Clinical and Experimental Dermatology
Multiple, bilateral periorbital blue macules C. Massone, P. Noll and R. Hofmann-Wellenhof Department of Dermatology, Medical University of Graz, Graz, Austria doi: 10.1111/ced.12284
Clinical findings A 52-year-old woman presented with a 9-year history of multiple facial lesions. There had been no increase in the size of the lesions over years, and no seasonal changes or any changes in humid and hot environments. The patient had been taking propranolol for hypertension for 12 years. There was no family history of similar lesions. On physical examination, multiple, dark-blue, periorbital, asymptomatic macules, 3–8 mm in size, were seen on the patient’s face (Fig. 1). The remainder of the clinical examinations revealed no abnormalities. Routine laboratory tests including full blood cell count, liver and renal function, glycaemia and thyroid hormones were within normal limits. Dermoscopy showed only a homogeneous, blue to black pattern (Fig. 2).
Figure 2 Dermoscopy showed only a homogeneous, blue to
black pattern.
Figure 3 Cystic lesion; lining was composed of two layers of flat
epithelial cells without signs of decapitation secretion. Figure 1 Multiple periorbital dark–blue, periorbital, asymptom-
atic macules. Correspondence: Dr Cesare Massone, Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz, Austria E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 27 October 2013
ª 2014 British Association of Dermatologists
Histopathological findings On histological examination, a cystic lesion was found in the reticular dermis. The cyst lining was composed of two layers of flat epithelial cells without signs of decapitation secretion (Fig. 3). What is your diagnosis?
Clinical and Experimental Dermatology (2014) 39, pp423–424
423
D CP
CED
CPD • Clinicopathological case
D
CP
Clinicopathological case
Diagnosis Multiple pigmented Robinson type.
eccrine
hidrocystomas
(EHs),
Discussion EHs are small (1–6 mm in diameter), translucent, tense, thin-walled cysts, usually located in the periorbital and malar regions. Rupture of the cyst, resulting in collapse of the lesion with the loss of a watery fluid, helps to confirm the diagnosis. The colour varies from amber-brown to blue-black (pigmented EH; PEH).1,2 Robinson first described multiple EHs in 1893 (the classic Robinson type).1 Most of his patients were women who worked in a hot and humid environment. An increase in size and number during hot and humid weather conditions can be seen with EH. Multiple EHs can also occur in association with Graves disease and Parkinson disease.2 In 1973, Smith and Chernosky described another group of patients with similar, but single lesions (Smith and Chernosky type).2 With this type, women and men are similarly affected. The lesions do not display any seasonal variation, and are located not only in the periorbital area, but also on the nose, head, trunk and popliteal fossa.2 EH results from the dilation of cystic excretory eccrine glands due to the retention of sweat, and the dilation or blockage of the sweat duct. Histologically, they appear as dilated cystic structures located in the dermis. The cyst wall is composed of one or two layers of low cuboidal or flat epithelial cells with round to oval nuclei. Unlike their apocrine counterpart, there is a lack of decapitation secretion in EH. Furthermore, apocrine hidrocystoma tends to have papillary projections into the lumen of the cyst.1–3 The clinical differential diagnosis includes apocrine hidrocystoma, syringoma and sebaceous hyperplasia. For the pigmented variant of EH, agminated blue naevus, haemangioma, basal cell carcinoma and even melanoma metastasis are possible diagnoses. The final diagnosis is possible only upon histopathological examination. To our knowledge, dermoscopy in EH has been reported only once by Correia et al.,3 who described well-demarcated cystic spaces without vessels. In our case, there was a homogenous blue pattern similar to that of blue naevus, haemangioma, basal cell carcinoma or metastatic melanoma.
