Cutaneous Cysts

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Cutaneous CystsA cyst is a circumscribed dermal or subcutaneous papule or nodule that contains fluid or semi-fluid material, so a cyst is fluctuant.Cysts can be classified by anatomic location (as they may occur in virtually any organ of the body), by embryologic derivation, or by histologic features (of the cyst lining).True cysts have an epithelial lining that may be composed of stratified squamous epithelium or other forms of epithelia. Some cysts have no epithelial lining at all (pseudocysts).Structure of Hair Follicle

Cutaneous CystsCLASSIFICATION OF CYSTS ACCORDING TO LINING:

Cysts with a lining of stratified squamous epitheliumCysts lined with non-stratified squamous epitheliumCysts without an epithelial liningTHE THREE MAIN CATEGORIES OF CUTANEOUS CYSTSTRATIFIED SQUAMOUS EPITHELIUMNON-STRATIFIED SQUAMOUS EPITHELIUMABSENCE OF EPITHELIUMEpidermoid cystMiliumTrichilemmal cystProliferating trichilemmal cystProliferating epidermoid cystVellus hair cystSteatocystomaCutaneous keratocystPigmented follicular cystDermoid cystVerrucous cystEar pit cystPilonidal cystHidrocystomaEccrineApocrineBronchogenic cystThyroglossal duct cystBranchial cleft cystCutaneous ciliated cystCiliated cyst of the vulvaMedian raphe cystOmphalomesenteric duct cystMucoceleDigital mucous cystGanglionPseudocyst of the auricleCutaneous metaplastic synovial cyst

CYSTS LINED WITH STRATIFIED SQUAMOUS EPITHELIUMEpidermoid CystEpidermoid CystSYNONYMS: Epidermoid inclusion cyst Epidermal cyst Epidermal inclusion cystInfundibular cyst It is the most common cutaneous cyst.Tiny superficial epidermoid cysts are known as milia.

Pathogenesis of Epidermoid CystIt is derived from the follicular infundibulum.They may be primary, or they may arise from disrupted follicular structures or traumatically implanted epithelium (hence the synonym epidermal inclusion cyst).

Epidermoid cystTypical clinical appearance

Epidermoid Cysts

Puncti of Epidermoid CystsDark color keratin plug overlying cyst cavity tether the cyst to the overlying epidermisEpidermoid Cystcommonly present on the face

Epidermoid Cystsyellowish dermal nodules

Palpation of Epidermoid Cyst

C/P of Epidermoid CystThese lesions are firm to fluctuant well-demarcated, skin-colored to yellowish mobile dermal nodules, and they may have a clinically visible punctum representing the follicle from which the cyst is derived range from a few millimeters to several centimeters in diameter.These cysts may be flat or flush to the surface of the skin or elevated well above the surface. In either case, they are easily palpable. It can occur anywhere on the skin, but are most common on the face, scalp, postauricular, neck, scrotum and upper trunk.Non-inflamed epidermoid cysts are usually asymptomatic, but, with pressure, cyst contents may be expressed that may have an foul odor.

Large sized Epidermal Cyst

Epidermal cyst in the epigastric region of > 10 years durationthe skin overlying the cyst has been atrophied with some dilated vessels due to the pressure effect produced by the cyst. The punctum in the central part of the cyst is so evident.

C/P of Epidermoid CystUnlike pilar cysts, the epidermal cyst wall is fairly delicate and thus prone to rupture.Rupture of the cyst wall can result in an intensely painful inflammatory reaction, and this is a common reason for presentation to a physician.Rupture is followed by foreign body reaction to keratin extruded into the dermis and acute inflammation.

Inflamed Epidermoid CystSuch painful inflammatory reactions to cyst rupture are a frequent cause for presentation to a physician

C/P of Epidermoid CystDevelopment of a BCC or SCC within an epidermoid cyst is a very rare event.Multiple epidermoid cysts may occur in the following settings: Individuals with a history of significant acne vulgaris. Multiple scrotal cysts may lead to scrotal calcinosis via dystrophic calcification.Gardner syndrome (familial adenomatous polyposis). Nevoid BCC syndrome.

Multiple Postauricular Epidermoid Cysts

Multiple Epidermal Cysts Of The Scrotum

Multiple Epidermal Cysts Of The Scrotum

HP of Epidermoid Cyst Cystic cavity filled with lamellated keratin lined by a flattened stratified squamous epithelium including a granular layer.A surrounding inflammatory response with both acute and chronic granulomatous inflammation may be seen as evidence of prior rupture and resolves with scarring.In individuals with Gardner syndrome, some cysts show, as a characteristic feature, columns of pilomatricoma-like shadow cells projecting into the cyst cavity.

