site of the lesion, the patient’s past medical, surgical, family, and social histories were otherwise unremarkable. The patient denied any suicidal or homicidal ideation and screened negative for depression. During physical examination, the patient was noted to be an active, well-developed, well-appearing boy with no signs of physical or emotional distress. His vital signs were normal. Local head and neck examination revealed a 6-mm-diameter, smooth, firm, somewhat-mobile papule located at the right medial eyebrow with no overlying skin changes and no central punctum. There were no neurologic or functional impairments to cranial nerves I to XII and no noted behavioral problems or signs of dysphoric mood. Given the patient’s uncertain history, lack of overlying skin changes, and anatomic location and size of the lesion (larger than what might be expected for a normal BB), a broad differential diagnosis was considered, including pilomatricoma, dermoid cyst,
The importance of understanding how skin care products affect skin barrier function is becoming better recognized (16). Some manufacturers of new products on the market are beginning to evaluate how their products affect pediatric skin (2,3,17). More work is still needed, even regarding some of the most basic questions in skin care, such as how often should we bathe our children, what type of cleanser should be used, how often should we use emollients on our children, what type of emollient is best, and do additives help or hurt the skin? As we better understand the role of the skin barrier in the initiation and persistence of skin disease and as the skin care product market continues to grow, answers to these questions become increasingly important. REFERENCES 1. Mintel Group. Disposable baby products—US— March 2012 [online]. Available at http://oxygen.mintel.com/display/590262/. Accessed on July 11, 2012. 2. Nebus J, Wallo W. Evaluating the tolerance and safety of a colloidal oatmeal cream and cleanser in babies and children with atopic dermatitis. Aveeno Active Naturals Professional Center. Clinical Studies [online]. Available at http://www.aveenoprofessional.com/clinicals. Accessed on January 10, 2014. 3. Simpson E, Trookman NS, Rizer RL et al. Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: results from an open-label study. Pediatr Dermatol 2012;29:590–597. 4. Loden M. Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders. Am J Clin Dermatol 2003;4:771–788. 5. Levin J, Miller R. A guide to the ingredients and potential benefits of over-the-counter cleansers and moisturizers for rosacea patients. J Clin Aesthet Dermatol 2011;4:31–49. 6. Danby SG, Al Enezi T, Sultan A et al. Effect of olive and sunflower seed oil on the adult skin barrier: implications for neonatal skin care. Pediatr Dermatol 2013;30:42–50. 7. Cork M, Robinson D, Vasilopoulos Y. The rising prevalence of atopic eczema and environmental trauma to the skin. Dermatol Pract 2002;10:22–26. 8. Kownatzki E. Detergents and atopic dermatitis in children. Pediatr Dermatol 2004;21:179–180. 9. Proksch E, Elias PM. Epidermal barrier in atopic dermatitis. In: Bieber T, Leung DYM, eds. Atopic dermatitis. New York: Marcel Dekker, 2002: 123–143. 10. Blume-Peytavi U, Hauser M, Stamatas GN et al. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol 2012;29:1–14. 11. Lavender T, Bedwell C, O’Brien E et al. Infant skincleansing product versus water: a pilot randomized, assessor-blinded controlled trial. BMC Pediatr 2011;11:35.
12. Garcia Bartels N, Scheufele R, Prosch F et al. Effect of standardized skin care regimens on neonatal skin barrier function in different body areas. Pediatr Dermatol 2010;27:1–8. 13. Rendell ME, Baig-Lewis SF, Berry TM et al. Do early skin care practices alter the risk of atopic dermatitis? A case-control study Pediatr Dermatol 2011;28:593–595. 14. Boyapati A, Tam M, Tate B et al. Allergic contact dermatitis to methylisothiazolinone: exposure from baby wipes causing hand dermatitis. Australas J Dermatol 2013;54:264–267. 15. Walker L, Downe S, Gomez L. Skin care in the well term newborn: two systematic reviews. Birth 2005;32:224–228. 16. Mohammed D, Matts PJ, Hadgraft J et al. Influence of aqueous cream BP on corneocyte size, maturity, skin protease activity, protein content and transepidermal water loss. Br J Dermatol 2011;164:1304–1310. 17. Ehretsmann C, Schaefer P, Adam R. Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin. J Eur Acad Dermatol Venereol 2001;15:16–21. Xiang Gao, B.S. Eric L. Simpson, M.D., M.C.R. Department of Dermatology, Oregon Health & Science University, Portland, Oregon Address correspondence to Eric L. Simpson, M.D., M.C.R., OHSU Dermatology (CH16D), 3303 SW Bond Avenue, Portland, OR 97239, or e-mail: [email protected].