424
Clinical and Experimental Dermatology (2014) 39, pp423–424
Treatment of multiple EHs is difficult. The use of oral or topical atropine and topical scopolamine, or 0.5% glycopyrrolate aqueous solution has been reported, with transitory results.3,4 Drainage or surgical excision are alternative options. Cryosurgery, microdermabrasion, electrodesiccation, and CO2 laser and 585-nm flashlamp-pumped pulse dye laser have been tried with variable results.5 Botulinum toxin A seems to be effective, with at least good relief for some months, and the advantage that it can be repeated, and side effects are minimal and transitory.6 Our patient refused any treatment, and at the 2-year follow-up, the lesions had not increased in size or number.
Learning points
•
PEH is clinically difficult to differentiate from apocrine hidrocystoma, agminated blue naevus, haemangioma, basal cell carcinoma and even melanoma metastasis. • In our case, dermoscopy showed a homogenous blue pattern similar to that of blue naevus, haemangioma, basal cell carcinoma or metastatic melanoma. • Botulinum toxin A seems to be effective, with at least good relief for some months and the advantage that the treatment can be repeated.
References 1 Robinson AR. Hidrocystoma. J Cutan Genitourin Dis 1893; II: 293–3. 2 Lee MR, Ryman W. Multiple eccrine hidrocystomas. Australas J Dermatol 2004; 45: 178–80. 3 Correia O, Duarte AF, Barros AM, Rocha N. Multiple eccrine hidrocystomas—from diagnosis to treatment: the role of dermatoscopy and botulinum toxin. Dermatology 2009; 219: 77–9. 4 Amirhoushang E, Mostafa MS, Maryam A et al. Topical 0.03% atropine vs. 15% aluminum chloride in treating multiple eccrine hidrocystomas: a randomized single blind controlled study. Indian J Dermatol 2010; 55: 47–9. 5 Madan V, August PJ, Ferguson J. Multiple eccrine hidrocystomas—response to treatment with carbon dioxide and pulsed dye lasers. Dermatol Surg 2009; 35: 1015–17. 6 Kontochristopoulos G, Markantoni V, Stefanaki C et al. Multiple eccrine hidrocystomas treated with botulinum toxin A. Clin Exp Dermatol 2011; 36: 95–6.
ª 2014 British Association of Dermatologists
Multiple, bilateral periorbital blue macules C. Massone, P. Noll and R. Hofmann-Wellenhof Department of Dermatology, Medical University of Graz, Graz, Austria doi: 10.1111/ced.12284
Clinical findings A 52-year-old woman presented with a 9-year history of multiple facial lesions. There had been no increase in the size of the lesions over years, and no seasonal changes or any changes in humid and hot environments. The patient had been taking propranolol for hypertension for 12 years. There was no family history of similar lesions. On physical examination, multiple, dark-blue, periorbital, asymptomatic macules, 3–8 mm in size, were seen on the patient’s face (Fig. 1). The remainder of the clinical examinations revealed no abnormalities. Routine laboratory tests including full blood cell count, liver and renal function, glycaemia and thyroid hormones were within normal limits. Dermoscopy showed only a homogeneous, blue to black pattern (Fig. 2).
Figure 2 Dermoscopy showed only a homogeneous, blue to
black pattern.
Figure 3 Cystic lesion; lining was composed of two layers of flat
epithelial cells without signs of decapitation secretion. Figure 1 Multiple periorbital dark–blue, periorbital, asymptom-
atic macules. Correspondence: Dr Cesare Massone, Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz, Austria E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 27 October 2013
ª 2014 British Association of Dermatologists
Histopathological findings On histological examination, a cystic lesion was found in the reticular dermis. The cyst lining was composed of two layers of flat epithelial cells without signs of decapitation secretion (Fig. 3). What is your diagnosis?
