Cutaneous Cysts

CUTANEOUS

CYSTS

ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts

facebook.com/groups/dermatologycourseonline

http://www.free-powerpoint-templates-design.com/free-powerpoint-templates-design

A 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

CLASSIFICATION OF CYSTS ACCORDING TO

LINING:

I. Cysts with a lining of stratified squamous

epithelium

II. Cysts lined with non-stratified squamous

epithelium

III. Cysts without an epithelial lining

STRATIFIED SQUAMOUS EPITHELIUM

NON-STRATIFIED SQUAMOUS EPITHELIUM

ABSENCE OF EPITHELIUM

1. Epidermoid cyst2. Milium3. Trichilemmal cyst4. Proliferating trichilemmal

cyst5. Proliferating epidermoid

cyst6. Vellus hair cyst7. Steatocystoma8. Cutaneous keratocyst9. Pigmented follicular cyst10. Dermoid cyst11. Verrucous cyst12. Ear pit cyst13. Pilonidal cyst

1. Hidrocystoma• Eccrine• Apocrine

2. Bronchogenic cyst3. Thyroglossal duct cyst4. Branchial cleft cyst5. Cutaneous ciliated cyst6. Ciliated cyst of the vulva7. Median raphe cyst8. Omphalomesenteric duct cyst

1. Mucocele2. Digital mucous cyst3. Ganglion4. Pseudocyst of the auricle5. Cutaneous metaplastic

synovial cyst

SYNONYMS:

1. Epidermoid inclusion cyst

2. Epidermal cyst

3. Epidermal inclusion cyst

4. Infundibular cyst

It is the most common

cutaneous cyst.

Tiny superficial epidermoid

cysts are known as milia.

It 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 cyst

Typical clinical appearance

Epidermoid Cysts

Puncti of Epidermoid Cysts

Dark color keratin plug overlying cyst cavity tether the cyst to the overlying epidermis

Epidermoid Cyst

commonly present on the face

Epidermoid Cysts

yellowish dermal nodules

Palpation of Epidermoid Cyst

These 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 duration

the 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.

Unlike 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 inflammatoryreaction, and this is a common reasonfor presentation to a physician.

Rupture is followed by foreign bodyreaction to keratin extruded into the dermis and acute inflammation.

Inflamed Epidermoid Cyst

Such painful inflammatory reactions to cyst rupture are a frequent cause for presentation to a physician

Development of a BCC or SCC within an epidermoid

cyst is a very rare event.

Multiple epidermoid cysts may occur in the following

settings: 1. Individuals with a history of significant acne vulgaris.

2. Multiple scrotal cysts may lead to scrotal calcinosis via dystrophic

calcification.

3. Gardner syndrome (familial adenomatous polyposis).

4. Nevoid BCC syndrome.

Multiple Postauricular Epidermoid Cysts

Multiple Epidermal Cysts Of The Scrotum

Cystic cavity filled with lamellated keratinlined by a flattened stratified squamousepithelium including a granular layer.

A surrounding inflammatory response with both acute and chronic granulomatousinflammation may be seen as evidence of prior rupture and resolves with scarring.

In individuals with Gardner syndrome, somecysts show, as a characteristic feature, columns of pilomatricoma-like shadow cellsprojecting into the cyst cavity.

Histopathology of Epidermoid Cyst

Histopathology of Epidermoid Cyst

showing 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 scrotum

epidermal 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.

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.

1. Incision and drainage.

2. Antibiotic therapy, occasionally.

3. Intralesional triamcinolone may be helpful in speeding the resolution of the inflammation.

Epidermoid Cyst Removal

Macroscopic appearance of a resected cyst

They 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.

Present as 1–2 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 oftopical 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, Bazexsyndromes 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 on the Eye Lids

Palatal Cyst Of Newborn

Gingival Cysts Of Newborn

Bilateral Retro-auricular Milia En Plaque

Periorbital Bilateral Milia En Plaque

Milia en Plaque In a Traumatic Scar

Milia Following Bullous Pemphigoid

Histologic features are exactly

similar to those of a small

epidermoid cyst.

