Trichilemmoma PHILIP CHAN, M.D., MAJ., M.C., STEPHEN W. WHITE, M.D., LTC., M.C., DEAN L. PIERSON, M.D., LTC., M.C., M.P.H., AND O. G. RODMAN, M.D., COL., M.C.
Trichilemmoma is an uncommon cutaneous neoplasm that originates in the outer hair sheath. We are reporting two cases, one of lobular pattern, the other a massing of cells o f the follicular infundibulum. In each case, the clinical appearance was nonspecific and the mistaken clinical diagnosis was basal-cell carcinoma.
d i a g n o s i s of trichilemmoma should be consid ered in any papule on the face that is not distinctive. The differentiation from basal-cell carcinoma is impor tant because management may then be planned to the best cosmetic result rather than to the primary consid eration of extirpating a malignancy regardless of cosmesis.
T he
CASE REPORT #1
A 72-year-old white man presented himself with a papule on his left cheek that was four millimeters in diameter and had been present for two years. The ini tial clinical diagnosis was basal-cell carcinoma. Histopathological examination of sections of a shave biopsy stained by hematoxylin and eosin revealed the epidermis to be acanthotic in a lobular pattern and to contain many clear cells (Fig. 1). The clear cells (Fig. 2) were PAS positive and diastase sensitive, indicating the presence of glycogen. A diagnosis of trichilem moma of lobular pattern was made. Dr. Chan is a Resident Physician, Dermatology Service, Depart ment of Medicine, Walter Reed Army Medical Center, Washington, D.C. Dr. White is a Resident Physician, Dermatology Service, Depart ment of Medicine, Walter Reed Army Medical Center, Washington, D.C. Dr. Pierson is Assistant Chief, Dermatology Service, Department of Medicine, Walter Reed Army Medical Center, Washington, D.C. Dr. Rodman is Chief, Dermatology Service, Department of Medi cine, Walter Reed Army Medical Center, Washington, D.C. Address reprint requests to Dr. Philip Chan, Maj., M.C., Dermatology Service, Dept, of Medicine, Walter Reed Army Medi cal Center, Washington, D.C. 20012. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
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J. Dermatol. Surg. Oncol. 5:1 January 1979
The lesion was solitary. There was nothing in the patient’s personal or family history to suggest a hamartomatous syndrome1. CASE REPORT #2
A 67-year-old white woman presented herself with a one-year history of a crusted papule on the nose that was three millimeters in diameter and occasionally pruritic (Fig. 3). Histopathologic examination of sec tions of a shave biopsy stained with hematoxylin and eosin revealed in the upper dermis a basophilic neo plasm whose cells were arranged in a flattened, “ plate like” fashion with peripheral palisading but without retraction spaces (Fig. 4). The mass had clear cells and was attached to the epidermis in several places. The clear cells were PAS positive and diastase sensitive. The diagnosis was trichilemmoma of the follicular infundibulum.2 The patient had no other abnormalities of the skin except scattered seborrheic keratoses and no evidence of Cowden’s disease. She had no family history of hereditable neoplasms. COMMENT
Trichilemmoma is a neoplasm of the outer hair sheath. It is an indifferent-looking papule or verrucous growth, usually taken clinically to be a basal-cell carcinoma or verruca vulgaris. In a review of 40 cases Brownstein and Shapiro found no record of this hamartoma being clinically diagnosed correctly before histopathological examination.3 There are two recognized histologic types, namely, one of lobular pattern and another, a flattish mass aris ing from the follicular infundibulum. The lobular type is usually a solitary lesion, characteristically occurring
CHAN ET AL.
FIGURE 1. Histologic appearance o f a trichilemmoma o f lobular pattern showing clear cells within a lobule. (H&E, xIOO)
FIGURE 2. Higher power view o f Fig. I showing more detail o f the clear cells. (H&E, x400)
FIGURE 4. His tologic appear ance o f the trichilemmoma pictured in Fig. 3. The cellular mass is plate-like, con tains clear cells and has peripheral palisading, but no retraction. (H&E, xIOO)
FIGURE 3. Clinical appearance o f a trichilemmoma on the nose. It appears to be a pearly papule.
