Multiple apocrine hidrocystomas of the eyelids treated with trichloroacetic acid

ARTICLE

Auteur(s) : Akira Shimizu, Atsushi Tamura, Osamu Ishikawa

Department of Dermatology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan

An 83-year-old woman presented in our department with a 10-year history of a symmetrical distribution of translucent cysts on her eyelids (figure 1A). Physical examination revealed multiple translucent cysts on bilateral upper and lower eyelids. A biopsy specimen was removed from the cyst. Histopathological examination revealed a cystic cavity lined by an epithelial wall in the dermis (figure 1B). A high-power view demonstrated that the cavity was lined partly by a double layer of ductal epithelium and partly by a single row of epithelial cells, which were primarily columnar and showed decapitation secretion (figure 1C). From these characteristic clinico-pathological findings, we diagnosed the lesions as multiple apocrine hidrocystomas of the eyelids.

To treat the cysts with TCA, we employed the technique followed by Dailey et al. [1]. The patient was reclined in a supine position. After local anesthesia, a 22-gauge indwelling needle was attached to an empty 5-ml syringe. The contents of the cyst were then aspirated, and the inner needle was withdrawn. A second syringe containing 0.2 mL of 20% TCA, made from TCA solution (Wako Pure Chemical Industries, Osaka, Japan) diluted by distilled water, was attached to the outer tube. The cyst was then refilled with TCA. The walls of the cyst immediately turned white. The TCA remained in the cyst for 1 minute. We modified the treatment time because when we performed TCA treatment for 5 sec as described by Dailey et al., it was too short to see frosting in our case. The cyst contents were then aspirated to collapse the cyst completely. Distilled water was injected into the cyst and then completely aspirated to wash out the remaining TCA. Suction was maintained as the needle was withdrawn to avoid spread of TCA into surrounding tissue. No complications occurred during the procedure. Some small cysts including that of left inner canthus could not be treated. In these cysts the small amount of aspirated fluid was mostly left within the lumen of needle, which prevented us replacing it with TCA. We treated 1 or 2 lesions each time. The intervals ranged from 2 to 6 months. There was at least 2 months to follow-up for each lesion. Examination of the cysts 2 years after the initial treatment revealed that, although some small cysts relapsed or remained, most lesions were either well healed or shrunken (figure 1D).

While multiple apocrine hidrocystomas frequently occur in the periocular region, causing significant disfigurement, few effective treatment modalities have been described. Treatments with 1,450-nm diode laser, carbon dioxide laser, and electrosurgery have been reported to date [2-4]. These treatments were effective for multiple small lesions. However, it is not known whether they would also be effective for large cysts. Treatment of cysts with TCA is technically simpler than surgical excision and can be used for large cysts, which has advantage over other ablation techniques [1]. Even if TCA spreads into the surrounding tissue, skin contact should not represent a hazard to the patient, as the concentration of the TCA is the same as that used during cosmetic chemical peel procedures. On the other hand, Sakai et al. reported that epidermal Langerhans cells from TCA-treated skin were more significantly reduced than those from liquid nitrogen-treated skin. Therefore, when we perform long-term treatment using TCA, we have to take into account potential carcinogenesis [5]. As Kerscher et al. suggested, the practice of cosmetic dermatology requires a knowledge of skin physiology and its responses to exogenous factors [6]. We need more cases to optimize TCA treatment.

Acknowledgements

References

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