Cysts - Proliferating Cysts

Proliferating Cysts are malignant cysts that are fortunately very rare and are infrequently encountered in my The Woodlands dermatology and Conroe dermatology offices.  All cyst like lesions that I excise are always examined by a board certified dermatopathologist to ensure they are benign and to evaluate for malignancy such as a Proliferating Cyst mimicking a benign cyst. Proliferating Cysts can arise from either Epithelial Inclusion Cysts or Pilar Cysts.  Proliferating Epithelial Inclusion Cysts are more common in men and are most often found in the pelvic/anogenital area.  They are usually locally aggressive where they enlarge and invade into normal structures but can metastasize in some cases.  Proliferating Pilar Cysts are almost exclusively found on the scalp and back of the neck.  They are very large (over 25 cm) nodules and behave similar to squamous cell cancers of the skin.  Unlike Proliferating Epithelial Inclusion Cysts, they are much more common in women and are typically seen in patients over age 65.  Treatment for Proliferating Cysts is excision with a margin of normal skin.

 Proliferating Cyst (http://www.ispub.com/journal/the-internet-journal-of-dermatology/volume-4-number-2/proliferating-trichilemmal-cyst-of-the-arm.article-g01.fs.jpg)

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Cysts - Steatocystomas

Steatocystomas are the only true "sebaceous cysts" which I encounter in my The Woodlands dermatology and Conroe dermatology clinics.  "Sebaceous cyst" is a misnomer when applied to Epithelial Inclusion Cysts or any other cyst that arises from the hair shaft and not the sebaceous glands (oil glands).  Steatocystomas are rare in comparison with Epithelial Inclusion Cysts and appear at puberty or later in life when the sebaceous glands have matured.  Steatocystomas clinically resemble other cysts as they are flesh colored nodules, however they compress easier with manual pressure and feel softer.  When an incision is made into the Steatocystoma, an oily viscous liquid appears which resembles melted butter unlike the cheesy white paste-like contents of Epithelial Inclusion Cysts.  Steatocystomas do not have a true sac lining so are more difficult to eradicate than Epithelial Inclusion Cysts and Pilar Cysts.  On histology, steatocystomas have a characteristic pink cuticle lining the cyst cavity but this lining is not clinically apparent. Steatocystomas can be solitary (Steatocystoma Simplex) or multiple (Steatocystoma Multiplex).  Steatocystoma Mulitplex may occur sporadically or it can be associated with an autosomal dominant disorder due to a defect in Keratin 17.  Pachyonychia Congenita Type 2 is a genodermatosis in which the patients may develop Steatocystoma Multiplex as one of the constellation of clinical findings.  Pachyonychia Congenita also involves defects in Keratin 17.  Treatment of Steatocystomas involves incision and drainage of the cysts or excision of the entire steatocystoma. 

Steatocystomas- (http://t2.gstatic.com/images?q=tbn:ANd9GcREoGTilSU0ovnojH7ZV6bAEfXkBpmQnuEZszGHjZ9ZJzQQ0z4S)

Steatocystomas- (http://t2.gstatic.com/images?q=tbn:ANd9GcT4uWEHfypmPLkorJDAiMF8q4eqSvg3XpgiPfNypUskZ9jh7_D54eHA3JyMuA)

Steatocystoma- Histology (http://t2.gstatic.com/images?q=tbn:ANd9GcQPVL-s3jz0rM8XC5bhzHXgKrex3eON74FJBj1Pekgnelsn62T0Vw)

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Cysts - Epidermal Inclusion Cysts

