Sebaceous Hyperplasia Mimicking Linear Wart over Ear.

Sebaceous hyperplasia (SH), a common, benign condition of sebaceous gland, presents most commonly over face. Lesions are usually described as asymptomatic, soft, discrete, and yellow with a surface that ranges from smooth to slightly verrucous. The pathogenesis is not fully understood. It does not require treatment, but many time lesions can be cosmetically unfavorable than, need to be destroyed or excised. A case of 23-year-old male presenting with the skin colored to hyperpigmented linear hyperkeratotic plaque mimicking a wart, over the right ear is presented here, which was diagnosed as SH.

INTRODUCTION

Sebaceous hyperplasia (SH) is a common, benign condition of sebaceous glands in adults of middle age. It presents as yellow papules most commonly over face with occasional involvement of chest or genitalia.[1] Typical facial papules appear in middle age, are larger than lesions on areola or mouth and display a central dell that corresponds to a central follicular infundibular ostium.

It is a benign neoplasm as it does not involute clinically. It has also been associated with long-term immunosuppression in posttransplantation patients taking cyclosporin A.[2] Premature or familial cases have been reported in which younger individuals are affected with multiple lesions, suggesting a genetic predisposition.[3] SH occurred in 16% of immune-suppressed organ transplant recipients.[4]

A case of 23-year-old male presenting with the skin colored to hyperpigmented linear hperkeratotic plaque mimicking a wart over the right ear, diagnosed as SH by histopathology is presented here.

CASE REPORT

A 23-year-old male presented with single lesion over the posterior aspect of right ear for 5 years. History of increase in the size of the lesion gradually, over a period of 2-3 years was present. No history of itching, oozing, bleeding, or pain present. No heterotopic ossification trauma over the site or any seasonal changes present.

On examination, multiple, discrete skin colored to hyperpigmented verrucous papules forming a plaque of around 2 cm × 1 cm size in a linear pattern over the posterior aspect of the right ear [Figure 1]. Surrounding skin was normal. Patient wanted to get it removed, so electrocautery was done, whole of the lesion was removed and was sent to histopathology keeping linear epidermal verrucous nevus and warts as differential.

Figure 1

Multiple, discrete skin colored to hyperpigmented verrucous papules forming a plaque in a linear pattern over posterior aspect of right ear

Section showed acanthosis and papillomatosis of the epidermis [Figure 2a]. The dermis showed enlarged sebaceous glands composed of numerous lobules grouped around centrally located wide sebaceous gland. Lobules show more than one row of undifferentiated generative cells in which there were few or no lipid droplets [Figure 2b]. Many small capillary sized vessels and hemorrhage were seen. Diagnosis of SH was made.

Figure 2

(a) Epidermis showed hyperkeratosis with enlarged sebaceous glands in dermis (H and E, ×4), (b) Dermis showed enlarged sebaceous glands composed of numerous lobules grouped around centrally located wide sebaceous gland. Lobules show more than one row of undifferentiated generative cells (H and E, ×10)

DISCUSSION

Sebaceous glands are present throughout the skin with exclusion over palmar and plantar surfaces. The largest and greatest number of sebaceous glands is found on the face, chest, back, and the upper outer arms. They developed after birth due to the effect of maternal hormones, enlarge during puberty, and remain same up to middle age with the tendency to decrease slowly later on.[5]

SH consists of multiple asymptomatic small, soft discrete yellow papules commonly seen over face and rarely over chest and genitals. The surface ranges from smooth to slightly verrucous.[1]

Rarely reported variants included a diffuse and giant form,[6] a linear[7] or zosteriform pattern where cases were sporadic and not familial with the distribution of the papules along the Blaschko's line, suggesting that cases might have occurred as a result of mosaic mutation.[8]

Juxta-clavicular beaded lines, an additional variant characterized by closely placed papules arranged in parallel rows was also reported.[910]

Four cases of a clinically discernible hyperplasia of sebaceous glands in a linear pattern of papules were seen and studied at the Dominican Dermatological Institute in the past 3 years in three men and one woman. Lesions were characterized by linear papules on the pre- and retro-auricular regions, neck, and chin.[11]

Our case was unique with linear pattern of presentation and verrucous lesions over the posterior aspect of the right ear mimicking warts.

The pathogenesis of SH is not known exactly. Sebaceous glands secret by total cellular disintegration is affected by both internal and external factors. Ultraviolet radiation possibly represents a cofactor. SH can occur over sun protected as well as unprotected sites. Lesions are benign with no known malignant potential.[412]

Differential diagnosis of SH is acrocordon, basal cell carcinoma, calcinosis cutis, colloid milium, granuloma annulare, lichen nitidus, sebaceous adenoma, and sebaceous carcinoma. Dermoscopy may be useful as a noninvasive tool to aid in the clinical diagnosis and in distinguishing between nodular basal cell carcinoma and SH, reducing unnecessary surgery.[13] Histopathological examination through biopsy can help in the confirmation of diagnosis.

A universally accepted definition of SH is not yet available. It is a sebaceous differentiation of epidermal tumors. SH was defined by the presence of more than four sebaceous lobules attached to the infundibulum of each pilosebaceous unit.[1] Lesions reveal discrete enlarged glands with lobules. The lobules have lipid-filled sebocytes.

Lesions tend to recur unless the entire unit is destroyed. Therapeutic options include photodynamic therapy (with combined use of 5-aminolevulinic acid and visible light),[14] cryotherapy, electrocautery, topical chemical treatments (e.g., with bichloroacetic acid or trichloroacetic acid),[15] laser therapy,[16] and excision. Atrophy, scarring, or pigmentary changes may occur following above procedures.

Oral isotretinoin has proven effective in clearing some lesions after 2–6 weeks of treatment, but lesions often recur upon discontinuation of therapy. Maintenance doses of oral isotretinoin in the range of 10–40 mg every other day or 0.05% isotretinoin gel is rarely indicated as a suppressive treatment for widespread disfiguring SH. SH should be diagnosed appropriately, and exact mode of treatment is required to avoid cosmetic disfigurement.

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