They 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, laserablation or electrodesiccation.

Nick 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 Cysts are usually clinicallyindistinguishable from epidermoidcysts, but they are fourfold to fivefoldless common.

They may be inherited as an autosomaldominant trait.

More frequent in middle-aged females.

90% of trichilemmal cysts are locatedon the scalp.

They may be solitary, but frequently they are multiple.

May 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

EPIDERMOID CYST PILAR CYST

Most common site Face, neck, trunk Scalp (90% of pilar cysts), scrotum

Central punctum Present Absent

Origin Epithelium or hair follicle infundibulum

Outer root sheath

Cyst wall Delicate and prone to rupture

Thick and less prone to rupture

Histology Granular layer present Granular layer absent

Excision More difficultThey deliver themselves through an incision easily without rupture

Cyst walls lined by stratified squamous epithelial

cells that show keratinization that has a palisaded

outer layer, analogous to that of the outer root

sheath of the hair follicle at the isthmus and the sac

surrounding catagen and telogen hairs become

swollen and pale close to the cystic cavity and show

abrupt keratinization without an intervening granular

layer.

The cyst contents consist of homogeneous very

brightly eosinophilic keratinaceous debris that

commonly shows foci of calcification in 25% of cases.

A foreign body giant cell response may surround the

cyst if prior wall rupture has occurred.

Histopathology of Pilar Cyst Wall

Histopathology of Pilar Cyst

Focal Calcification

Elective excision before rupture prevents scarring.

Surgical treatment involves either of the following methods: 1. Enucleation of the cyst. Typically, they “deliver”

themselves through an incision withoutrupture more easily than do epidermoid cysts, and, therefore, the distinction between a trichilemmal cyst and an epidermoid cyst can often be correctly made at the time of excision.

2. Incision followed by expression of contents and removal of cyst wall – this is often best achieved with a surgical punch with the cyst expressed through the hole.

Quite rare asymptomatic small, dome-

shaped papules.

They may be inherited in an autosomal

dominant pattern when they occur in early

childhood. Sporadic forms tend to develop

later in teenage years.

Occasionally, solitary cysts are seen. Multiple

lesions are known as “ERUPTIVE” VELLUS

HAIR CYSTS (may be seen in conjunction with

steatocystoma multiplex or pachyonychia

congenita).

Eruptive Vellus Hair Cysts

They are asymptomatic except for cosmetic concerns.

Most commonly present as numerous, small, dome-shapedpapules, ranging from skin-colored to darkly pigmented. They may be dimpled or umbilicated.

Most commonly located on the trunk especially the anterior chest.

Most lesions persist indefinitely.

The diagnosis of eruptive vellus hair

cysts is often made clinically, because

of typical age of onset, the site of the

lesions, and their appearance.

Incision or puncture of the cyst and

examination of the contents under a

microscope will reveal the vellus

hairs.

Skin biopsy may confirm the

diagnosis.

Small cystic structure lined by

stratified squamous

epithelium with epidermoid

keratinization. The cysts

contain loose laminated keratin

and numerous vellus hairs.

A follicle may be found entering

the lower portion of the cyst.

Histopathology of Vellus Hair Cyst

Within the dermis there is a cyst lined by squamous epithelium with a granular layerand containing laminated keratin and numerous vellus hairs.

Medical: Topical retinoic, salicylic acid or lactic acid (long term).

Surgical:1. Incision and drainage.

2. Needle evacuation.

3. Puncture followed by forceps assisted extraction.

4. Cryotherapy.

5. Laser.

Steatocystomas occur as:

I. Single (STEATOCYSTOMA SIMPLEX) or;

II. Multiple (STEATOCYSTOMAMULTIPLEX).

Steatocystoma multiplex is rare and can be inherited as an autosomal dominantcondition, and is due to mutations in the KRT17 gene. It may occur in associationwith eruptive vellus hair cysts and pachyonychia congenita.

It is due to hamartomatous malformationsof the pilosebaceous duct junction.

