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Observation Letter
88 (
3
); 404-408
doi:
10.25259/IJDVL_670_2021
pmid:
35389024

Dermoscopic features of epidermoid cyst beyond punctum

Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Department of Dermatology, Venereology and Leprology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
Corresponding author: Dr. Rashmi Kumari, Department of Dermatology, Venereology and Leprology, Jawaharlal Institute of Postgraduate Medical Education and Research, Gorimedu, Puducherry, India.
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Behera B, Kumari R, Thappa DM, Gochhait D. Dermoscopic features of epidermoid cyst beyond punctum. Indian J Dermatol Venereol Leprol 2022;88:404-8.

Sir,

Epidermoid cyst, also called sebaceous cyst, is the most common benign cutaneous cyst encountered during clinical practice. It usually presents as an asymptomatic slow-growing, spherical, smooth, elastic and dome-shaped keratin-filled cyst. Due to variable size, colour, and consistency, it often resembles various benign adnexal and non-adnexal tumours clinically. The dermoscopic examination is primarily aimed at demonstrating the punctum, which facilitates the diagnosis.

All our patients were skin phototypes IV and V. None of them presented with punctum either clinically or dermoscopically. Table 1 lists the clinical and dermoscopic (Heine Delta 20, under non-polarised mode) details of our patients [Figures 17]. Each diagnosis was confirmed by histopathology. Neither patient showed any feature of rupture, secondary bacterial infection, or calcification. All lesions were successfully excised without any recurrence.

Table 1:: Clinical and dermoscopic features of seven sebaceous cysts
Cases Age/gender Location Morphology Differential diagnosis Dermoscopic features
1 16/M Chin Yellowish nodule with telangiectasia Non-Langerhans histiocytosis Yellowish-white homogeneous area with arborising vessels
2 46/M Lower back Macro comedone Dilated pore of Winer Pilar sheath acanthoma Brown keratotic plug surrounded by bluish-white homogeneous area
3 24/M Shoulder Bluish cyst with telangiectasia Sebaceous cyst Hidrocystoma White homogeneous area with arborising vessels
4 40/M Abdomen Light blue firm nodule Sebaceous cyst Bluish-white homogeneous area
5 60/F Arm Hyperpigmented keratotic papule Keratoacanthoma Central brown-black keratotic area surrounded by bluish-white homogeneous area
6 45/F Elbow Skin-coloured cyst Sebaceous cyst Phaeohyphomycosis Skin coloured to white homogeneous area
Focal hairpin vessels
Peripheral ridge and groove area
7 50/M Abdomen Reddish-brown nodule Aneurysmal or haemosiderotic
Dermatofibroma Leiomyoma
Grey-to-grey-white homogeneous area
Pigment network and rings
Linear irregular crypts
White clods
Figure 1a:: Yellowish nodule with surface telangiectasia
Figure 1b:: Dermoscopy (Heine Delta 10×, under non-polarised mode) shows a yellowish-white homogeneous area with arborizing vessels
Figure 2a:: Macro-comedone with keratotic plug
Figure 2b:: Dermoscopy shows (Heine Delta 10×, under non-polarised mode) brown keratotic plug surrounded by bluish-white homogeneous area
Figure 3a:: Bluish cyst with telangiectasia
Figure 3b:: Dermoscopy shows (Heine Delta 10×, under non-polarised mode) white homogeneous area with arborizing vessels
Figure 4a:: Light blue-coloured firm nodule
Figure 4b:: Dermoscopy shows (Heine Delta 10×, under non-polarised mode) bluish-white homogeneous area
Figure 5a:: Hyperpigmented keratotic papule
Figure 5b:: Dermoscopy (Heine Delta 10×, under non-polarised mode) shows a central brown-black keratotic area surrounded by bluish-white homogeneous area
Figure 6a:: Solitary skin-coloured cyst on the elbow
Figure 6b:: Dermoscopy shows (Heine Delta 10×, under non-polarised mode) skin-coloured to white structureless area
Figure 7a:: Reddish-brown nodule
Figure 7b:: Dermoscopy shows (Heine Delta 10×, under non-polarised mode) gray to gray-white homogeneous area, pigment network (red arrow) and rings (blue arrow), linear irregular crypts, and white clods (black arrow)

Diagnosis of epidermoid cyst is essentially clinical. A cystic consistency with central punctum is usually diagnostic. However, diagnostic dilemma arises when the cystic consistency becomes firm or hard with or without tenderness which may be secondary to bacterial infection, inflammation, and calcification. Additionally, lack of punctum and colour variation, especially in darker skin, may result in misdiagnosis.

In this series, the clinical differentials were diverse due to following reasons: morphological variation ranging from cyst, nodule, open macro-comedone to keratotic papule and heterogeneous colour such as skin coloured, yellow and blue to reddish-brown.

Dermoscopic examination is a useful supplementary tool in diagnosing various cutaneous cysts and tumours. In epidermoid cysts, demonstration of a punctum, called the pore sign, facilitates the diagnosis.1 Other features include white, yellow, and blue homogeneous areas and arborizing vessels.2-4 Dermoscopy revealed the punctum in almost 60% cases, even when clinically invisible.1 In our experience, the pore sign helps in differentiating facial and scalp epidermoid cysts from trichilemmal cyst, another common cystic lesion. Likewise, in acral areas, the pore sign helps in ruling out phaeohyphomycosis and myxoid cyst. A recent study reported that pore sign, blue-white veil and arborizing vessels were associated with unruptured epidermoid cyst while red lacunae and peripheral branched linear vessels indicated ruptured epidermoid cysts.5

In the present series, we included patients who did not reveal any punctum, either clinically or dermoscopically. We observed seven dermoscopic patterns, which are mentioned in Table 2 along with relevant differential diagnoses.

Table 2:: Dermoscopic differential diagnoses of different patterns observed in this series Patterns Dermoscopic features Dermoscopic differentials
Patterns Dermoscopic features Dermoscopic differentials
Pattern 1 Yellow-white homogeneous area with arborising vessels • Non-Langerhans cell histiocytosis
Pattern 2 Brown keratotic plug surrounded by bluish-white homogeneous area • Dilated pore of Winer
Pattern 3 White homogeneous area and arborising vessels • Non-pigmented basal cell carcinoma
• Solitary apocrine hidrocystoma
Pattern 4 Bluish-white homogenous area • Chondroid syringoma
• Solitary apocrine hidrocystoma
Pattern 5 Central brown-black keratotic area surrounded by bluish-white homogeneous area • Keratoacanthoma
Pattern 6 Skin coloured to white homogeneous area • Neurofibroma
• Dermatofibroma
Pattern 7 Grey-to-grey-white homogeneous area with linear irregular crypts • Neurofibroma
• Dermatofibroma

The white homogeneous areas represent keratin, the yellow colour results from mass effect of concentric layers of laminated keratin, brown homogeneous areas occur due to increase epidermal melanin and the bluish colour may be attributed to Tyndall effect, as described in apocrine hidrocystoma.

In conclusion, we describe some diverse and unreported dermoscopic features of epidermoid cysts without punctum, in seven patients with skin of colour. Additionally, grey homogeneous areas, pigment networks and rings may be observed in such patients. Thus, an epidermoid cyst without dermoscopic pore sign may mimic various appendageal tumours, and a pathological examination is necessary for accurate diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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