Angiolymphoid Hyperplasia with Eosinophilia: A Previously Unreported Complication of Ear Piercing Abstract: Angiolymphoid hyperplasia with eosinophilia is a rare, benign vascular lesion characterized by discrete, painful papules. Although the exact etiology is unknown, trauma precedes many cases. We present a case of angiolymphoid hyperplasia with eosinophilia in the earlobes of a 15-year-old girl after ear piercing.
A 15-year-old girl was referred to plastic surgery clinic for multiple, painful papules on her earlobes. The lesions appeared several months after ear piercing and had been worsening. Physical examination revealed multiple tan-brown 0.5-cm papules on the anterior and posterior left earlobe (Fig. 1). The right ear lobe also had a palpably thickened area with several papules. The initial clinical impression was that keloids had developed in the areas of trauma after ear piercing.
Brief Reports 739
A
B
C
D
E
F
Figure 1. Multiple papules on the anterior (A) and posterior (B) of the left ear near site of piercing. The right ear and left ear are presented 6 months (C and D) and 11 months (E and F) after treatment with triamcinolone steroid injection and surgical excision, respectively.
740 Pediatric Dermatology Vol. 31 No. 6 November/December 2014
A
B
C
D
Figure 2. Histopathologic images of excised lesion. (A) Dense inflammation with lymphoid follicles present (hematoxylin and eosin [H&E] stain, 950). (B) Medium-power view shows dilated vascular channels with endothelial cells that have a “hobnail” shape that bulge into the lumen (H&E stain, 9200). (C) High-power view shows many eosinophils in the inflammatory infiltrate (H&E stain, 9400). (D) CD21 highlights the follicular dendritic network in the lymphoid follicles (CD21, 9100).
Lesions on the left earlobe were excised and sent for histopathologic examination. The right ear lobe was injected with intralesional triamcinolone. The histologic sections showed a nodular proliferation of chronic inflammatory cells including mature lymphocytes and focally forming germinal centers with histiocytes and numerous eosinophils within the superficial and deep dermis. The inflammatory infiltrate also incorporated a proliferation of small vascular structures that focally demonstrated prominent endothelial cells with a “hobnail” appearance (Fig. 2). CD3 and CD20 stains demonstrated a mixture of T- and B-cells, consistent with a reactive process, with an intact dendritic cell network highlighted by CD21. These findings were consistent with angiolymphoid hyperplasia with eosinophilia (ALHE). The final diagnosis of ALHE secondary to ear piercing was made. Six months after treatment, lesions were absent. Papules re-appeared on the right earlobe 11 months after steroid injection and were surgically excised (Fig. 1). Pathologic findings were again consistent with ALHE. DISCUSSION ALHE, also known as epithelioid hemangioma, is an uncommon, benign vascular proliferation that usually
presents as a single or multiple purple or brown papules. Approximately 85% present in the head and neck and commonly affect the periauricular and scalp areas (1,2). Histopathologically, ALHE shows proliferation of thick-walled and irregular blood vessels that are often lined by enlarged epithelioid- or histiocyctic-appearing ‘hobnail’ endothelial cells with ovoid nuclei and intracytoplasmic vacuoles protruding into the lumen of vessels. A perivascular inflammatory infiltrate accompanies the vascular findings, with eosinophils accounting for 5–15%. The vascular proliferations accumulate in loosely lobular patterns with surrounding fibrous stroma and occasional lymphoid follicles (1,3,4). Thought to be part of the Kimura disease spectrum that Wells and Whimster first described in 1969, ALHE has since been determined to be a separate entity (4). Confusion surrounding its pathology, etiology, and classification has led to many names through the years, including histiocytoid hemangioma, pseudo or atypical pyogenic granuloma, and inflammatory angiomatous nodules (1,3). Multiple studies, including the most comprehensive analysis of 116 histologically confirmed cases, show that approximately 10% are associated with previous trauma (1,3). Case reports have also described ALHE after local trauma, including a
Brief Reports 741
