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Year : 2020  |  Volume : 11  |  Issue : 2  |  Page : 253-255  

Trichilemmoma coexisting with sebaceous nevus

Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India

Date of Web Publication9-Mar-2020

Correspondence Address:
Angoori G Rao
F12, B8, HIG-2, APHB, Baghlingampally, Hyderabad - 500 044, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/idoj.IDOJ_91_19

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How to cite this article:
Rao AG, Reddy VS, Tejal M, Divya M. Trichilemmoma coexisting with sebaceous nevus. Indian Dermatol Online J 2020;11:253-5

How to cite this URL:
Rao AG, Reddy VS, Tejal M, Divya M. Trichilemmoma coexisting with sebaceous nevus. Indian Dermatol Online J [serial online] 2020 [cited 2020 Jul 8];11:253-5. Available from: http://www.idoj.in/text.asp?2020/11/2/253/276594


A 42-year-old male was presented with asymptomatic plaque over the scalp since childhood which had been growing very slowly. Examination revealed single well-defined skin colored, verrucous, non-tender plaque of size 3 × 4 cm over scalp with a hyperpigmented verrucous nodule over it. [Figure 1] The oral and genital examination was non-contributory. Systemic examination was unremarkable. Sebaceous nevus was the considered diagnosis and verrucous epidermal nevus and wart were entertained in the differential diagnosis. Routine hematological, biochemical investigations, thyroid profile revealed normal study. Serology for human immunodeficiency virus (HIV) was non-reactive. The lesion was totally excised and was subjected to the histopathological examination which revealed hyperkeratosis, acanthosis, focal prominence of granular layer and well-defined collection of tumor cells in the dermis with peripheral palisading. The tumor cells were more vacuolated at basal areas. Few sebaceous structures and squamous eddies were also visible consistent with the diagnosis of Trichilemmoma with a sebaceous nevus. There was no evidence of other benign or malignant changes [Figure 2], [Figure 3], [Figure 4].
Figure 1: (Original) Well-defined skin-coloured plaque over the scalp with a hyperpigmented verrucous nodule

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Figure 2: (Original) Histopathology of excision biopsy showing hyperkeratosis, acanthosis, focal prominence of granular layer. Well-defined collection tumor cells in the dermis. Few sebaceous structures are also seen. (H and E, ×100)

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Figure 3: (Original) Histopathology of excision biopsy. Peripheral palisading is notable. (H and E, ×400)

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Figure 4: (Original) Histopathology of excision biopsy. Vacuolated tumor cells with thick hyaline cuticle. (H and E, ×400)

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Trichilemmoma is a benign solid tumor first described by Headington in 1962. It originates from external sheath cells of pilosebaceous follicles and characteristically presents as smooth or verrucous asymptomatic papules of 1-1.5 mm size over neck and face.[1] The cause of trichilemmoma is unknown; however, Schaller et al. demonstrated human papilloma virus (HPV) in the lesional biopsies by the polymerase chain reaction (PCR) validating the cause.[2] Histopathological differential diagnosis of Trichilemmoma include clear cell basal cell carcinoma (BCC) and warts. Clear cell BCC shows mucinous stroma, mitosis and absence of eosinophilic hyalinised cuticle, whereas in warts there is marked hyperkeratosis, hypergranulosis, koilocytes and absence of eosinophilic hyalinised cuticle. The tricholemmoma in the index case is an isolated hamartoma and not a component of Cowden's disease (multiple hamartoma syndrome) as the trichilemmoma is single and there is no clinical evidence of oral fibromas, gastrointestinal polyposis or goiter which are the usual accompaniments of Cowden's disease. Nevus Sebaceus (NS) was first described by Josef Jadassohn in 1895. It is a congenital cutaneous hamartoma comprising of epidermal, dermal, follicular, and apocrine appendages and was found to be caused by postzygotic HRAS or KRAS mutations.[3] NS develops in three distinct stages; the first one is characterized by papillomatous hyperplasia and immature hair follicles and occurs in childhood. The second stage begins at puberty under the influence of sex hormones, characterized by verrucous hyperplasia. In the third stage, there is benign or malignant transformation. It usually affects the scalp and face. Prevalence of benign and malignant neoplasias arising in a nevus sebaceous is 5%-6%. Nonetheless, Chun et al. reported a prevalence of benign and malignant neoplasias in 8.5% in their retrospective study of 450 cases of nevus sebaceous.[4] Most common among them were trichoblastoma, syringocystadenoma papilliferum, and BCC. Development of trichilemmoma from NS in the index case is noteworthy. Similarly, Jardim et al. documented a case of desmoplastic trichilemmoma associated with a NS.[5] Furthermore, Gozel et al. reported six neoplasias including a syringocystadenoma papilliferum, pigmented trichoblastoma, tubular apocrine adenoma, sebaceoma, tumor of the follicular infundibulum and superficial epithelioma with sebaceous differentiation arising in a long-standing NS on the scalp in a 70-year-old man.[6] Additionally, a case of trichilemmoma, desmoplastic trichilemmoma and BCC arising from NS was reported by Lee et al.[7] [Table 1] Available treatment options for trichilemmoma and NS range from simple surgical excision to carbon dioxide laser tissue ablation. However, carbon dioxide laser has the advantage of precise tissue ablation with minimal morbidity and multiple lesions can be treated easily.
Table 1: (Original) Coexistence of Trichilemmoma with various skin tumors

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   References Top

Headington JT, French AJ. Primary neoplasms of the hair follicle. Histogenesis and classification. Arch Dermatol 1962;86:430-41.  Back to cited text no. 1
Schaller J, Rohwedder A, Burgdorf WH, Itin PH, Lautenschlager S. Identification of human papillomavirus DNA in cutaneous lesions of Cowden syndrome. Dermatology 2003;207:134-40.  Back to cited text no. 2
Tsai JH, Huang WC, Jhuang JY, Jeng YM, Cheng ML, Chiu HY, et al. Frequent activating HRAS mutations in trichilemmoma. Br J Dermatol 2014;171:1073-7.  Back to cited text no. 3
Ming-Chun HSU, Liua JY, Hong JL, Cheng Y, Liao YH, Chen JS, et al. Secondary neoplasms arising from nevus sebaceus: A retrospective study of 450 cases. Taiwan J Dermatol 2016;43:175-80.  Back to cited text no. 4
Jardim MML, Bruno de Castro S, Fraga RC, Fraga RC. Rare desmoplastic trichilemmoma associated with sebaceous nevus. Ann Bras Dermatol 2017;92:836-7.  Back to cited text no. 5
Gozel S, Donmez M, Akdur NC, Yikilkan H. Development of six tumors in a sebaceous nevus of Jadassohn: Report of a case. Korean J Pathol 2013;47:569-74.  Back to cited text no. 6
Lee CA, Kang SJ, Jeon SP, Sun H, Kang MS. Simultaneous development of three different neoplasms trichilemmoma, desmoplastic trichilemmoma and basal cell carcinoma arising from nevus sebaceus. Arch Craniofac Surg 2017;18:46-9.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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