Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Quiz
2013:79:6;847-848
doi: 10.4103/0378-6323.120754
PMID: 24177630

Painless dells on the cheek

Deniz Duman1 , Emel ztrk Durmaz1 , Emel D etin2 , Şkr Yazar3 , Sedef Şahin1
1 Department of Dermatology, Acıbadem University School of Medicine, Istanbul, Turkey
2 Department of Pathology, Acıbadem University School of Medicine, Istanbul, Turkey
3 Department of Plastic, Reconstructive and Aesthetic Surgery, Acıbadem University School of Medicine, Istanbul, Turkey

Correspondence Address:
Emel ztrk Durmaz
Acıbadem Maslak Hospital, Bykdere Caddesi 40, Maslak 34457, Istanbul
Turkey
How to cite this article:
Duman D, Durmaz E, etin ED, Yazar &, Şahin S. Painless dells on the cheek. Indian J Dermatol Venereol Leprol 2013;79:847-848
Copyright: (C)2013 Indian Journal of Dermatology, Venereology, and Leprology

A 30-year-old woman presented with a 15-year history of two asymptomatic dells on her right cheek. There was no history of preceding acne or inflammatory skin disease.

Dermatologic examination revealed two 0.5 cm and 0.3 cm-sized, sharply-demarcated, skin-colored papules with cup-shaped central depressions, located on the zygomatic [Figure - 1] and mandibular regions of the right cheek. On close inspection, follicular plugging was evident.

Figure 1: A well-circumscribed umbilicated patch on the right zygomatic region

Histopathological examination displayed a partially well-circumscribed tumor in the dermis with an overlying sharp depression. The tumor was composed of small cords and islands of basaloid cells that showed connection to the follicular infundibulum. Tumor strands were surrounded by a desmoplastic fibrous stroma [Figure - 2] and [Figure - 3]. Several keratinous cysts and foci of dystrophic calcification were also noted. Immunohistochemically, the tumor cells stained positive with anti-pancytokeratin (CK), anti-CK15 and negative with anti-carcinoembryonic antigen (CEA), anti-CK7 and anti-epithelial membrane antigen antibodies. The tumor was focally immunopositive for CK20 antibody, indicating the presence of scattered Merkel cells.

Figure 2: Thin cords and islands of basaloid cells in a dense fibrous stroma (H and E, ×100)
Figure 3: Closer view of Figure 2 (H and E, ×200)

What is Your Diagnosis?



Click here to view answer. View Answer

Discussion

Desmoplastic trichoepithelioma (DTE) is a rarely encountered benign adnexal tumor with an estimated incidence of 2 in 10.000 skin biopsies. [1],[2] The age range varies from 0 to 80. The lesion usually develops on the face of a young woman (71-85%). [2] The cheek is the most frequent site of affection (50%). [1],[2],[3] There is a propensity for DTE development on the right side of the face. [2] DTE presents as an asymptomatic, solitary, annular, firm, white to yellowish papule or as a sclerotic plaque smaller than 2 cm. The lesion has a thread-like raised and rolled border and a non-ulcerated central dell. [1],[2] The clinical appearance may be reminiscent of basal cell carcinoma (BCC).

The histologic portrait in previous reports encompasses narrow strands of basaloid cells, keratinous cysts and desmoplastic stroma. [2] The well-demarcated solid tumor is situated symmetrically within the papillary and reticular dermis. [2],[3] Small basaloid cells with prominent oval nuclei and scant cytoplasm are arranged in slender strands containing one to three rows of cells. There is often a focal connection to the overlying epidermis through the follicular infundibulum. The stroma surrounding the strands of basaloid cells consists of ample homogeneous eosinophilic collagen and multiple horn cysts. There is no cleft between the nests of tumor cells and sclerotic stroma. While palisading is lacking, epidermal hyperplasia may be noted. [2] Foreign body granulomas from broken cysts, areas of calcification or ossification might be observed. [2],[4]

The list of differential diagnostic considerations embraces trichoadenoma, trichoepithelioma, syringoma, sebaceous hyperplasia, granuloma annulare, BCC, microcystic adnexal carcinoma and squamous cell carcinoma. [2] Differentiation from morphea-like BCC may be extremely difficult, especially when a lesion is sampled only in part. Immunohistochemical markers may help the pathologist to distinguish DTE and morphea-like BCC. In particular, identification of CK20-positive Merkel cells within the lesion, the presence of CK15 expression in tumoral cells and CD34 expression in peritumoral stroma, along with the absence of CEA androgen receptor and Periodic Acid-Schiff (PAS) expressions may support a diagnosis of DTE and vice versa. [2],[3],[4] So far, CK20 is the most reliable immunohistochemical marker in differentiating DTE from morphea-like BCC. [4] However, CK 20 expression in DTEs may be focal. [2],[3],[4]

Once the diagnosis is established, DTE may be clinically followed-up with an expectant policy. [1] Cryotherapy, dermabrasion or laser surgery may pose risks of recurrence and/or scar formation. Imiquimod has been used in two cases as an adjunctive therapeutic measure, but without apparent benefit. [5] In equivocal cases, the best treatment is complete surgical excision. [1] If there is a consideration of microcystic adnexal carcinoma or morphea-like BCC or if tissue preservation is crucial, Mohs micrographic surgery may be recommended. [1],[2]

References
1.
Moynihan GD, Skrokov RA, Huh J, Pardes JB, Septon R. Desmoplastic trichoepithelioma. J Am Acad Dermatol 2011;64:438-9.
[Google Scholar]
2.
Mamelak AJ, Goldberg LH, Katz TM, Graves JJ, Arnon O, Kimyai-Asadi A. Desmoplastic trichoepithelioma. J Am Acad Dermatol 2010;62:102-6.
[Google Scholar]
3.
Jedrych J, Leffell D, McNiff JM. Desmoplastic trichoepithelioma with perineural involvement: A series of seven cases. J Cutan Pathol 2012;39:317-23.
[Google Scholar]
4.
Costache M, Bresch M, Böer A. Desmoplastic trichoepithelioma versus morphoeic basal cell carcinoma: A critical reappraisal of histomorphological and immunohistochemical criteria for differentiation. Histopathology 2008;52:865-76.
[Google Scholar]
5.
Seo SH, Kim GW, Sung HW. Imiquimod as an adjuvant treatment measure for desmoplastic trichoepithelioma. Ann Dermatol 2011;23:229-31.
[Google Scholar]

Fulltext Views
116

PDF downloads
63
Show Sections