on the face. The distinguishing histological feature is lobular architecture oriented around a hair follicle. The neoplasm is found closely approximated to the epidermis. Besides a large number o f clear cells at tributable to high content o f glycogen, there is a ten dency for keratinization to occur in the center o f the lobules.4 Histologically, the differential diagnosis o f the lobular type o f trichilemmoma includes the clear cell acanthoma o f Degos, clear-cell hidradenoma, cutaneous metastasis from a renal adenocarcinoma, neoplasms o f sebaceous origin, and basal-cell car cinoma w ith sebaceous differentiation.3 The tum or o f the follicular infundibulum occurs as single or several papules on the face. Histologically, such a lesion appears as a plate-like growth o f cells in the upper dermis w ith numerous connections to the epidermis, clear cells in the center, and basaloid cells in peripheral palisading.2 The clear cells containing PAS positive, diastase sensitive glycogen differentiate it from a basal-cell carcinoma, but the character o f
these cells may be overlooked in sections stained with hematoxylin and eosin. A correct diagnosis gives the patient the opportunity to elect complete surgical excision, a less radical treatment like topical application o f 5-fluorouracil (1% in propylene glycol), or no treatment at all. Further more, the patient does not need the follow-up care required for a basal-cell carcinoma. Trichilemmomas in multiplicity are a part o f the multiple hamartoma syndrome (Cowden’s disease).1 Because o f the associ ation o f the full-blown syndrome with malignancies o f the thyroid, breast and gastrointestinal tract, a patient with even a solitary trichilemmoma deserves examina tion and observation for other stigmata o f Cowden’s disease on the off-chance that it is a forme fruste o f that condition or premonitory o f it.
1. 2. 3. 4.
REFERENCES Weary, P. E ., et al. Multiple hamartoma syndrome (Cowden’s disease). Arch. Dermatol. 106:682-690, 1972. Mehregan, A. H., and Butler, J. D. A tumor of the follicular infundibulum. Arch. Dermatol. 83:924-927, 1961. Brownstein, M. H., and Shapiro, L. Trichilemmoma: analysis of 40 new cases. Arch. Dermatol. 107:866-869, 1973. Lever, W. F., and Schaumburg-Lever, G. Histopathology of the Skin. 5th ed., Philadelphia, J. B. Lippincott Co., 1975, pp. 522-523.
J. Dermatol. Surg. Oncol. 5:1 January 1979
59
Trichilemmoma is an uncommon cutaneous neoplasm that originates in the outer hair sheath. We are reporting two cases, one of lobular pattern, the other a massing of cells o f the follicular infundibulum. In each case, the clinical appearance was nonspecific and the mistaken clinical diagnosis was basal-cell carcinoma.
d i a g n o s i s of trichilemmoma should be consid ered in any papule on the face that is not distinctive. The differentiation from basal-cell carcinoma is impor tant because management may then be planned to the best cosmetic result rather than to the primary consid eration of extirpating a malignancy regardless of cosmesis.
T he
CASE REPORT #1
A 72-year-old white man presented himself with a papule on his left cheek that was four millimeters in diameter and had been present for two years. The ini tial clinical diagnosis was basal-cell carcinoma. Histopathological examination of sections of a shave biopsy stained by hematoxylin and eosin revealed the epidermis to be acanthotic in a lobular pattern and to contain many clear cells (Fig. 1). The clear cells (Fig. 2) were PAS positive and diastase sensitive, indicating the presence of glycogen. A diagnosis of trichilem moma of lobular pattern was made. Dr. Chan is a Resident Physician, Dermatology Service, Depart ment of Medicine, Walter Reed Army Medical Center, Washington, D.C. Dr. White is a Resident Physician, Dermatology Service, Depart ment of Medicine, Walter Reed Army Medical Center, Washington, D.C. Dr. Pierson is Assistant Chief, Dermatology Service, Department of Medicine, Walter Reed Army Medical Center, Washington, D.C. Dr. Rodman is Chief, Dermatology Service, Department of Medi cine, Walter Reed Army Medical Center, Washington, D.C. Address reprint requests to Dr. Philip Chan, Maj., M.C., Dermatology Service, Dept, of Medicine, Walter Reed Army Medi cal Center, Washington, D.C. 20012. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
58
J. Dermatol. Surg. Oncol. 5:1 January 1979
