Original Investigation

Unusual Eyelid Dermal Keratinous Cysts of Pilosebaceous Origin Frederick A. Jakobiec, M.D., D.Sc.*, Anna M. Stagner, M.D.*, Suzanne K. Freitag, M.D.†, and Michael K. Yoon, M.D.† *David G. Cogan Ophthalmic Pathology Laboratory; and †Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A.

Purpose: To describe 2 types of previously unrecognized dermal keratinous cysts of the eyelids—2 single sebaceous duct cysts derived from the glands of Zeis and 2 cases of multiple eruptive vellus hair cysts, both types associated with the pilosebaceous apparatus. Methods: Clinical records and paraffin sections subjected to hematoxylin and eosin and acid-fast staining were critically reviewed from each case, and additional sections were immunoreacted for cytokeratins (CKs) 7, 14, and 17. Results: Two patients had a slowly enlarging solitary sebaceous duct keratinous cyst at the eyelid margin where the glands of Zeis are located. The squamous cell lining displayed a corrugated squamous membrane manifesting an eosinophilic, refractile, surface cuticle. Either a sebaceous gland or a hair was proximate to the cyst. The squamous lining was CK7−, CK14+, and CK17+. Two other patients developed over 2 and 10 years a different condition consisting of unilateral or bilateral clusters, respectively, of small papules of the upper eyelids. These were lined by keratinizing squamous epithelium without a cuticular membrane. Numerous small vellus hairs along with keratin in the lumens were discovered with acid-fast staining. The epithelium was also CK7−, CK14+, and CK17+. Conclusions: Histopathologic and immunohistochemical studies can separate these 2 disparate new eyelid entities from the more common keratinous epidermoid cyst of the surface epidermis or the upper hair follicle (CK7−, CK14+, and CK17−). Simple local excision of the anterior lamella of the eyelid is appropriate for the sebaceous duct keratinous cysts of Zeis, but the multiple vellus hair cysts are comparatively refractory to treatment. Both superficial types of cysts are totally unrelated to the deeper Meibomian keratinous cyst, which is not associated with a hair structure and is situated in the tarsus rather than the dermis of the eyelids. (Ophthal Plast Reconstr Surg 2016;32:93–97)

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here are more cutaneous cysts of different kinds1 than have been described in the eyelids.2 This fact may be partially attributed to anatomical variations throughout the integument that are responsible for such disparate conditions. Alternatively, some of the failure to identify a wider variety of eyelid cysts may be due to their rarity in the eyelids or to subtle individuating microscopic features leading to their erroneous categorization Accepted for publication January 8, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Frederick A. Jakobiec, M.D., DS.c., David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Suite 328 Boston, MA 02114. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000423

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among more common entities. Care must also be taken to exclude cysts that can secondarily cause a bulge in the eyelid but do not originate in the dermis and are not filled with keratin, such as dacryops of the palpebral lobe of the lacrimal gland3 or lesions of the intratarsal accessory glands of Wolfring.4 The superficial keratinous cysts described herein are apparently rare and must be distinguished from deeper keratinous cysts that are located in the tarsus and are also rare.5 In this article, a clinicopathologic description is offered of 2 keratinous duct cysts6 of the Zeis sebaceous glands that were located in the dermis of the eyelid margin, and 2 cases of multiple eruptive vellus hair cysts (EVHC)7 that diffusely affected the eyelid and periocular skin. Both types of cyst arose from the dermal pilosebaceous unit and were united by similar immunohistochemical cytokeratin (CK) findings; these cysts have not been previously reported in the ophthalmic literature. Improved diagnostic precision of eyelid cysts based on careful histomorphologic analysis and the application of immunohistochemistry can lead to appropriate recommendations for therapy, especially with regard to the more troublesome and refractory EVHC.

