What Are These Cystic Lesions Adjacent to the Eyelids?
A 49-year-old Caucasian man developed non-tender, non-pruritic vesicular lesions adjacent to the eyelids. The lesions slowly enlarged onto the eyelids over 5 years. No lesions were present elsewhere. Physical examination revealed eight shiny, translucent vesicles and bullae with overlying telangiectasias. The lesions ranged in size from 2 mm to 15 mm in diameter. A shave biopsy was obtained for histological examination.
Diagnosis: Eccrine Hidrocystomas
Eccrine hidrocystomas most commonly appear as solitary lesions on the face adjacent to the eyelids. Occasionally a few — and rarely numerous — lesions may occur. They are tense and translucent or slightly bluish in color. They result from dilation of cystic excretory eccrine glands due to retention of sweat caused by blockage of the sweat duct. These benign lesions may swell in the summer in association with increased temperature and regress in the winter when temperatures are lower. Histologically, two layers of cuboidal cells are present in the cyst wall. Unlike their apocrine counterpart, secretory cells demonstrating decapitation secretion are not present1,2.
The clinical differential diagnosis includes apocrine hidrocystoma. This benign adnexal tumor is clinically undistinguishable from eccrine hidrocystoma. Histologically, however, apocrine hidrocystomas demonstrate multiloculated cystic spaces with papillary projections. The inner row of cells shows apocrine “decapitation” secretion. In the case of a solitary cystic lesion with telangiectasias on the face, cystic basal cell carcinoma could be considered, although it would be unusual to develop this many lesions concurrently. A biopsy with characteristic basaloid tumor cells and cyst formation would distinguish basal cell carcinoma from eccrine hidrocystoma.
Cylindroma, or “turban tumor,” is a dominantly inherited adnexal tumor that appears as multiple small papules or large dome-shaped nodules; however, there were no fluid-filled cysts observed in this patient. Histologically, it demonstrates variably sized islands of basaloid epithelial cells that fit together like a jigsaw puzzle.
Similarly, syringoma are benign adnexal tumors of sweat glands that occur frequently in women after puberty. These small 0.2-mm to 1-mm skin-colored or pale papules are present on the lower eyelids. They do not produce fluid-filled cysts. Their histopathology demonstrates many nests of cells, some with ducts, and an overall structure resembling that of a “tadpole.”
Management of patients with multiple large hidrocystomas is difficult. Incision and drainage produces prompt improvement, but recurrence is expected unless the cyst wall is removed2. Treatment by shave excision is a commonly used modality. Wound care using an antibiotic ointment or petrolatum applied four to six times per day is recommended to promote healing and minimize scarring. Since the cyst wall is often difficult to visualize during surgery, complete destruction of the cyst wall cannot be ensured, and recurrences over a period of months are common. Full-thickness excision of these lesions is unfavorable, as it is technically challenging and may be associated with ectropion formation and linear scar production.
One reviewed case report suggests that pulsed dye laser therapy is an effective, non-scarring modality for treatment of eccrine hidrocystoma, although two studies failed to show efficacy3,4. The mechanism of action is not clear. This evolving therapy could be tested on one or a few lesions to assess its utility. Another option, carbon dioxide laser vaporization, offers precise vaporization of tissue so that the depth of destruction can be more easily judged than with electrodessication, but this modality is highly operator-dependent5.
Other evolving treatments include the use of topical 1.0% atropine or scopolamine cream. Small trials suggest eccrine hidrocystoma may respond to these efforts to decrease eccrine gland output as cyst contents are resorbed6. Further study of the safety and efficacy of this approach is needed. Similarly, the local injection of botulinum toxin decreases eccrine gland output by blocking Type A cholinergic terminals and collapsing these cysts as fluid is resorbed. Further study is required to assess the methodology, safety and the need for additional treatment that is required over time. No recurrence was shown in one case report after 18 months7.
A definitive diagnosis of eccrine hidrocystoma was made in our patient by shave excision of two larger lesions, which demonstrated a characteristic unilocular cyst and cuboidal cell bilayer (see figures 1 and 2). These lesions are located in the mid to superficial dermis. These sites healed well, although one cyst recurred 4 months after treatment. Other lesions were incised and drained. Six weeks later, the patient was satisfied with the degree of improvement and promised to follow up if lesions enlarged again (see figures 3a and 3b). We plan to continue to treat the larger, more disfiguring lesion with this shave excision technique every 3 to 4 months until further information is available about the successful implementation and recurrence rate associated with the emerging treatments noted above.
Ms. Kiracofe is a medical student at Case Western Reserve University School of Medicine in Cleveland, OH.
Dr. Gener is with the Department of Pathology, Forum Health, Northside Medical Center in Youngstown, OH.
Dr. Brodell is Northeastern Ohio Universities College of Medicine in Rootown, OH; Case Western Reserve University School of Medicine in Cleveland, OH; and University of Rochester School of Medicine and Dentistry in Rochester, NY.
Disclosures: The authors have no conflicts of interest to declare. No funding was used for this research.