Steatocystoma Multiplex

numerous cystic nodules on the neck


A yellow creamy discharge after puncture of a yellow cyst.

They tend to be small (2-20 mm) but they may be several centimetres in diameter and appear as soft to firm semi-translucentcysts in the dermis that drain oily fluid if punctured.

They are most numerous on the chest and in the axillae, abdomen, upper arms and groin. There are unusual facial and acral variants as well as a rare congenital linear form.

Steatocystomas develop at pubertypresumably due to hormonal stimulus of the pilosebaceous unit and persist indefinitely.

They are usually asymptomatic except for cosmetic concerns.

Dermal cyst lined by a thin

stratified squamous epithelium,

without a granular layer and

surmounted by a characteristic

thin, irregular, corrugated

eosinophilic lining (cuticle).

Small sebaceous lobules are

found in or immediately adjacent

to the cyst wall.

Histopathology of Steatocystoma

The cyst wall is characterized by an undulated, thin stratified epithelium lacking a stratum granulosum and lined by an eosinophilic cuticle. A search may be required to identify small sebaceous lobules in or immediately adjacent to the cyst wall (insert)

Medical: Oral isotretinoin is not curative but may temporarily

shrink the cysts and reduce inflammation.

Oral antibiotics; to reduce the inflammation if present.

Surgical:1. Excision; If it is tethered to the underlying skin.

2. Incision with removal of the cyst wall; In most cases, small incisions allow the cyst and its contents to be extracted through the opening.

3. Cryotherapy.

4. Electrosurgery.

5. Laser.

Cutaneous dermoid cyst typically present in an

infant along an embryonic fusion plane as a

discrete, subcutaneous nodule.

It results from sequestration of ectodermal tissue

along embryonic fusion planes during development.

Although dermoid cysts are congenital defects and

may be recognized at birth, these lesions often

escape notice until they become enlarged, infected

or inflamed. This typically occurs by early childhood.

Dermoid cysts in other parts of the body, such as

within the skull, spine or abdominal cavity

particularly the ovaries, may present at any time in

people of all ages.

Common Sites Of Dermoid Cysts

Dermoid cyst

This dermoid cyst presented in an infant as a firm subcutaneous nodule superior to the lateral left eyebrow.

Dermoid Cyst

Medial Dermoid Cyst

Note the fullness below the head of the right brow. This lesion must be imaged to confirm the diagnosis and to distinguish it from an encephalocoele or mucocele.

Dermoid Cyst

A subcutaneous mass at the lateral aspect of the right upper eyelid, under the tail of the brow. Note that the overlying skin is not erythematous, edematous or discolored.

Present as firm, non-compressible, non-pulsatile subcutaneousnodules that often reach a size of 1–4 cm in diameter.

The lesions usually do not transilluminate.

They are most commonly located around the eyes, particularly the lateral eyebrow but may also occur anywhere in the body e.g. nose, scalp (often over the anterior fontanelle or the midline occiput), neck, sternum, sacrum and scrotum.

They can be associated with a nearby pit and/or sinus tract to underlying tissues.

Dermoid cysts on the nose or midline scalp have a much higher likelihood of intracranial extension than those in a periocular location.

Lined by keratinizing stratified

squamous epithelium including a

granular layer.

They contain other normal mature

adnexal cutaneous structures such as

hair, sebaceous lobules, eccrine

glands, apocrine glands, or smooth

muscle.

Histopathology of Dermoid Cyst

The cyst wall demonstrates a hair follicle (arrow), one of the adnexal structures that are commonly found in walls of dermoid cysts. Note the kertinized stratified squamous epithelium lining the cyst.

Surgical Excision.

However, as there may be sinus tract or neural

heterotopias, imaging studies may be appropriate prior

to excision, to exclude a connection to the CNS.

Surgical Excision of Dermoid Cyst

Before removal, one week and 1.5 years after removal.

Hidrocystomas can traditionally divided by histologic

features into;I. APOCRINE HIDROCYSTOMAS

II. ECCRINE HIDROCYSTOMAS

Also can divided according to number into; I. SOLITARY (SMITH TYPE)

II. MULTIPLE (ROBINSON TYPE)

May be due to occlusion or blockage of the sweat duct

apparatus, which results in the retention of sweat and a

dilated cystic structure.