METHODS This retrospective clinicopathologic study with chart and microscopic slide review was prepared in accordance with the tenets of the Declaration of Helsinki and the Health Insurance Portability and Accountability Act and with the approval of the Institutional Review Board of the Massachusetts Eye and Ear Infirmary, Boston, MA (protocol number 656236-1). The clinical records, operative reports, and clinical photographs of the 4 cases comprising this study were reviewed when available. The biopsies were fixed in 10% buffered formalin and analyzed microscopically with the benefit of standard staining of paraffin-embedded sections with hematoxylin and eosin and acid-fast staining to facilitate identification of intracystic vellus hairs. Immunohistochemical staining was conducted with mouse monoclonal antibodies reacting against CK7 (Dako, Carpinteria, CA, U.S.A.), CK14 (Leica Biosystems, Newcastle, United Kingdom), and CK17 (Leica). All the immunoperoxidase staining was performed in the Division of Diagnostic Immunohistology of the Department of Pathology at the Massachusetts General Hospital, Boston, MA. Immunohistochemical staining was performed using the Leica Bond III with appropriate controls to validate antibody quality. The chromogen diaminobenzidine was used for the detection of any immune reaction product, and the tissues were counterstained with hematoxylin.

RESULTS Clinical Findings. Case 1.

A 50-year-old man was referred to the Ophthalmic Plastic Surgery Clinic at the Massachusetts Eye and Ear Infirmary for

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removal of a left upper eyelid margin cyst that had been present for 5 months. A lesion in the same location had been excised 5 years earlier with a pathologic diagnosis of “epidermal inclusion cyst.” On examination, a 4-mm cystic lesion of the temporal left upper eyelid margin appeared to be filled with white material and did not transilluminate (Fig. 1, top left). There was some loss or displacement of the eyelashes. The remainder of the ocular examination was unremarkable. The patient denied pain, ulceration, or history of malignancy, and the cyst was excised for cosmetic regions. Case 2.

A 53-year-old woman presented for cosmetic removal of bilateral eyelid lesions. These small white lesions had been present for several years and had not changed. She had not used any warm compresses or received any medications. The lesions were small papules no larger than a millimeter and appeared to be located immediately beneath the epidermis within the eyelash line. There were 3 in each lower eyelid. Associated chalazia and madarosis were not observed.

Case 3.

A 16-year-old girl developed over a 2-year interval an increasing number of small lesions in a cluster over her right upper eyelid with extension toward the brow (Fig. 1, top right); they were thought to be syringomas or other benign adnexal neoplasms by her dermatologist. She had no family history of similar lesions. She was asymptomatic, but stated that 1 lesion had “popped” several months earlier. Ophthalmic examination without pupillary dilation was unremarkable. The right upper eyelid displayed around ten 1-mm to 2-mm, skin colored papules, some with a keratotic yellow/white core. Given the unusual grouping of these lesions, a biopsy was performed. Case 4.

A 21-year-old woman was referred by her dermatologist with a 10-year history of bilateral upper eyelid lesions, greater on the left than right. She had been given a previous diagnosis of “milia.” The patient stated that the number of lesions had increased particularly over the past 2 years. She reported no pain or discharge. Family history was significant for psoriasis and vitiligo. Ophthalmic examination without pupillary dilation was unremarkable. The upper eyelids bilaterally were littered with numerous 1-mm to 2-mm white papules, more numerous on the left side, several of which were excised for diagnostic and cosmetic reasons. Histopathologic and Immunohistochemical Findings.

FIG. 1.  Clinical (Cases 1, 3, and 4) and histopathologic (Cases 1 and 2) features of eyelid keratinous cysts. Top left, Case 1: sebaceous duct keratinous cyst. A 50-year-old man developed a left, medial upper eyelid margin cyst over 5 months. Top right, Case 3: eruptive vellus hair cysts. A 16-year-old girl developed a crop of right upper eyelid small papules over 2 years. Middle left, Case 4: eruptive vellus hair cysts. A 21-year-old woman displayed an increased number of white papules bilaterally on her upper eyelids over 10 years. Middle right, Case 1: beneath the epidermis (E) is an elongated, partially collapsed cyst (arrows). A sebaceous gland lobule (crossed arrow) is seen in the adjacent dermis. Bottom left, The cyst is lined by a keratinizing squamous epithelium without a keratohyalin granular layer. There is an intensely staining, inner eosinophilic cuticular membrane (arrows) surmounting the undulating lining. Strands of keratin are present in the lumen. Bottom right, Case 2: sebaceous duct keratinous cyst. This lesion is microscopically located near the epidermis (E) and has an associated hair (arrow). It contains a lamellar or onion-skinning collection of keratin (K) (middle right, bottom left, bottom right: hematoxylin and eosin, ×100, ×400, ×100, respectively).

