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Dome-Shaped White Papules on the Earlobe
Dome-Shaped White Papules on the Earlobe
THE DIAGNOSIS: Trichodiscoma
Histologic evaluation revealed an unremarkable epidermal surface and a subjacent well-demarcated superficial dermal nodule showing a proliferation, sometimes fascicular, of wavy and spindled fibroblasts with some stellate forms within a variably loose fibrous stroma. Some angioplasia and vascular ectasia also were seen (Figure). A diagnosis of trichodiscoma was made based on these histologic findings.
While the patient’s personal and family history of pneumothorax originally had been attributed to other causes, the diagnosis of trichodiscoma raised suspicion for Birt-Hogg-Dubé syndrome due to the classic association of skin lesions (often trichodiscomas), renal cell carcinoma, and spontaneous pneumothorax in this condition. The patient was sent for genetic testing for the associated folliculin (FLCN) gene, which was positive and thereby confirmed the diagnosis of Birt-Hogg-Dubé syndrome. At the most recent follow-up almost 2 years after initial presentation, the lesions on the earlobe were stable. The patient has since undergone screening for abdominal and renal neoplasia with negative results, and he has had no other occurrences of pneumothorax.
Our case highlights the association between trichodiscomas and Birt-Hogg-Dubé syndrome, which necessitates screening for renal cell carcinoma, pneumothorax, and lung cysts.1 Birt-Hogg-Dubé syndrome is an autosomal- dominant disorder of the skin and lungs that is characterized by a predisposition for renal carcinoma, pneumothorax, and colon polyps as well as cutaneous markers that include fibrofolliculomas, acrochordons, and trichodiscomas; the trichodiscomas tend to manifest as numerous smooth, flesh-colored or grayish-white papules on the face, ears, neck, and/or upper trunk.1
Trichodiscomas are benign lesions and do not require treatment2; however, if they are cosmetically bothersome to the patient, surgical excision is an option for single lesions. For more widespread cutaneous disease, combination therapy with a CO2 laser and erbium-doped yttrium aluminum garnet laser may be utilized.3 The differential diagnosis for trichodiscoma includes basal cell carcinoma, fibrous papule, dermal nevus, and trichofolliculoma.
Basal cell carcinoma is the most common type of skin cancer.4 Clinically, it typically manifests as pink or flesh-colored papules on the head or neck, often with overlying ulceration or telangiectasia. Due to its association with chronic sun exposure, the median age of diagnosis for basal cell carcinoma is 68 years. Histopathologically, basal cell carcinoma is characterized by islands or nests of atypical basaloid cells with palisading cells at the periphery.4 Treatment depends on the location and size of the lesion, but Mohs micrographic surgery is the most common intervention on the face and ears.5
In contrast, fibrous papules are benign lesions that manifest clinically as small, firm, flesh-colored papules that most commonly are found on the nose.6,7 On dermatopathology, classic findings include fibrovascular proliferation and scattered multinucleated triangular or stellate cells in the upper dermis.7 Due to the benign nature of the lesion, treatment is not required6; however, shave excision, electrodessication, and laser therapies can be attempted if the patient chooses to pursue treatment.8
Dermal nevus is a type of benign acquired melanocytic nevus that manifests clinically as a light-brown to flesh-colored, dome-shaped or papillomatous papule.9 It typically develops in areas that are exposed to the sun, including the face.10 There also have been cases of dermal nevi on the ear.11 Histopathology shows melanocytic nevus cells that have completely detached from the epidermis and are located entirely in the dermis.12 While dermal nevi are benign and treatment is not necessary, surgical excision is an option for patients who request removal.13
Trichofolliculoma is a benign tumor of the adnexa that shows follicular differentiation on histopathology.14 On physical examination, it manifests as an isolated flesh-colored papule or nodule with a central pore from which tufted hairs protrude. These lesions usually appear on the face or scalp and occur more commonly in women than in men. While these may be clinically indistinguishable from trichodiscomas, the absence of protruding hair in our patient’s case makes trichofolliculoma less likely. When biopsied, histopathology classically shows a cystically dilated hair follicle with keratinous material and several mature and immature branched follicular structures. Preferred treatment for trichofolliculomas is surgical excision, and recurrence is rare.14
- Toro JR, Glenn G, Duray P, et al. Birt-Hogg-Dubé syndrome: a novel marker of kidney neoplasia. Arch Dermatol. 1999;135:1195-202. doi:10.1001/archderm.135.10.1195
- Tong Y, Coda AB, Schneider JA, et al. Familial multiple trichodiscomas: case report and concise review. Cureus. 2017;9:E1596. doi:10.7759/cureus.1596
- Riley J, Athalye L, Tran D, et al. Concomitant fibrofolliculoma and trichodiscoma on the abdomen. Cutis. 2018;102:E30-E32.