The lesion was solitary. There was nothing in the patient’s personal or family history to suggest a hamartomatous syndrome1. CASE REPORT #2
A 67-year-old white woman presented herself with a one-year history of a crusted papule on the nose that was three millimeters in diameter and occasionally pruritic (Fig. 3). Histopathologic examination of sec tions of a shave biopsy stained with hematoxylin and eosin revealed in the upper dermis a basophilic neo plasm whose cells were arranged in a flattened, “ plate like” fashion with peripheral palisading but without retraction spaces (Fig. 4). The mass had clear cells and was attached to the epidermis in several places. The clear cells were PAS positive and diastase sensitive. The diagnosis was trichilemmoma of the follicular infundibulum.2 The patient had no other abnormalities of the skin except scattered seborrheic keratoses and no evidence of Cowden’s disease. She had no family history of hereditable neoplasms. COMMENT
Trichilemmoma is a neoplasm of the outer hair sheath. It is an indifferent-looking papule or verrucous growth, usually taken clinically to be a basal-cell carcinoma or verruca vulgaris. In a review of 40 cases Brownstein and Shapiro found no record of this hamartoma being clinically diagnosed correctly before histopathological examination.3 There are two recognized histologic types, namely, one of lobular pattern and another, a flattish mass aris ing from the follicular infundibulum. The lobular type is usually a solitary lesion, characteristically occurring
CHAN ET AL.
FIGURE 1. Histologic appearance o f a trichilemmoma o f lobular pattern showing clear cells within a lobule. (H&E, xIOO)
FIGURE 2. Higher power view o f Fig. I showing more detail o f the clear cells. (H&E, x400)
FIGURE 4. His tologic appear ance o f the trichilemmoma pictured in Fig. 3. The cellular mass is plate-like, con tains clear cells and has peripheral palisading, but no retraction. (H&E, xIOO)
FIGURE 3. Clinical appearance o f a trichilemmoma on the nose. It appears to be a pearly papule.
on the face. The distinguishing histological feature is lobular architecture oriented around a hair follicle. The neoplasm is found closely approximated to the epidermis. Besides a large number o f clear cells at tributable to high content o f glycogen, there is a ten dency for keratinization to occur in the center o f the lobules.4 Histologically, the differential diagnosis o f the lobular type o f trichilemmoma includes the clear cell acanthoma o f Degos, clear-cell hidradenoma, cutaneous metastasis from a renal adenocarcinoma, neoplasms o f sebaceous origin, and basal-cell car cinoma w ith sebaceous differentiation.3 The tum or o f the follicular infundibulum occurs as single or several papules on the face. Histologically, such a lesion appears as a plate-like growth o f cells in the upper dermis w ith numerous connections to the epidermis, clear cells in the center, and basaloid cells in peripheral palisading.2 The clear cells containing PAS positive, diastase sensitive glycogen differentiate it from a basal-cell carcinoma, but the character o f
these cells may be overlooked in sections stained with hematoxylin and eosin. A correct diagnosis gives the patient the opportunity to elect complete surgical excision, a less radical treatment like topical application o f 5-fluorouracil (1% in propylene glycol), or no treatment at all. Further more, the patient does not need the follow-up care required for a basal-cell carcinoma. Trichilemmomas in multiplicity are a part o f the multiple hamartoma syndrome (Cowden’s disease).1 Because o f the associ ation o f the full-blown syndrome with malignancies o f the thyroid, breast and gastrointestinal tract, a patient with even a solitary trichilemmoma deserves examina tion and observation for other stigmata o f Cowden’s disease on the off-chance that it is a forme fruste o f that condition or premonitory o f it.
1. 2. 3. 4.
REFERENCES Weary, P. E ., et al. Multiple hamartoma syndrome (Cowden’s disease). Arch. Dermatol. 106:682-690, 1972. Mehregan, A. H., and Butler, J. D. A tumor of the follicular infundibulum. Arch. Dermatol. 83:924-927, 1961. Brownstein, M. H., and Shapiro, L. Trichilemmoma: analysis of 40 new cases. Arch. Dermatol. 107:866-869, 1973. Lever, W. F., and Schaumburg-Lever, G. Histopathology of the Skin. 5th ed., Philadelphia, J. B. Lippincott Co., 1975, pp. 522-523.
J. Dermatol. Surg. Oncol. 5:1 January 1979
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