Apocrine hidrocystomas are relatively common

benign cystic proliferations of the apocrine glands.

In general, eccrine hidrocystomas are thought to

develop from cystic dilation of eccrine ducts due to

retention of eccrine secretions while apocrine

hidrocystomas are thought to represent adenomas of

apocrine secretory sweat gland coils.

Apocrine Hidrocystoma

A single, slightly bluish, translucent papule on the lower eyelid near the

lateral canthus .

Eccrine Hidrocystomas

Numerous, tiny, translucent or bluish papules on the lower eyelid (A) or the

cheek (B)

Asymptomatic. No seasonal variation. Appear during adulthood, grow slowly, and

usually persist indefinitely. Typically present as skin-colored to bluish and

shiny cysts. They are usually solitary soft, dome-shaped,

translucent papules or nodules and most frequently are located on the eyelids, especially the inner canthus also head, neck, and trunk.

Consistency is fluctuant and cystic. Size varies from a few millimeters to approximately 1.5 cm.

Walls, although translucent, are sufficientlythick & tense that they seldom rupture spontaneously.

Apocrine Hidrocystoma

Giant Multi-loculated Apocrine Hidrocystoma

Typically present as translucent, clear, skin-colored cysts on the face although they may occur in other sites.

May be solitary or multiple and are occasionally quite numerous and usually smaller in size and less bluish than apocrine hidrocystoma.

They are associated with seasonalvariations can enlarge with heatexposure or during the summer and regress with exposure to cold and winter.

They are more frequent in females than in males.

Eccrine Hidrocystoma

Puncture of a representative lesion with a sterile needle shows exudation of clear fluid

Eccrine Hidrocystoma

They are unilocular to multilocular dermalcysts lined by one to several layers of apocrine-type secretory epitheliumcuboidal-to columnar that show bulbousprotrusions (“snouting”) or papillaryprojections extend from the secretory layerinto the cyst cavity representing luminaldecapitation secretion.

The outer layer of cells composing the cyst wall is formed by myoepithelial cells.

Express human milk-fat globulin antigen, while “true” eccrine hidrocystomas do not.

Histopathology of Apocrine Hidrocystoma

Cystic spaces appear empty because sweat is removed during processing.Decapitation secretion often is seen in the lining.

Unilocular cyst containing clear

fluid, lined by ductal cells

composed of one to two layers

of cuboidal to flattened

epithelium.

Luminal protrusions ("apocrine

snouts") and myoepithelial cells

are absent.

Histopathology of Eccrine Hidrocystoma

Medical: Topical 1% atropine in aqueous solution; Multiple eccrine

hidrocystomas may be treated with daily application, although lesions

reappear within days of discontinuing therapy.

Botulinum toxin A injections may be helpful.

Surgical: Excision; punch, scissors, or elliptical.

Electrodesiccation; electrosurgical destruction of the cyst wall with a

fine tipped probe often is recommended to prevent recurrence.

Cryotherapy.

Laser; CO2 or pulsed dye laser.

Mucocele are usually the result of

trauma in the mouth disruption

of the ducts of minor salivary

glands an accumulation of

mucinous material a reactive

inflammatory response, and the

development of surrounding lining of

granulation tissue.

Mucocele

Mucoceles most frequently develop on the lowerlabial mucosa (75% of cases), but they also occur on the floor of the mouth, buccalmucosa, and tongue.

They appear as smooth, soft, dome-shaped, fluid-filled papules or nodules that are bluish or translucent and range in size from a fewmillimeters to over a centimeter.

Single or multiple but usually single.

In most cases of superficial mucocele lesions tend to persist for several days or weeks, rupture spontaneously (usually while eating).

It shows one or several spaces within the connective tissue

filled with mucinous material, but without an epithelial

lining.

The spaces are surrounded by chronic inflammation, mucin

containing macrophages, and granulation tissue.

A salivary duct may be seen at the periphery of these

findings.