recent report that found it to be secondary to venipuncture (2,3). ALHE and common traumatic lesions share similar findings, including elastic tissue alteration, mucosaccharide elaboration, and reactive vessel formation, although multiple factors found in lesions may drive the unique pathologic vascular and inflammatory proliferation seen in ALHE: large numbers of mast cells that release histamine, interleukin-5, and vascular endothelial growth factor; high renin and angiotensin II levels; and a lack of periendothelial cells (1,3,5,6). To our knowledge, this is the first reported case of ALHE secondary to ear piercing. Although lesions can regress spontaneously, various treatments are used to speed resolution (2,5). Simple surgical excision, Mohs surgery, intralesional steroid injections, laser therapy, retinoids, cyro- and radiotherapy, and electrodesiccation have all been successful, with varying rates of recurrence. Therefore, regardless of the modality of treatment, followup is required (1–3,5). It is important for clinicians to consider the diagnosis of ALHE after ear piercing, especially because the lesions can clinically mimic keloids. REFERENCES 1. Olsen TG, Helwig EB. Angiolymphoid hyperplasia with eosinophilia: a clinicopatholgic study of 116 patients. J Am Acad Dermatol 1985;12(5 pt. 1):781–796. 2. Stewart N, Zagarella S, Mann S. Angiolyphoid hyperplasia with eosinophilia occurring after venipuncture trauma. J Dermatol 2013;40:393–395. 3. Vadlamudi G, Schinella R. Traumatic pseudoaneurysm: a possible early lesion in the spectrum of epithelioid hemangioma/angiolymphoid hyperplasia with eosinophilia. Am J Dermatopathol 1998;20:113–117. 4. Chun SI, Ji HG. Kimura’s disease and angiolymphoid hyperplasia with eosinophilia: clinical and histopathologic differences. J Am Acad Dermatol 1992;27(6 Pt 1):954–958. 5. Trindade F, Haro R, Requena L. Giant angiolymphoid hyperplasia with eosinophilia on the chest. J Cutan Pathol 2009;36:493–496. 6. Busquets AC, Sanchez JL. Angiolymphoid hyperplasia with eosinophilia induced by trauma. Int J Dermatol 2006;45:1211–1214. Jonathan S. Okman, M.D., M.B.A.* Tricia R. Bhatti, M.D.† Oksana A. Jackson, M.D.à Adam I. Rubin, M.D.¶ *Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, †Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, àDivision of Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, ¶Department of Dermatology, Division of Dermatopathology, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Address correspondence to Adam I. Rubin, M.D., Department of Dermatology, Division of Dermatopathology, University of Pennsylvania Health System, 2 Maloney, 3600 Spruce Street, Philadelphia, PA 19104, or e-mail: [email protected].
Utility of the “Magnet Sign” in the Differential Diagnosis of a Firm Papule in the Skin Abstract: A symptomatic retained foreign body can be frustrating to physicians and patients alike. Herein we present a case of a retained metal ball bearing from an air gun injury. This brief communication highlights an innovative “bedside” technique that helped to confirm the diagnosis and allow for immediate and definitive management.
A 17-year-old boy presented to the department of pediatric and adolescent dermatology for evaluation of a persistent “hard bump” within his right medial eyebrow. He noted the lesion was “pretty close” to where, 2 years before, he had been accidentally shot by a ball bearing (BB) air gun. The patient had thought that the BB had “bounced off” of his skin after the injury, so he did not sought medical care at that time. Other than frequent, focal headaches emanating from the site of the lesion, the patient’s past medical, surgical, family, and social histories were otherwise unremarkable. The patient denied any suicidal or homicidal ideation and screened negative for depression. During physical examination, the patient was noted to be an active, well-developed, well-appearing boy with no signs of physical or emotional distress. His vital signs were normal. Local head and neck examination revealed a 6-mm-diameter, smooth, firm, somewhat-mobile papule located at the right medial eyebrow with no overlying skin changes and no central punctum. There were no neurologic or functional impairments to cranial nerves I to XII and no noted behavioral problems or signs of dysphoric mood. Given the patient’s uncertain history, lack of overlying skin changes, and anatomic location and size of the lesion (larger than what might be expected for a normal BB), a broad differential diagnosis was considered, including pilomatricoma, dermoid cyst,