- McDaniel B, Badri T, Steele RB. Basal cell carcinoma. StatPearls [Internet]. Updated March 13, 2024. Accessed December 19, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482439/
- Bittner GC, Kubo EM, Fantini BC, et al. Auricular reconstruction after Mohs micrographic surgery: analysis of 101 cases. An Bras Dermatol. 2021;96:408-415. doi:10.1016/j.abd.2020.12.008
- Damman J, Biswas A. Fibrous papule: a histopathologic review. Am J Dermatopathol. 2018;40:551-560. doi:10.1097/DAD.0000000000001083
- Jacyk WK, Rütten A, Requena L. Fibrous papule of the face with granular cells. Dermatology. 2008;216:56-59. doi:10.1159/000109359
- Macri A, Kwan E, Tanner LS. Cutaneous angiofibroma. StatPearls [Internet]. Updated July 19, 2024. Accessed December 19, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482470/
- Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103. doi:10.2147/CCID.S57782
- Conforti C, Giuffrida R, Agozzino M, et al. Basal cell carcinoma and dermal nevi of the face: comparison of localization and dermatoscopic features. Int J Dermatol. 2021;60:996-1002. doi:10.1111/ijd.15554
- Alves RV, Brandão FH, Aquino JE, et al. Intradermal melanocytic nevus of the external auditory canal. Braz J Otorhinolaryngol. 2005;71:104-106. doi: 10.1016/s1808-8694(15)31295-7
- Muradia I, Khunger N, Yadav AK. A clinical, dermoscopic, and histopathological analysis of common acquired melanocytic nevi in skin of color. J Clin Aesthet Dermatol. 2022;15:41-51.
- Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103. doi:10.2147/CCID.S57782
- Massara B, Sellami K, Graja S, et al. Trichofolliculoma: a case series. J Clin Aesthet Dermatol. 2023;16:41-43.
THE DIAGNOSIS: Trichodiscoma
Histologic evaluation revealed an unremarkable epidermal surface and a subjacent well-demarcated superficial dermal nodule showing a proliferation, sometimes fascicular, of wavy and spindled fibroblasts with some stellate forms within a variably loose fibrous stroma. Some angioplasia and vascular ectasia also were seen (Figure). A diagnosis of trichodiscoma was made based on these histologic findings.
While the patient’s personal and family history of pneumothorax originally had been attributed to other causes, the diagnosis of trichodiscoma raised suspicion for Birt-Hogg-Dubé syndrome due to the classic association of skin lesions (often trichodiscomas), renal cell carcinoma, and spontaneous pneumothorax in this condition. The patient was sent for genetic testing for the associated folliculin (FLCN) gene, which was positive and thereby confirmed the diagnosis of Birt-Hogg-Dubé syndrome. At the most recent follow-up almost 2 years after initial presentation, the lesions on the earlobe were stable. The patient has since undergone screening for abdominal and renal neoplasia with negative results, and he has had no other occurrences of pneumothorax.