Epidermal inclusion cysts (EICs) are one of the most common skin lesions I encounter in my The Woodlands dermatology and Conroe dermatology clinics.  EICs arise spontaneously without a known precipitating cause in many cases, but may occur secondary to acne or trauma which places the epidermis into the dermis or subcutaneous tissue.  They begin as an outgrowth of the infundibular portion of the hair shaft which forms a silver/white sac lining.  As this sac lining is connected to a skin pore, oil and debris fill this sac lining like a balloon gradually getting larger and expanding under the skin rather than extruding the contents out of the pore.  Patients may notice a soft mass or swelling under their skin that becomes larger over time.  EICs can occur anywhere on the body except the scalp.  The scalp can produce a cyst called a Pilar cyst, which is slightly different than an EIC.  Cysts are removed surgically by anesthetizing the area around the cyst with a local anesthetic and making an incision into the cyst large enough to extract the entire cyst sac lining and its contents.  If the lining is not completely removed, the cyst will recur.  Simply, incising and draining the the cyst will not remove the sac lining.  Occasionally, the cyst contents rupture out of the sac lining and enter into the dermis or subcutaneous layer of the skin.  This causes an intense inflammatory reaction as the cyst material is treated as a foriegn object by the patient's immune system.  The EIC becomes swollen, tender and red and appears infected.  Many patients present when their cyst has become inflamed.  I typically inject a low dose kenalog (steroid) into the inflammed cyst to calm the inflammatory reaction and place the patient on a two week course of antibiotics prior to excising the cyst, since an inflammed cyst cannot be excised and sutured closed without the risk of dehiscence or infection.

Epidermal Inclusion Cyst- (http://t1.gstatic.com/images?q=tbn:ANd9GcRJhs9dZclw88cfXnvgG3WEyo34lyURH_zlfdedp753e132GKzSqQ)Epidermal Inclusion Cyst- Ruptured (http://t2.gstatic.com/images?q=tbn:ANd9GcTAUxd-VhNWww66_BPgWZckySh61TNlL4jdW-c7rJ9rpr0-vJCOcA) 

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Viruses - Sandfly Fever

Sandfly Fever, also called Phlebotomus fever, is common to Asia and the Mediterranean region but is very rare in the United States and I have not encountered it in my The Woodlands dermatology and Conroe dermatology offices.  It is caused by bites from the sandfly, Phlebotomus papatasii.  Most patients are asymptomatic but it causes 80% of all cases of aseptic meningitis during the Summer in endemic areas.  Some patients develop a rash, which begins as small red papules at the site of the sandfly bite and can last 5 days.  After another 5 days, patients develop fever, malaise, stiff neck, nausea, abdominal pains, and conjunctivitis.  After this prodrome, an intensely erythematous (red) rash occurs on the face and neck.  There is no specific treatment for Sandfly Fever other than supportive care.

Sandfly Fever- Sandfly Bite (http://t0.gstatic.com/images?q=tbn:ANd9GcQFN6kBmcboBCn9D3ztDdOdoguXsjGmYTEeHApAZezSQLdt5M6E)

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Viruses - Dengue

Dengue, also called break-bone fever, is an arborvirus spread by the Aedes aegypti mosquito, which I normally do not encounter in my The Woodlands dermatology and Conroe dermatology offices.  It is endemic to Southeast Asia but can be found in tropical regions around the world.  Within two weeks of being bitten by the Aedes mosquito, patients develop a very high fever, headache, back pains, joint and bone pains, pain behind the eye (retroorbital pain), fatigue and depression.  A morbilliform erythematous (red) rash occurs on the chest, back and joint flexors.  Some patients recover completely at this point but some develop a second rash that is very purpuric (bruise like) around the 3rd to 4th day after the first rash began.  A characteristic of this second purpuric rash are small "white islands in a sea of red" of spared skin which appear normal surrounded by the rash.  In 5% of patients, Dengue Hemorrhagic Fever occurs.  Thromboctyopenia (low platelets) develops which results in spontaneous bleeding in the skin, conjunctiva of the eyes, and gastrointestinal tract.  Approximately 30% of patients with Dengue Hemorrhagic Fever, progress to Dengue Shock Syndrome.  Dengue Shock Syndrome is fatal in 10% of patients as hypotension results secondary to hypovolemia.

 Dengue Fever- "White Islands in a Sea of Red" (http://www.articleslounge.com/wp-content/uploads/2010/10/Dengue-fever-skin-rash.jpg)

Dengue Fever- Dengue Hemorrhagic Fever (http://t3.gstatic.com/images?q=tbn:ANd9GcTD7lacVm27zaqKZn48onnD64Ph2FnlX4cLUBXJZ2B4YvcsB4-76Q)

Dengue Hemorrhagic Fever- Bleeding in the Conjunctiva ( http://smallcapworld.files.wordpress.com/2010/10/dengue_fever2.jpg?w=300&h=223)

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