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The lesions removed from patients 1 and 2 showed virtually identical features. Both were located in the dermis of the eyelid margin and were cysts lined by keratinizing squamous epithelium (Fig. 1, middle right). In Case 1, a small sebaceous acinus was discovered adjacent to the cyst (Fig. 1, middle right). The lumen of the cyst contained a small number of loosely arranged strands of keratin. The distinctive features of the lining were its undulating or crenated character, an intensely eosinophilic anuclear surface cuticular membrane that shed the keratin, and the absence of a keratohyalin layer (Fig. 1, bottom left). In Case 2, the cyst was intimately associated with a hair (Fig. 1, bottom right). In this lesion, the lumen possessed more strands of keratin that adopted an onion-skinning pattern. The lining of squamous cells lacked a keratohyalin layer, and the surface cuticular membrane had been detached and retracted from the epithelial lining due to its firm attachment to the intraluminal keratin (Fig. 2, top left). In Case 3, the lining displayed a smooth surface, lacked an undulating cuticular membrane, and was devoid of keratohyalin granules (Fig. 2, top right and bottom left). Amidst the keratin strands in the lumen, small vellus hairs were cross-sectioned or obliquely sectioned (Fig. 2, bottom left) and highlighted with acid-fast staining in Case 4 (Fig. 2, bottom right). In all 4 cases, the cystic lining was CK7 negative but the luminal keratin was positive (Fig. 3, top left); CK14 stained the basilar and parabasilar cells of the epithelium but not the luminal keratin (Fig. 3, top right); and CK17 stained most of the epithelium and luminal keratin but spared some segments of the basilar epithelial layer (Fig. 3, bottom left). Cases 3 and 4 therefore displayed the same CK staining results as the other 2 cases in this study (Fig. 3, bottom right). Portions of the epidermis contained in the specimens were CK7−, CK14+, and CK17−.

DISCUSSION During the embryologic development of the skin,8 focal hyperplasias of the epidermis first appear in the eyebrow and scalp regions at the third month of gestation. These thickenings become the primary epithelial or hair germs that extend downwards into the mesenchyme to create the pilosebaceous units. Every hair has an associated sebaceous gland—small ones attached to delicate vellus/lanugo hairs and large ones attached to “strong” hairs such as those of the scalp, eyebrows, and the eyelashes. The sebaceous

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FIG. 2.  Histopathologic features of keratinous lesions in Cases 2 and 3 and histochemical findings in Cases 3 and 4. Top left, Case 2: sebaceous duct keratinous cyst. The cuticular membrane (arrows) has been lifted off the squamous epithelial lining which lacks a keratohyalin layer. Top right, Case 3: vellus hair keratinous cyst. The cyst lumen contains conspicuous lamellae of keratin. Bottom left, The arrows indicate cross-sections of numerous delicate vellus hairs amidst the luminal keratin (K). Bottom right, Case 4: acid-fast stain highlights the vellus hairs in longitudinal and cross-sections in another case of eruptive vellus hair cyst (top left, top right, bottom left: hematoxylin and eosin, ×400, ×100, ×400; bottom right: acid fast, ×200).

glands of Meibom are embedded in the tarsus rather than in the dermis. They are virtually unique in the body for not being associated with a hair and form embryologically after the eyelids have begun to separate, at which stage the surface epidermis at the eyelid margin burrows vertically into the tarsus.

FIG. 3. Immunohistochemical features of sebaceous duct keratinous cyst and vellus hair cyst. Top left, Case 1: cytokeratin (CK) 7 fails to stain the lining a duct cyst but does stain the intraluminal stringy keratin (K). Top right, CK14 stains the basilar and parabasilar cells but not the superficial cells (arrows). Bottom left, Beneath the nonstaining epidermis (E), the cyst manifests full-thickness CK17 staining of its epithelial lining and the intraluminal keratin. Bottom right, Case 3: eruptive vellus hair cyst displays CK17 positivity of lining cells and luminal keratin (arrow). The inset shows the area in the box at higher power that contains a vellus hair (arrow) and a positively stained keratin flake (crossed arrow) (top left, top right, bottom left, bottom right: immunoperoxidase reaction, diaminobenzidine chromogen, hematoxylin counterstain, ×400, ×200, ×100, ×100, inset ×400).