Adjacent minor salivary glands may show chronic

inflammation and fibrosis.

The mucinous material is sialomucin, and the latter contains

both neutral and acid mucopolysaccharides, which stain

with PAS (diastase-resistant) and with Alcian blue or

colloidal iron, respectively.

Histopathology of Mucocele

well-delineated cavity that contains free mucinous material (blue arrow); this material is characteristic of these entities. The cavity wall lacks an epithelial lining and is considered a pseudocyst. The pseudocyst wall is composed of granulation tissue (red arrow).

Histopathology of Mucocele

showing granulation tissue with collected mucin and inflammatory cells (A: mucous acini, G: granulation tissue, M: mucin).

Mucoceles may resolve spontaneously especially

superficial mucocele and require no specific treatment.

If they do not, treatment options include;1. Intralesional corticosteroid injection

2. Surgical excision

3. Marsupialization

4. Electrodesiccation

5. Cryosurgery

6. Laser ablation e.g. CO2

There appear to be two variations; I. The first is a form of focal mucinosis, a

condition characterized by abnormal deposits

of mucins in the skin. It shouldn't be called a

cyst as it does not have a surrounding

capsule, and is better termed a "pseudocyst".

II. The other variation arises from extension of

the lining of the distal interphalangeal joint

space and is due to osteoarthritis – a type of

ganglion. A pedicle connecting the cyst to

the adjacent joint space can usually be

demonstrated.

Digital Mucous Cyst

Digital Mucous Cyst on the Toe

Most commonly occur on the dorsalsurface of the distal phalanx of the fingers. Toe lesions are less commonlyobserved.

These cysts have smooth shiny surfaceand skin-colored to bluish and translucent that drain clear gelatinousmaterial when punctured.

A characteristic depressed nail deformity may be seen distal to the cyst .

Transillumination of a Mucous Cyst

A cyst is translucent, so a light shines through it. Note a longitudinal groove in the nail.

Clefts are seen in the

dermis without an

epithelial lining. The

clefts and the surrounding

loose connective tissue

contain abundant acid

mucopolysaccharides,

which can be highlighted

by Alcian blue or

colloidal iron stains.

Treatments which may be successful include:

1. Repeatedly pressing firmly on the cyst.

2. Intralesional injection of corticosteroids.

3. Sclerosant injection

4. Cryotherapy.

5. Repeated puncture and drainage of a digital mucous cyst leads to

resolution in up to 70% of patients.

6. Surgical excision may give even higher success rates.

7. Identification and ligature of the connection to the joint capsule.

Ganglions are among the mostcommon tumors of the hand and wrist. For the most part, they are asymptomatic masses that are primarily cosmetic rather than functional disturbances.

Ganglia are frequently attached to a tendon sheath or the joint capsule, but usually do not communicate with the joint space.

Ganglion Cyst

Ganglion Cyst on The Palmar Side of The Wrist

Ganglion cyst in the foot

They occur more commonly in women and

may cause discomfort with activity,

impairment of mobility, or cosmetic

concerns.

Soft cystic compressible, subcutaneous,

transilluminating, and slightly mobile

masses up to 4 cm in diameter without

associated skin changes that most

commonly occur on the dorsal aspect of the

wrist; they may also be found on the volar

wrist or fingers, the dorsal aspect of the feet,

or the knees.

Myxoid change is seen within

the connective tissue that

ultimately forms cystic

spaces. These spaces

coalesce into a dominant

cystic space lined by fibrous

tissue sometimes with a

synovial lining.

Early lesions may respond to several

weeks of compression therapy.

Other options include aspiration plus

intralesional corticosteroid injection

or excision.

Recurrences are common, even with

excisional therapy.

Bolognia 3rd ed.

dermnetnz.org

http://emedicine.medscape.com

http://www.globalskinatlas.com

Google images

AAD; Benign Skin Lesions (Presentation)

Skin Tumors by Seyed Morteza Mahmoodi(Presentation)

Cutaneous Cysts

Health & Medicine

Transcript of Cutaneous Cysts