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Subcutaneous nodules on the abdomen
1. Subcutaneus Nodules on the
abdomen.
What is your diagnosis?
F. Peral Rubio, M.D.
Department of Dermatology
Hospital Universitario Virgen Macarena,
Seville, Spain.
www.dermatoblog.com
2. Subcutaneus Nodules on the abdomen
A 30-year-old woman presents with
multiple asymptomatic subcutaneous
nodules, round-to-oval, well-defined,
smooth-surfaced, yellow to skin-colored.
5-10 mm diameter firm papules scattered
on the abdomen.
The lesions have been present for about
10 years.
3.
4.
5. Subcutaneus Nodules on the abdomen
Biopsy specimens shows well-
encapsulated dermal cysts with infolded
walls lined by stratified squamous
epithelium without a granular layer.
Sebaceous gland lobules are found within
the cyst wall.
6. Subcutaneus Nodules on the
abdomen.
What is your diagnosis?
F. Peral Rubio, M.D.
Department of Dermatology
Hospital Universitario Virgen Macarena, Seville,
Spain.
www.dermatoblog.com
7. hospital with asymptomatic subcutaneous nodules
on her forearms. She first noticed the subcutaneous
nodules 10 years previously, and they had gradually
increased in both size and number. They were not associated
with any pain or tenderness. Her family history
and past clinical history were unremarkable. Physical
examination revealed multiple, mobile, well-defined,
elastic-hard, 5–10 mm subcutaneous nodules on the
flexor surface of the forearms; 8 on the right and 3 on
the left (Fig. 1). There were no other lesions except for
the forearms and no nail changes. Clinically, the lesions
were initially thought to be multiple lipomas and an
excisional biopsy was performed to confirm the suspected
diagnosis. Upon biopsy, a well-circumscribed
ovoid cyst was isolated in the superficial subcutaneous
fat layer. The cyst contained yellow creamy material.
Biopsy specimen showed a well-encapsulated subcutaneous
cyst with infolded walls lined by squamous
epithelium without a granular layer. Sebaceous gland
lobules are found within the cyst wall (Fig. 2). From
these findings, the diagnosis of SM was finally made.
8. Fig. 2. Histopathological features. Well-
encapsulated subcutaneous cysts with
infolded walls lined by stratified squamous
epithelium without a granular
layer (haematoxylin-eosin (H&E) stain;
original magnification, ×10). Inset
shows sebaceous gland lobules within the
cyst wall. (H&E stain; original
9. DISCUSSION
This case of SM is unique due to (i) its acral distribution
and (ii) presentation as subcutaneous nodules. SM
can appear anywhere on the body but is more common
in areas where the pilosebaceous apparatus is well
developed, such as the trunk, neck, axilla, inguinal
region, scalp and the proximal extremities. Acral SM,
which involves the extremities more prominent than
the trunk, is rare and has been described in only 2 reports
(1, 2). Chu (1) reported a 25-year-old man with
a 20-year history of asymptomatic nodules on the arms
and chest, which showed findings consistent with SM
upon histopathological analysis. The patient had no
family history and no nail changes like in pachonychia
congenita (PC). Rollins et al. (2) reported a 32-yearold
Filipino woman with an 8-year history of multiple
cystic nodules on the distal upper and lower extremities.
The patient’s family history was insignificant, and she
had no changes in the nails. With regard to the depth
of the lesion, steatocystoma is thought to result from a
hamartomatous malformation of the pilosebaceous duct
junction and is usually located in the mid-dermis (3).
In our case, the lesions were palpated as subcutaneous
nodules mimicking multiple lipomas, which is not a
well-described presentation in textbook SM references.
Dermatologists should be aware of that SM may present
as acral subcutaneous nodules.
Covello et al. (4) reported that keratin 17 mutations
commonly underlie both PC type-2 and SM, however,
10. they could not find a correlation between genotype and
phenotype. Furthermore, they could not detect any keratin
17 mutations in sporadic cases of SM (4). These
observations suggest a multifactorial basis, including
both genetic and environmental factors, for this disease.
The reason why our case exhibited an acral distribution
and presentation as subcutaneous nodules is not understood,
but a combination of genetic factors including
keratin 17 abnormalities, other keratin defects and/or
environmental factors, may be involved in the unique
clinical appearance.