Unusual Eyelid Keratinous Cysts

An unusual feature of the eyelashes and vellus hairs of the eyelid skin is the absence of arrector pilorum smooth muscles which usually insert into the bulge region of the hair follicle8 (Fig. 4). The duct of the sebaceous gland is distinctive in that it possesses a delicate surface eosinophilic refractile cuticle that manifests undulations or crenations.6,9 Strong hairs, but not vellus ones, typically have an associated apocrine gland that empties into the hair canal; therefore, the most complete differentiation of the primary epithelial germ is as a pilosebaceousapocrine unit. The apocrine duct connects with the uppermost portion of the hair canal (infundibulum) above the inserting duct of the sebaceous gland and immediately below the epidermis. In contrast, eccrine glands and their cysts arise totally independently of the pilosebaceous-apocrine unit.10 They empty their aqueous secretions via ducts that pass through epidermal pores (acrosyringia) (Fig. 4). The hair canal (follicle) and associated structures are divided into 4 regions8 (Fig. 4): the infundibulum, located immediately beneath the poral opening (acrotrichium) in the epidermis and extending to the level of the emptying duct of the associated sebaceous gland, where it discharges its secretions into the hair canal; the isthmus, located between the sebaceous gland duct and the hair bulge located midway down the hair canal; the suprabulbar segment, commencing at the hair bulge and extending inferiorly toward the matrical cells and the hair bulb. The matrical cells of the hair bulb can rest upon the anterior face of the tarsus but are completely separated from the Meibomian sebaceous glands by tarsal collagen. Each region of the canal generates cysts which adopt the characteristics of the keratinocytes lining that particular segment of the pilar canal (Fig. 4). Even the matrical cells of the hair bulb, the source of pilomatrixoma, can proliferate in a cystic fashion and exhibit focal intraluminal collections of the peculiar ghost or shadow cells of a full-fledged pilomatrixoma.6 Among cutaneous keratinous cysts, the most frequently encountered is the common infundibular or epidermoid cyst that arises from the uppermost portion of the hair follicle.1 The infundibulum is the uppermost portion of the hair follicle and is a reflection of the surface epidermis for a short distance into the upper hair follicle; therefore, its cysts will exhibit keratohyalin granules. These cysts are located in the eyelid dermis and uniformly display keratohyalin granules in the squamous (epidermoid) lining and loose basket-weave keratin in the lumen. They are usually referred to as epidermoid cysts or epidermal inclusion cysts if posttraumatic because of their resemblance to the epidermis; they may be floridly encountered in the nevus comedonicus.11 The origin of the spontaneous infundibular cysts is betrayed by a small poral aperture on their surface that permitted the emergence of an erstwhile hair shaft. Epidermal implantation or inclusion cysts do not differ in their lining as a result of arising from displaced epidermis after trauma (both surgical and accidental). Eyelid keratinous cysts situated in the skin should be distinguished from even more arcane keratinous cysts of the palpebral conjunctival epithelium12,13 and deeper intratarsal Meibomian gland keratinous cysts, discussed further below.5 Other previously characterized cystic entities are the so-called hybrid cysts (Fig. 4) that arise in overlapping anatomical segments of the hair follicle:14,15 one kind arising at the level of the apocrine duct is partially lined by apocrine ductal epithelium and keratin-shedding epidermoid cells; another is lined by segments of epidermoid cells with keratohyalin granules (epidermoid keratinization derived from the cells in the lower part of the infundibulum) alternating with those without keratohyalin granules (trichilemmal keratinization derived from cells of the upper portion of the isthmus). Trichilemmal (pilar) cysts develop in the lower isthmic portion of the hair canal and are characterized by swollen epidermoid cells that abruptly