Histopathology of Epidermoid Cyst

Histopathology of Epidermoid Cyst

Histopathology of Epidermoid Cystshowing the cyst wall lined by stratified squamous epithelium with a granular cell layer (arrow). The central portion of the cyst is filled with keratinaceous debris (star).

Histopathology of Epidermoid Cyst of the scrotumepidermal cyst wall with thin layer of benign stratified squamous epithelium (small solid arrows) and keratinous debris present in cyst (open arrows). Scrotal skin with basal pigmentation (large solid arrows) is also noted.

Treatment of Epidermoid Cyst Assurance:Small cysts (e.g. less than 5 mm) don't usually need treatment.Surgical excision:Removal may be accomplished by simple excision, or incision and expression of the cyst contents and wall through the defect. Other techniques of removal include punch biopsy aspiration followed by curettage and avulsion of the cyst wall. If the entire cyst wall is not removed, the cyst may recur. Cysts are more difficult to remove once they have ruptured.Inflamed epidermoid cysts: It is best to avoid surgery while the cyst is actively inflamed due to higher risk of infection, wound dehiscence and cyst recurrence. Following the resolution of the infection, the lesion is excised.Incision and drainage. Antibiotic therapy, occasionally. Intralesional triamcinolone may be helpful in speeding the resolution of the inflammation.Epidermoid Cyst Removal

Macroscopic appearance of a resected cyst

MILIAMiliaThey are small epidermoid cysts containing keratin usually multiple and are quite common, occurring in individuals of all ages and both sexes.These harmless cysts present as tiny pearly-white papules. Between 40% and 50% of infants will have milia usually resolve during the 1st four weeks of life while in adults tend to be persistent.

C/P of MiliaPresent as 12 mm pearly-white to yellow fixed subepidermal papules. Present most commonly on the face usually on the cheeks, eyelids and forehead.

CLINICAL TYPES OF MILIA1. Primary Milia 2. Secondary Milia 3. Milia En Plaque 4. Neonatal Milia 5. Juvenile Milia 6. Multiple Eruptive Milia - Found on the face especially around eyelids, cheeks, forehead and genitalia - May clear in a few weeks or persist for months or longer.

- Following blistering processes or superficial ulceration from trauma, burn or cosmetic procedures. - May also occur in areas of topical drugs e.g. corticosteroid, hydroquinone.- Multiple milia within an erythematous edematous plaque especially in middle-aged women.- Most often occurs in the postauricular area, but may also occur eyelid, cheeks or jaw. - Affect 40-50% of newborns. - Few to multiple.- Often seen on the nose, but may also arise inside the mouth on gum margins (Epstein pearls) or palate (Bohn nodules).- Usually resolve within1st four wk. - Persistent widespread milia may be congenital or appear later in life.- Associated with Rombo, basal cell naevus, Gardner, Bazex syndromes and other genetic disorders.- Crops of numerous milia appear over a few weeks to months.- Lesions may be asymptomatic or itchy.- Most often affect face, upper arms and upper trunk.Milia

Milia on the Eye Lids

Palatal Cyst Of Newborn

Gingival Cysts Of Newborn

Bilateral Retro-auricular Milia En PlaquePeriorbital Bilateral Milia En Plaque

Milia en Plaque In a Traumatic Scar

Milia Following Bullous Pemphigoid

Histopathology of MiliaHistologic features are exactly similar to those of a small epidermoid cyst.

Treatment of MiliaThey often clear up spontaneously within a few months.Elective removal for cosmesis.Medical:Topical retinoid: For multiple facial milia, may be helpful in reducing the number of milia and aiding in the ease of removal.Minocycline: may improve milia en plaque.Surgical:Milia may be de-roofed by incising the epidermis over the milium with a needle, scalpel or lancet and expressing the milium (may be aided by the use of a comedo extractor). They may be destroyed using and curettage, cryotherapy, laser ablation or electrodesiccation.Treatment of MiliaNick the surface with an 11 blade or an 18 gauge needle, then gently express the entire cyst, lining and contents. Dress with a dab of petrolatum.

Removal of Milia

PILAR (Trichilemmal) CYSTPilar CystPilar Cysts are usually clinically indistinguishable from epidermoid cysts, but they are fourfold to fivefold less common. They may be inherited as an autosomal dominant trait.More frequent in middle-aged females. 90% of trichilemmal cysts are located on the scalp. They may be solitary, but frequently they are multiple.

C/P of Pilar CystMay look similar to epidermoid cysts present as one or more firm, mobile, subcutaneous nodules measuring 0.5 to 5 cm in diameter. There is no central punctum, unlike an epidermoid cyst.

Pilar Cysts

Main Differences Between Pilar Cyst and Epidermoid CystEPIDERMOID CYSTPILAR CYSTMost common site Face, neck, trunk Scalp (90% of pilar cysts), scrotum Central punctum Present Absent