Giant multi-loculated apocrine hidrocystomas
Department of Dermatology, New York University, New York, New York
Giant, multi-loculated hidrocystomas represent a rare variant of the common, benign hidrocystoma. Hidrocystomas are generally 1-3 mm and rarely exceed 10 mm. We describe a case of giant multi-loculated hidrocystomas 1-2 cm in size that were located near both upper and lower eyelids. Multiple modalities have been used to treat hidrocystomas, including excision, pulsed-dye laser, electrodesiccation, curettage, tricholoracetic acid, botulinum toxin, and anticholinergics.
A 58-year-old man presented to the Dermatology Clinic at Bellevue Hospital Center in August, 2009, for evaluation of multiple growths around his eyes. The lesions first appeared approximately six years ago as small growths. For the past six months, the lesions had been increasing in size. They remained asymptomatic and the patient reported no pruritus, pain, bleeding, or discharge. There was no family history of similar lesions or of prior trauma. There had not been any previous treatments.
The patient was otherwise healthy without any relevant past medical history. He took no medications and had no known allergies to medications.
Multiple, soft, fluctuant, translucent, skin-colored 1-2 cm nodules were present around the eyes: one on the left upper eyelid, two on the right lower eyelid, and two on the right upper eyelid.
There is a cyst lined by papillated epithelium of predominantly two cell layers. Luminal cells have eosinophilic cytoplasm and exhibit decapitation secretion.
Hidrocystomas are adnexal tumors that contain cystic proliferations of apocrine or eccrine secretory glands. Cysts commonly appear as solitary, soft, translucent papules or nodules. They typically are 1-3 mm in diameter and almost always are smaller than 10 mm. They are most frequently located on the eyelids, especially the inner canthi. They grow slowly and, without treatment, usually persist indefinitely. The pathophysiology is unknown. However, plausible causes include occlusion or blockage of the sweat duct apparatus, which results in sweat retention and the dilated cystic structure. The cysts are benign, rarely cause symptoms, and seldom recur after removal. There is no predilection for race or sex. Clinically, the differential diagnosis includes hemangiomas, epithelial inclusion cysts, lymphangiomas, molluscum contagiosum, and atypical basalcell carcinomas.
Eccrine and apocrine hidrocystomas may have similar clinical appearances and tend to be distributed throughout eyelid skin. However, the eccrine type usually does not involve eyelid margins whereas the apocrine type may. The eccrine type tends to produce watery secretions whereas the apocrine type tends to produce oily, foamy secretions. The types also may be differentiated by histopathologic examination. Eccrine hidrocystomas have a single cystic cavity, which contains no papillary projections and is lined by one or two layers of small, cuboidal epithelial cells that secrete into the glandular lumen. Apocrine hidrocystomas demonstrate multiple cystic spaces, papillary projections, and an outer wall of myoepithelial cells.
Although hidrocystomas are relatively common lesions, giant forms rarely have been described. Only six case reports exist that describe giant hidrocystomas; these occured on the face [1, 2, 3], scalp [4, 5], and trunk . In the largest published series of eccrine hidrocystomas, the majority of patients have only a single tumor, which usually occurs on the upper eyelids . Giant hidrocystomas may cause appreciable functional and cosmetic morbidity as illustrated by a patient with mechanical ptosis and epiphora secondary to hidrocystomas .
Treatment can be both medical and surgical. Successful management usually requires excision with removal of the cyst wall to prevent recurrence. Treatment of multiple, smaller lesions has been achieved by pulsed-dye laser thermoablation, curettage, electrodesiccation, and, more recently, trichloroacetic acid chemical ablation and botulinum toxin [8, 9, 10]. Because the pathogenesis of hidrocystomas is associated with hyperhidrosis, it has been posited that anticholinergics could be beneficial. One patient was successfully treated with topical application of 1 percent atropine sulfate ointment , and one patient was successfully treated with an oral anticholinergic agent, glycopyrrolate, without side effects .
Giant hidrocystomas may invoke appreciable cosmetic disfigurement and impede surrounding ocular function. Spontaneous resolution rarely occurs. Appropriate treatment with medical or surgical modalities is determined by number, size, and patient preference.
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