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FIG. 4. Normal pilosebaceous-apocrine unit and locations of different kinds of keratinous cysts. The complete pilosebaceous-apocrine unit, illustrated in the middle structure, consists of the hair and its follicular epithelial ensheathment and an apocrine gland (of Moll when associated with an eyelash) which empties into the hair canal above a sebaceous gland (of Zeis when associated with an eyelash). The secretory portions of these glands are depicted in gray and the ductular components in white. A hair bulge is located about midway in the dermal extent of the follicle where the arrector pili muscle inserts (but it is notably absent in the eyelashes and vellus eyelid hairs). The germinal cells generating the hairs are located in the bulb with its supportive connective tissue papilla. The hair exits through an epidermal pore or passageway referred to as the acrotrichium (arrows). The hair follicle is divided into 4 sections: the infundibulum from the undersurface of the epidermis to insertion of the sebaceous gland duct; the isthmus from the sebaceous duct insertion to the middle of the hair bulge; the suprabulbar region from the middle of the hair bulge to the upper border of the hair bulb; and the bulb, which is the deep root of the hair containing the germinative or matrical cells. The eccrine gland with its exiting acrosyringium (crossed arrows) on the left is totally separate from the pilosebaceous-apocrine unit. On the right, the locations of 7 types of cysts arising from the pilosebaceous units that produce intraluminal keratin are indicated: 1) common epidermoid cysts; 2) hybrid epidermoid/apocrine duct cysts; 3) sebaceous duct cysts; 4) hybrid epidermoid/trichilemmal cysts; 5) vellus hair cysts; 6) trichilemmal cysts; and 7) rare matrical cysts.

transition, without the interposition of keratohyalin granules, into compact nonlamellar keratin.16,17 The 2 examples of the sebaceous gland duct cysts (also referred to as keratocysts)6 described in this report occurred in the dermis of the eyelid margin. In 1 case, a solitary lesion recurred 5 years after an earlier excision. In the second case, several lesions were situated at the eyelid margins of both lower eyelids. In both cases, these lesions were clinically nonvascularized, smooth, and white, owing to the accumulation of keratin in the cysts’ lumens. In Case 1, a small adjacent sebaceous acinus was detected microscopically, probably the remnant of a gland of Zeis associated with the eyelashes whose duct provided the source for the cyst; in Case 2, a hair was intimately associated with the cyst’s wall, providing further evidence of an origin from a pilosebaceous unit. These lesions are closely simulated by apocrine hidrocystomas, which develop only from the glands of Moll restricted anatomically to the eyelid margin.10 They are lined by a nonsquamous cuboidal to columnar epithelium (sometimes exhibiting apical decapitation) and filled with eosinophilic secretions rather than keratin. The essential distinguishing histopathologic features of the squamous lining were its corrugated or crenated character, the absence of keratohyalin granules, and an anuclear, eosinophilic, refractile cuticular surface representing a type of keratinization that sheds into the lumen as loose keratin lamellae or delicate strands that may focally become compacted. A

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virtually identical cystic lesion has been described in the caruncle,18 where an example arose from the duct of a sebaceous gland normally attached to a vellus hair of this structure.19 In the tarsus, similar cysts can arise from the usually nonkeratinizing squamous ducts of the Meibomian glands.5 These latter cysts occur preferentially in elderly individuals and are larger than Zeis gland cysts; the dermis slides over the intratrasal bulge, and on eversion of the eyelid, a well-defined white or blue placoid lesion of the palpebral surface will be discovered. In contrast to dermal epidermoid cysts, intratarsal keratinous cysts behave more aggressively and will recur multiple times if the lining epithelium is not completely surgically removed or extirpated by other means. Steatocystoma multiplex and simplex9,20–22 are lined by an identical corrugated epithelium, but unlike the present cysts, are larger and more complex nevoid malformations with abundant sebaceous glands in their walls and scattered sebaceous cells in the lining itself. They, furthermore, display a yellow, oily secretion (sebum) in their lumens rather than white, nonfluid keratin. Immunohistochemistry characterizing the cytoplasmic CK expression in the lining cells of eyelid sebaceous duct keratinous cysts can be helpful in confirming the diagnosis: CK14 and CK17 are both positive in the normal sebaceous gland duct23 and Meibomian gland duct.5 Parallel findings have also been described in noneyelid sebaceous duct keratinous cysts,6,23 Meibomian duct keratinous cysts,5 and steatocystomas.22 The

