CASE PRESENTATION

A 48-year-old Black woman presented with a 2-year history of a solitary, slowly enlarging, asymptomatic, translucent cyst on the left cheek, adjacent to the lateral canthus, that enlarged this past summer (Figures 1 and 2). The patient has no past medical history.

FIGURE 1. The image shows a translucent multiloculated cyst on the left cheek, adjacent to the lateral canthus.

FIGURE 2. Transillumination demonstrates the clear fluid present in eccrine hidrocystoma.

MULTIPLE-CHOICE QUESTION

Cystic basal cell carcinoma

Apocrine hidrocytoma

Eccrine hidrocystoma

Syringoma

Amelanotic nodular melanoma

DISCUSSION

Answer: C. Eccrine hidrocystoma

Eccrine hidrocystomas (EHs) are benign cystic lesions derived from eccrine ducts. They most commonly occur in 30- to 75-year-old women (Sarabi & Khachemoune, 2006) and present as translucent fluid-filled cysts on the face, although they can occur on the neck and trunk as well. Solitary EH lesions are typically found in the periorbital area of the lower eyelids, lateral to the canthi. They can be multiloculated as seen in this case. EHs most commonly occur after excessive heat exposure. The eccrine ducts enlarge as a result of sweat retention, growing 1-6 millimeters (mm) in diameter during the summertime and decreasing in size during the winter (Sarabi & Khachemoune, 2006; Singh et al., 2005; Smith & Chernosky, 1973). Treatment options for those with continual growth of the lesion include elective surgical excision or cauterization and electrodessication of the cyst wall (Correia et al., 2009; Sarabi & Khachemoune, 2006; Singh et al., 2005; Smith & Chernosky, 1973). For multiple EHs, successful treatment with oral atropine, intralesional botulinum toxin A, and laser therapy has been reported.

Cystic basal cell carcinomas (BCCs) can be distinguished from EHs based on clinical presentation (Sarabi & Khachemoune, 2006; Smith & Chernosky, 1973). BCCs are slow-growing, pearly, often crusted and ulcerated malignant skin lesions derived from follicular germ cells. They can occur at any age and classically present with arborizing vessels on close examination. A cystic variant of BCC can closely resemble EH when they occur on sun-exposed areas of the face. Accurate diagnosis of BCCs is important because they can be locally destructive and disfiguring. Treatment requires complete excision (Buckel et al., 2004). Unlike BCCs, EHs do not exhibit desquamation, ulceration, telangiectasias, or bleeding (Buckel et al., 2004).

Apocrine hidrocystomas (AHs) are rare, benign, dome-shaped cystic lesions derived from the proliferation of apocrine sweat glands. Similar to EHs, they occur as asymptomatic lesions of the orbital, head, and neck regions (Sarabi & Khachemoune, 2006). Unlike EHs, AHs are primarily solitary tumors ranging from 3 to 15 mm in diameter and located along the inner canthus of the eyelid margin. They typically occur in both men and women ages 30-75 years (Hafsi et al., 2021; Sarabi & Khachemoune, 2006). Other distinguishing characteristics of AHs include their translucent, and rarely dark blue to black, coloration and insensitivity to temperature.

Syringomas are common benign intraepidermal lesions derived from eccrine ducts. They typically involve the eyes and neck but can also be found in the axillae, abdomen, genitalia, and scalp, which helps distinguish them from EHs. Syringomas commonly affect adolescent women and present as 1- to 3-mm brown, yellow, or skin-colored papules in clusters. A form of syringomas localized to the eyelid has been identified in middle-aged women, but they are not translucent. Conclusive diagnosis can be made with histopathological examination (Ghanadan & Khosravi, 2013).

Amelanotic nodular melanomas (NMs), the most aggressive form of melanomas, are lethal, rapid, vertically growing tumors with metastatic potential. They typically occur in patients older than 50 years old and do not show the ABCs (Asymmetry, irregular Border, variegation of Color) of pigmented melanoma. They are located on the sun-exposed areas of the head, neck, and lower limbs. Unlike EHs and AHs, NMs are not translucent. Late diagnosis contributes to the poor prognosis in amelanotic NMs (Dordevic Brlek et al., 2016).

In this patient, shave excision led to complete resolution without recurrence.

REFERENCES