I found a strange histologic finding of acantholytic dyskeratosis in the lining epithelium of epidermal inclusion cyst, which is more commonly found in acantholytic dermatitis such as Darier's disease, Warty dyskeratoma etc.
I found this pathologic feature might suggest a diagnosis of familial dyskeratotic comedons or something like that. But there is no familial tendency in this patient (30yrs-old male) but only a few histories that he got surgical removals of epidermal inclusion cysts over a period from another site of his body.
Is there any other disease that I should differential diagnose in this case?
Thank you for such precious and impressive histological pictures. I often found these cells in epidermal cysts by Quick Tzanck test for herpes simplex viral （ＨＳＶ） infection.
Ｉｔｓ ｒｅｌａｔｉｏｎｓｈｉｐ ｗｉｔｈ Ｄａｒｉｅｒ‘ｓ ｄｉｓｅａｓｅ ｉｓ ｄｉｓｃｕｓｓｅｄ ｉｎ ｏｎｅ ｏｆ ｍｙ ｐａｐｅｒｓ．
Ｐｌｅａｓｅ ｃｏｎｓｕｌｔ：Considerable Remission after Continuous Oral Antiviral Therapy in Darier's Disease: Two Sisters. WebmedCentral VIROLOGY 2012;3(12):WMC003883 doi: 10.9754/journal.wmc.2012.003883
Ｔｈｅｓｅ acntholytic ｄｙｓｋｅｒａｔｏｔｉｃ ｃｅｌｌｓ ａｒｅ ｒｅｓｕｌｔｅｄ ｆｒｏｍ ｂａｌｌｏｏｎ ｄｅｇｅｎｅｒａｔｉｏｎ ｏｆ ＨＳＶ infection． Ｉｆ ｔｈｅ Quick Tzanck test is positive, the patient will respond to anti-viral agents. I suppose this is an excision tissue, the patient do not need further medication.
The Quick Tzanck test can be applied easily as bed-side cytologic examination. Please see below WS for its usage in other skin diseases.
http:// limitlessly.weebly.com/
Might also think about Verrucous cysts? Not perfect for it:
http://dx.doi.org/10.5858/arpa.2011-0381-CR
Those are not findings of either HSV infection or verrucous cyst. What you saw are focal suprabasal acantholysis in an epidermal cyst. You can also see corps ronds and grains there. It's uncommon but not rare. You can make the diagnosis of epidermal cyst with focal suprabasal acantholysis (features of warty dyskeratoma) or hybrid cyst (epidermal cyst and warty dyskeratoma) according to the whole pattern. It may also represent an early stage of warty dyskeratoma.
Thank you for your kind answer, Dr. Wu.
I agree with your opinion.
Would you mind if I ask you for a reference that I can look into a little more?
Any article or case report?
Thank you in advance.
It's interesting that I can't find a good reference article for you. I did a search in our database. There are two or three similar cases that have been recorded within 10,000 removed cysts in our system. It seems to be a rare condition instead of uncommon.
More or less apparent dyskeratosis could uncommonly be visible in epidermal cysts. However I have seen a very interesting case longtime ago (I must verify if I published or if I only presented it in a couple of lectures). A lady with Darier disease had multiple epitelial cysts on her face and all had prominenet dyskeratosis. Her son had only minimal unapparent lesions but also one single cyst with prominent dyskeratosis. Your pictures look really very similar to my case. Very interesting. Best regards to all of you
Dear Prof. Mascaro,
Isn't the case you experienced long time ago a case of familial dyskeratotic comedones or warty dyskeratoma? If I found multiple (more than just a few) lesions with similar feature, I would definitely concern the possibility of familial dyskeratotic comedones. I think I can exclude familial dyskeratotic comedones by relatively small number of the lesions and warty dyskeratoma by formation of perfectly inclusive cyst rather than follicular involvement.
Thank you for sharing your experience though, professor.
I would definitely like to see your case if possible.
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