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authors have examined 1 unpublished case of a periocular trichilemmal cyst that was CK7−, CK14+, and CK17+. In contrast, epidermoid cysts are CK7−, CK14+, and CK17−.13 Because keratinous cysts of the glands of Zeis are limited to the anterior lamella of the eyelids, only this layer needs to be excised. Eruptive vellus hair cysts that appear in clusters as multiple small papules are unknown to most practicing ophthalmologists and ophthalmic pathologists. In a review of 222 cases,7 the most common anatomical locations were the chest, abdomen, face, and upper limbs; the eyelids were noted in passing to be involved in 3 cases. Two detailed case reports in the nonophthalmic literature of predominantly bilateral upper eyelid involvement have been documented—1 in a 15-year-old African-American girl24 and another in a 13-year-old AfricanAmerican boy.25 In each case, there was a 4-year history from onset to presentation. In general, the condition tends to occur in the first 3 decades of life in groups or crops; around 4% of cases appear as solitary lesions. There is a female to male ratio of 1:3. Clinically, EVHC papules are soft and are 1 mm to 2 mm in diameter exhibiting a normal skin coloration, but they may be occasionally white, yellow, or inflamed if they have undergone spontaneous rupture. Around the eyes, the lesions can simulate syringomas. According to reported cases, and also manifested by the current lesions, they differ by mostly involving the upper eyelids rather than the lower, which is more typical for of syringomas. They usually develop sporadically but may demonstrate an autosomal dominant inheritance in approximately 9% of cases. In 6.3% of all cases, steatocystoma multiplex may be associated. Familial psoriasis and vitiligo can be seen, as in our case 4. Single lesions are observed in 4% of patients as a noninherited manifestation. The current lesions were investigated immunohistochemically and were established to share similar CK staining properties (CK7+/ CK17−) with sebaceous duct keratinous cysts. No serious systemic disease has been established to be consistently aligned with EVHC, although pregnancy, renal failure, and trauma have been indicted as triggering factors.7 In their evolution, spontaneous resolution of EVHC happens in a minority of cases, generally due to rupture with transepidermal elimination of the cysts’ contents. The majority, however, prove to be more refractory to treatment. Histopathologically, they are found in the mid to upper dermis and exhibit a keratinizing squamous lining that can focally display keratohyalin granules, while other areas may exhibit trichilemmal keratinization (absence of keratohyalin granules). A cuticular membrane is not identified. Small vellus hairs are observed in cross or oblique sections in the cysts’ lumens. There are no features that distinguish eyelid EVHCs from those elsewhere in the skin. The lesions are believed to originate in the infundibulum of the pilar canal or at the follicular infundibular/isthmus junction. An occlusive disturbance of normal keratinization may be responsible for the malformed vellus hairs and follicular cystic dilation.7,26 Rupture of the cysts leads to a surrounding dermal granulomatous reaction with fibrosis, which can cause resolution. The lesions have been successfully treated by excision, dermabrasion, laser therapy, and retinoic acid, but they have been nonresponsive to several other topical therapies.7

