Rare Benign Cystic Lesions on Face: Apocrine Hidrocystoma.

Sir,

A 65-year-old female presented to our Tertiary Care Centre with multiple mild itchy lesions on face since 2 years. The lesions started as few translucent, tiny, skin-colored elevated lesions which gradually increased in number and size involving symmetrical areas on the face. She had an exacerbation of lesions in summer. There was no history of similar lesions in her family.

On examination, the lesions were symmetrically arranged, multiple, papules, tense, skin colored, and shiny with cystic consistency over the nose, perinasal and periorbital areas [Figure 1]. Yellowish serous fluid oozed out of the lesion on pricking the lesion. Systemic examination revealed no abnormality. Various differential diagnoses including apocrine/eccrine hidrocystoma, syringoma, trichoepithelioma, and multiple basal cell carcinomas were considered.

Figure 1

(a) Clinical picture symmetrically arranged lesions on the face. (b) Multiple localized papules, tense, skin colored with cystic consistency

Though multiple apocrine hidrocystoma (AH) types are rare, clinical diagnosis was done, and skin biopsy was sent for histopathological confirmation.

Histopathologically, the upper dermis has a large dilated cystic structure lined by apocrine type epithelium with papillary projections, covered by two layers of secretory cells [Figure 2a]. The innermost cells were columnar-shaped with eosinophilic cytoplasm with typical apical projections and decapitation secretion, periodic acid-Schiff-positive, and diastase-resistant granules [Figure 2b]. Below this cystic structure were seen several apocrine glands. The epidermis is normal and free of the dermal cyst. No inflammatory infiltrate is seen.

Figure 2

(a) The innermost cells are columnar-shaped with eosinophilic cytoplasm with typical apical projections (H and E, ×40). (b) The cytoplasm and decapitation secretion shows periodic acid-Schiff (PAS)-positive and diastase-resistant granules with typical apical projections (PAS stain, ×40)

The patient was counseled about recurrence of lesions and was asked to maintain a regular follow-up of 2 monthly visits for the first 1-year and thereafter with every 4 months visit for the next successive years. She was treated with radiofrequency ablation under topical anesthesia using lidocaine.

Hidrocystomas, which are rare, benign, adenomatous, cystic lesions of the skin, may be either eccrine or apocrine depending on their morphological differentiation. The apocrine glands are most frequently present in the axillae, groin, external auditory canal, eyelids, and on the nipple. AH are often found on the head especially periocular area, neck and trunk region.[1] They also are reported to occur on other regions having apocrine glands such as a penis, axilla, and perianal regions. AH (syndrome: Cysts of Moll's gland, sudoriferous cysts), present as translucent or semitransparent, round, skin-colored or bluish vesicles, cystic lesions, and contain a watery fluid. They are commonly presented as solitary cystic lesions but can be rarely multiple. They are prevalent in adults who are between 30 and 70 years of age, with a diameter of 3–15 mm.[2] Both sexes are equally affected.

The exact cause is unknown, but they are thought to be due to occlusion or blockage of the sweat duct apparatus, which results in the retention of sweat and a dilated cystic structure.[3] The lesions are benign and usually asymptomatic. The lesions grow slowly, usually persist indefinitely, and seldom recur after removal. No seasonal variation or familial tendencies have been identified. The diagnosis of this rare case multiple AH is though clinical yet biopsy aids in confirmation and differentiating it from other head and neck lesions [Table 1].

Table 1

Differential diagnosis of AH

Multiple eyelid AH's are associated with an autosomal recessive syndrome, Schopf–Schulz–Passarge. It is characterized by palmoplantar hyperkeratosis, hypodontia, and hypotrichosis. AH may also be associated with X-linked dominant Goltz–Gorlin or focal dermal hypoplasia syndrome include microphthalmia; periocular multiple hidrocystomas; papillomas of the lip, tongue, anus, and axilla; skeleton abnormalities; and mental retardation.[4]

The treatment provided in this case using radiofrequency ablation of lesions under topical anesthesia with prilocaine and lidocaine proved superior to other methods due to its low scarring and recurrence rates. The most common approach to the treatment of AH is simple needle puncture. Multiple lesions of AH have been successfully treated with topical 1% atropine or scopolamine creams, although anticholinergic side effects could cause patients to discontinue the treatment.[4] Other methods that have shown success are carbon dioxide laser vaporization and laser treatment.[5] Treatment of cysts with trichloroacetic is technically simpler and much less time-consuming than surgical excision.[6]

Though few cases of multiple AH over the face are reported, its resemblance to many other appendageal benign and malignant tumors may be of help in diagnosis and management of the condition. As this condition, commonly presents on face recurrence of lesions were not found proving the management of this case using radiofrequency ablation superior to other methods of treatment.

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Conflicts of interest

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