Clinical and Experimental Dermatology (2014) 39, pp423–424
423
D CP
CED
CPD • Clinicopathological case
D
CP
Clinicopathological case
Diagnosis Multiple pigmented Robinson type.
eccrine
hidrocystomas
(EHs),
Discussion EHs are small (1–6 mm in diameter), translucent, tense, thin-walled cysts, usually located in the periorbital and malar regions. Rupture of the cyst, resulting in collapse of the lesion with the loss of a watery fluid, helps to confirm the diagnosis. The colour varies from amber-brown to blue-black (pigmented EH; PEH).1,2 Robinson first described multiple EHs in 1893 (the classic Robinson type).1 Most of his patients were women who worked in a hot and humid environment. An increase in size and number during hot and humid weather conditions can be seen with EH. Multiple EHs can also occur in association with Graves disease and Parkinson disease.2 In 1973, Smith and Chernosky described another group of patients with similar, but single lesions (Smith and Chernosky type).2 With this type, women and men are similarly affected. The lesions do not display any seasonal variation, and are located not only in the periorbital area, but also on the nose, head, trunk and popliteal fossa.2 EH results from the dilation of cystic excretory eccrine glands due to the retention of sweat, and the dilation or blockage of the sweat duct. Histologically, they appear as dilated cystic structures located in the dermis. The cyst wall is composed of one or two layers of low cuboidal or flat epithelial cells with round to oval nuclei. Unlike their apocrine counterpart, there is a lack of decapitation secretion in EH. Furthermore, apocrine hidrocystoma tends to have papillary projections into the lumen of the cyst.1–3 The clinical differential diagnosis includes apocrine hidrocystoma, syringoma and sebaceous hyperplasia. For the pigmented variant of EH, agminated blue naevus, haemangioma, basal cell carcinoma and even melanoma metastasis are possible diagnoses. The final diagnosis is possible only upon histopathological examination. To our knowledge, dermoscopy in EH has been reported only once by Correia et al.,3 who described well-demarcated cystic spaces without vessels. In our case, there was a homogenous blue pattern similar to that of blue naevus, haemangioma, basal cell carcinoma or metastatic melanoma.
424
Clinical and Experimental Dermatology (2014) 39, pp423–424
Treatment of multiple EHs is difficult. The use of oral or topical atropine and topical scopolamine, or 0.5% glycopyrrolate aqueous solution has been reported, with transitory results.3,4 Drainage or surgical excision are alternative options. Cryosurgery, microdermabrasion, electrodesiccation, and CO2 laser and 585-nm flashlamp-pumped pulse dye laser have been tried with variable results.5 Botulinum toxin A seems to be effective, with at least good relief for some months, and the advantage that it can be repeated, and side effects are minimal and transitory.6 Our patient refused any treatment, and at the 2-year follow-up, the lesions had not increased in size or number.
Learning points
•
PEH is clinically difficult to differentiate from apocrine hidrocystoma, agminated blue naevus, haemangioma, basal cell carcinoma and even melanoma metastasis. • In our case, dermoscopy showed a homogenous blue pattern similar to that of blue naevus, haemangioma, basal cell carcinoma or metastatic melanoma. • Botulinum toxin A seems to be effective, with at least good relief for some months and the advantage that the treatment can be repeated.
References 1 Robinson AR. Hidrocystoma. J Cutan Genitourin Dis 1893; II: 293–3. 2 Lee MR, Ryman W. Multiple eccrine hidrocystomas. Australas J Dermatol 2004; 45: 178–80. 3 Correia O, Duarte AF, Barros AM, Rocha N. Multiple eccrine hidrocystomas—from diagnosis to treatment: the role of dermatoscopy and botulinum toxin. Dermatology 2009; 219: 77–9. 4 Amirhoushang E, Mostafa MS, Maryam A et al. Topical 0.03% atropine vs. 15% aluminum chloride in treating multiple eccrine hidrocystomas: a randomized single blind controlled study. Indian J Dermatol 2010; 55: 47–9. 5 Madan V, August PJ, Ferguson J. Multiple eccrine hidrocystomas—response to treatment with carbon dioxide and pulsed dye lasers. Dermatol Surg 2009; 35: 1015–17. 6 Kontochristopoulos G, Markantoni V, Stefanaki C et al. Multiple eccrine hidrocystomas treated with botulinum toxin A. Clin Exp Dermatol 2011; 36: 95–6.
ª 2014 British Association of Dermatologists