REFERENCES
1. Chu DH. Steatocystoma multiplex. Dermatol Online J 2003;
9: 18.
2. Rollins T, Levin RM, Heymann WR. Acral steatocystoma
multiplex. J Am Acad Dermatol 2000; 43: 396–399.
3. Sabater-Marco V, Perez-Ferriols A. Steatocystoma multiplex
with smooth muscle. A hamartoma of the pilosebaceous
apparatus. Am J Dermatopathol 1996; 18: 548–550.
4. Covello SP, Smith FJ, Sillevis Smitt JH, Paller AS, Munro
CS, Jonkman MF, et al. Keratin 17 mutations cause either
steatocystoma multiplex or pachyonychia congenita type 2.
Br J Dermatol 1998; 139: 475–480.
Acta
11. A 70-year-old man presents with multiple asymptomatic,
round-to-oval, well-defined, smooth-surfaced, yellow to
skin-colored, 5-11-mm diameter firm papules scattered
on the scalp; the lesions have been present for about 30
years (Fig. 1). There are no similar lesions on the other
parts of the body. The smaller papules are skin-colored
and, when punctured, discharge a clear or milky, oily
liquid (Fig. 2). The larger lesions are yellow and, when
punctured, discharge a yellow, creamy-to-cheesy
material (Fig. 3). On examination, he also has Hamilton
type VIII androgenetic alopecia. There is no history of
erythema, tenderness, or infection of the lesions. There
is no family history of similar lesions.
12. Biopsy specimens shows well-encapsulated dermal
cysts with infolded walls lined by stratified squamous
epithelium without a granular layer. Sebaceous gland
lobules are found within the cyst wall. The smaller, skin-
colored lesions have atrophic walls with from two to five
layers of flat epithelial cells and empty lumina. The
larger, yellow lesions have from three to five layers of
cuboidal epithelial cells with a thin layer of crenulated,
eosinophilic material on the luminal surface and a little
eosinophilic horny material in some parts of the lumen
(Fig. 4). No connection between the cyst walls and
overlying epidermis is found in the serial sections.
13. In contrast with the typical steatocystoma multiplex patients, lesions are
limited to the scalp in our case. There have been only a few cases with such
a limited distribution [4 6, 9, 10] Table 1 presents a review of the English-
language literature of the published cases of localized forms of
steatocystoma multiplex. In the reported cases of localized steatocystoma
multiplex, the lesions are confined to the head and neck or genitalia. The
terms facial papular variant of steatocystoma multiplex and
sebocystomatosis have been used to describe some of these localized
forms as distinctive variants of the disease [3, 11, 12]. However,
involvement of these areas is not infrequent in typical cases of
steatocystoma multiplex [1]. There are reports of the cases with
steatocystoma multiplex involving predominantly the face or head and neck
with scattered lesions on the trunk [13]. The pathological and clinical
features of the localized forms are not different from typical cases.
Therefore, we believe that the localized forms of steatocystoma multiplex
are not distinctive variants of the disease. Steatocystoma multiplex should
be considered as a spectrum with different variations in anatomical
distribution.
14. A 21-year-old male presented with a 1-year history of multiple dark bumps
on his chest and abdomen since his deployment to Kuwait. These lesions
were itchy and became worse in hot climates but did not worsen in cooler
temperatures. An allergic reaction to his dog tag necklace was deemed less
likely because the affected area persisted and grew larger after removal of
the presumed antigen. Treatment with over-the-counter acne medications
did not help.
Physical examination revealed multiple bluish-black superficial and deep
subcutaneous papules in clusters on the chest (Fig. 1). The clinical
differential diagnosis was comedonal acne and SM. A biopsy specimen
showed cyst without cyst contents and sebaceous glands within and close to
the cyst wall (Fig. 2). The cyst wall was composed of stratified squamous
epithelium without a granular layer, and a thick, homogenous, eosinophilic
layer protruding towards the cyst lumen (Fig. 3).
An empty cyst with sebaceous lobules within and close to the cyst wall. (H &
E, original magnification
The cyst wall shows squamous epithelium without a granular layer, a
sebaceous lobule within the cyst wall and an eosinophilic thick horny layer.
(H & E, original magnification × 100).