2) 1334 indicated, based on the clinical presentation of the lesion. Ifthe eyst has ruptured or has become infected, excision of the lesion should be deferred until the inflammation has decreased which will decrease the likelihood of wound dehiscence. Pieces einGn enka Trichilemmal cysts are keratin-filled, epithelial-lined cysts usually on the scalp that arise from the outer root sheath of the hai follicle. EPIDEMIOLOGY. Trichilemmal cysts can be found in 5%-10% of the population, most commonly in middle-aged women, ETIOLOGY AND PATHOGENESIS. Pilar cysts arise from the epithelium located between the orifice of the sebaceous gland and the arrector pili muscle, This squamous epithelium undergoes rapid keratinization resulting in a cyst wall without a granulae layer. CLINICAL FEATURES. Pilar cysts are mobile, firm, welleircumscribed nodules located overwhelmingly in the scalp (Fig. 118-21). These lesions can also be found on the face, head, and neck. Most patients have more than one lesion, with 10% of people having moze than 10 lesions. Rapid growth is abnormal and can bea sign of infection oF malignant transformation.” COMPLICATIONS. although these lesions largely remain asymptomatic, rupture and infection can occur Proiferating trichilemmal tumors are a variant ofthis benign lesion and are commonly found on the scalp of elderly women. This lesion can desttoy adjacent lesions and ulcerate, mimicking skin cancer. Malignant degeneration of ilar cysts into malignant proliferating tvichidemmal eysts can occasionally occur. PATHOLOGY. The hallmark finding of these cysts js the absence of a granular layer within the eyst wall (Fig, 118-22) The eyst content is usualy eosinophilic keratin, but basophilic areas of calcification may occur in the lumen of these lesions. If lobules of squamous Figure 118-21 Trichilemmal cysts showing an epithelial Tining that lacks a granular layer. Figure 118-22 Primary millum. A 3.mm, hard, seed like white papule epithelium are seen in the walls of the lesion, it s most Likely a proliferating trichilemmal cyst. Invasion of the ‘cyst ining into the surrounding tumor indicates malig- nancy. DIFFERENTIAL DIAGNOSIS. See Section “Differ- ‘ential Diagnosis” under “Epidermoid Cyst.” ‘TREATMENT, The treatment isthe same as with epi dermoid cysts. Because the cyst wall of these tumors clinically more firm than that of epidermoid cysts, itis, possible to extract the lesion through a small incision, ‘made with a dermal punch trephine. MILIUM Millia are minute epidermoid cysts, lined with epider- ris and filled with keratin, EPIDEMIOLOGY. Milia are common congenital and acquired lesions in both infants and adults. Men and. women are affected equally. ETIOLOGY AND PATHOGENESIS. Milia are thought to result from pilosebaceous or eccrine sweat duct plugging. These superficial lesions can be primary or secondary, with the latter resulting from injury to the basement membrane ofthe skin, Secondary lesions are common in subepidermal blistering diseases such as epidermotysis bullosa and porphyria cutanea tarda, burns, after dermabrasion or ablative laser resurfacing, or in conjunction with topical therapy such as ghuco- corticoid therapy or 5fluorouracil treatment." CLINICAL FEATURES. Mili are 1-to 2-mm, white, domed papules commonly located on the cheeks and eyelids of adults (Fig. 118-23). In infants, milia are ‘common on the face and the mucosa, Epstein’s pearls are milia on the palate. Eruptive milia have been reported, though this is a rare occurrence. Mila en plague isa plaque-type, inflammatory variant of milia that is commonly located on the ear Acquired miliaFigure 118-23 Steatocystome m color ions on the trunk. ex. Multiple skin (cfg, 118-23. in online edition) can be located anywhere the predisposing trauma or other factors have occurred, PATHOLOGY. The pathology of a milium is similar to that of an epidermoid cyst, but the small size and occasional connection to eccrine ducts or vellus hait follicles distinguish these two entities. Bacteria are not usually seen in mila TREATMENT. Congenital milia tend to spontane- ously resolve. Acquited milia can resolve spontane ously as well, but can also be removed by disrupting the overlying epidermis with light electro-desiccation or incision, Usually with an 1i-blade and expressing the keratin contents STEATOCYSTOMA MULTIPLEX Steatocystoma multiplex are numerous, epithelial Tined, sebum-flled dermal cysts with characteristic sebaceous glands inthe cyst wall, ETIOLOGY AND PATHOGENESIS. Steato- cystoma multiplex, (sebocystomatosis, epidermal polycystic disease) can be a sporadic or autosomal- dominant disorder. These lesions can also be found in syndromes such as Alagille syndrome and pachyo- nychia congenita type I. Inthe latter, lesions are asso- ciated with mutations in K17. Sporadic solitary lesions are termed steatocystoma simplex. CLINICAL FEATURES. These lesions present as asymptomatic, yellow of skin-colozed dermal papules fr cysts loeated most commonly on the trunk, upper arms, scrotum, or chest (Fig, 118-24). Olly material can. Figure 118-24 Painful n ‘of chondrodermatitis be expressed from these lesions when incised, These lesions can become infected and suppurate, resulting in sinus formation and scarring, PATHOLOGY. The cyst walls of steatocystoma mul- Liplex are composed of stratified, squamous epithe lkam with an absent granular layer. Sebaceous glands are located in the cyst wall (¢Fg. 118-241 in online edition). Thee isan eosinophilic cuticle on the lumi nal side of this wall with keratin, oil, and hairs in the lumen DIFFERENTIAL DIAGNOSIS. Eruptive vellus hhair cysts can mimic steatocystoma multiplex clini- cally. They may have a tuft of hairs protruding, from the cyst centrally, with findings of vellus hairs in the amen with follicles in the wall. Epidermal inchision cysts also have to be excluded. The pathogenesis of steatocystoma, epidermal inclusion cysts, and eruptive vellus hair cysts may be similar’ TREATMENT, At times, simple excision or drain- age with manual removal of the cyst wall results in the clinical resolution of lesions." Inflamed lesions have been reported to respond to intralesional ste- roids, carbon dioxide laser, oral retinoids, or cryo therapy." DERMOID CYST Dermoid cysts are epitheliab-ined cysts containing various appendageal structures resulting from retained epithelium along embryonic fusion planes, These cysts fare either congenital or develop in childhood. The prevalence is equal in men and women. ya 1335