Unusual Eyelid Keratinous Cysts

REFERENCES 1. Patterson JW, Wick MR, eds. AFIP Atlas of Tumor Pathology: Nonmelanocytic Tumors of the Skin. Washington, DC: American Registry of Pathology Press, 2006:1–10. 2. Yanoff M, Sassani JW. Ocular Pathology. Philadelphia, PA: Mosby Elsevier, 2015:171–4. 3. Jakobiec FA, Zakka FR, Perry LP. The cytologic composition of dacryops: an immunohistochemical investigation of 15 lesions compared to the normal lacrimal gland. Am J Ophthalmol 2013;155:380–96.e1. 4. Weatherhead RG. Wolfring dacryops. Ophthalmology 1992;99:1575–81. 5. Jakobiec FA, Mehta M, Iwamoto M, et al. Intratarsal keratinous cysts of the Meibomian gland: distinctive clinicopathologic and immunohistochemical features in 6 cases. Am J Ophthalmol 2010;149:82–94. 6. Weedon D. Weedon’s Skin Pathology. Philadelphia, PA: Churchill Livingstone/Elsevier, 2010:446–7. 7. Torchia D, Vega J, Schachner LA. Eruptive vellus hair cysts: a systematic review. Am J Clin Dermatol 2012;13:19–28. 8. Valezquez EF, Murphy GF. Histology of the skin. In: Elder DE, ed. Lever’s Histopathology of the Skin. Philadelphia, PA: LippincottRaven, 2009:24–31. 9. Brownstein MH. Steatocystoma simplex. A solitary steatocystoma. Arch Dermatol 1982;118:409–11. 10. Jakobiec FA, Zakka FR. A reappraisal of eyelid eccrine and apocrine hidrocystomas: microanatomic and immunohistochemical studies of 40 lesions. Am J Ophthalmol 2011;151:358–74.e2. 11. Mendoza PR, Jakobiec FA, Townsend DJ. Bilateral nevus comedonicus of the eyelids. Ophthal Plast Reconstr Surg 2013;29:e95–8. 12. Jakobiec FA, Mehta M, Sutula F. Keratinous cyst of the palpebral conjunctiva. Ophthal Plast Reconstr Surg 2009;25:337–9. 13. Mendoza PR, Jakobiec FA, Yoon MK. Keratinous cyst of the palpebral conjunctiva: new observations. Cornea 2013;32:513–6. 14. Milman T, Iacob C, McCormick SA. Hybrid cysts of the eyelid with follicular and apocrine differentiation: an under-recognized entity? Ophthal Plast Reconstr Surg 2008;24:122–5. 15. Requena L, Sánchez Yus E. Follicular hybrid cysts. An expanded spectrum. Am J Dermatopathol 1991;13:228–33. 16. Kang SJ, Wojno TH, Grossniklaus HE. Proliferating trichilemmal cyst of the eyelid. Am J Ophthalmol 2007;143:1065–7. 17. Meena M, Mittal R, Saha D. Trichilemmal cyst of the eyelid: masquerading as recurrent chalazion. Case Rep Ophthalmol Med 2012;2012:261414. 18. Jakobiec FA, Mehta M, Greenstein SH, et al. The white caruncle: sign of a keratinous cyst arising from a sebaceous gland duct. Cornea 2010;29:453–5. 19. Jakobiec FA, Lam H, Bhat P, et al. Non-syndromic supernumerary caruncles causing ocular irritation after cataract surgery: a critical review of caruncular dysgeneses. Am J Ophthalmol 2010;149:398– 404.e1–2. 20. Cho S, Chang SE, Choi JH, et al. Clinical and histologic features of 64 cases of steatocystoma multiplex. J Dermatol 2002;29:152–6. 21. Tirakunwichcha S, Vaivanijkul J. Steatocystoma simplex of the eyelid. Ophthal Plast Reconstr Surg 2009;25:49–50. 22. Stagner AM, Jakobiec FA, Yoon MK. Ruptured canthal steatocystoma simplex presenting as a lacrimal sac mass. Clin Exp Ophthalmol 2014; [Epub ahead of print]. 23. Kurokawa I, Nishijima S, Kusumoto K, et al. Cytokeratin expression in steatocystoma multiplex. Br J Dermatol 2002;146:534–6. 24. Sina B, Burnett JW. Eruptive vellus hair cysts. Cutis 1984;33:503–4. 25. Reep MD, Robson KJ. Eruptive vellus hair cysts presenting as multiple periorbital papules in a 13-year-old boy. Pediatr Dermatol 2002;19:26–7. 26. Calonje E, Brenn T, Lazar AJ, et al. Cutaneous cysts. In: McKee PH, ed. McKee’s Pathology of the Skin. Philadelphia, PA: Elsevier, 2012:1578–80.

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Unusual Eyelid Dermal Keratinous Cysts of Pilosebaceous Origin.

To describe 2 types of previously unrecognized dermal keratinous cysts of the eyelids-2 single sebaceous duct cysts derived from the glands of Zeis an...
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