Our case highlights the association between trichodiscomas and Birt-Hogg-Dubé syndrome, which necessitates screening for renal cell carcinoma, pneumothorax, and lung cysts.1 Birt-Hogg-Dubé syndrome is an autosomal- dominant disorder of the skin and lungs that is characterized by a predisposition for renal carcinoma, pneumothorax, and colon polyps as well as cutaneous markers that include fibrofolliculomas, acrochordons, and trichodiscomas; the trichodiscomas tend to manifest as numerous smooth, flesh-colored or grayish-white papules on the face, ears, neck, and/or upper trunk.1
Trichodiscomas are benign lesions and do not require treatment2; however, if they are cosmetically bothersome to the patient, surgical excision is an option for single lesions. For more widespread cutaneous disease, combination therapy with a CO2 laser and erbium-doped yttrium aluminum garnet laser may be utilized.3 The differential diagnosis for trichodiscoma includes basal cell carcinoma, fibrous papule, dermal nevus, and trichofolliculoma.
Basal cell carcinoma is the most common type of skin cancer.4 Clinically, it typically manifests as pink or flesh-colored papules on the head or neck, often with overlying ulceration or telangiectasia. Due to its association with chronic sun exposure, the median age of diagnosis for basal cell carcinoma is 68 years. Histopathologically, basal cell carcinoma is characterized by islands or nests of atypical basaloid cells with palisading cells at the periphery.4 Treatment depends on the location and size of the lesion, but Mohs micrographic surgery is the most common intervention on the face and ears.5
In contrast, fibrous papules are benign lesions that manifest clinically as small, firm, flesh-colored papules that most commonly are found on the nose.6,7 On dermatopathology, classic findings include fibrovascular proliferation and scattered multinucleated triangular or stellate cells in the upper dermis.7 Due to the benign nature of the lesion, treatment is not required6; however, shave excision, electrodessication, and laser therapies can be attempted if the patient chooses to pursue treatment.8
Dermal nevus is a type of benign acquired melanocytic nevus that manifests clinically as a light-brown to flesh-colored, dome-shaped or papillomatous papule.9 It typically develops in areas that are exposed to the sun, including the face.10 There also have been cases of dermal nevi on the ear.11 Histopathology shows melanocytic nevus cells that have completely detached from the epidermis and are located entirely in the dermis.12 While dermal nevi are benign and treatment is not necessary, surgical excision is an option for patients who request removal.13
Trichofolliculoma is a benign tumor of the adnexa that shows follicular differentiation on histopathology.14 On physical examination, it manifests as an isolated flesh-colored papule or nodule with a central pore from which tufted hairs protrude. These lesions usually appear on the face or scalp and occur more commonly in women than in men. While these may be clinically indistinguishable from trichodiscomas, the absence of protruding hair in our patient’s case makes trichofolliculoma less likely. When biopsied, histopathology classically shows a cystically dilated hair follicle with keratinous material and several mature and immature branched follicular structures. Preferred treatment for trichofolliculomas is surgical excision, and recurrence is rare.14
THE DIAGNOSIS: Trichodiscoma
Histologic evaluation revealed an unremarkable epidermal surface and a subjacent well-demarcated superficial dermal nodule showing a proliferation, sometimes fascicular, of wavy and spindled fibroblasts with some stellate forms within a variably loose fibrous stroma. Some angioplasia and vascular ectasia also were seen (Figure). A diagnosis of trichodiscoma was made based on these histologic findings.
While the patient’s personal and family history of pneumothorax originally had been attributed to other causes, the diagnosis of trichodiscoma raised suspicion for Birt-Hogg-Dubé syndrome due to the classic association of skin lesions (often trichodiscomas), renal cell carcinoma, and spontaneous pneumothorax in this condition. The patient was sent for genetic testing for the associated folliculin (FLCN) gene, which was positive and thereby confirmed the diagnosis of Birt-Hogg-Dubé syndrome. At the most recent follow-up almost 2 years after initial presentation, the lesions on the earlobe were stable. The patient has since undergone screening for abdominal and renal neoplasia with negative results, and he has had no other occurrences of pneumothorax.
Our case highlights the association between trichodiscomas and Birt-Hogg-Dubé syndrome, which necessitates screening for renal cell carcinoma, pneumothorax, and lung cysts.1 Birt-Hogg-Dubé syndrome is an autosomal- dominant disorder of the skin and lungs that is characterized by a predisposition for renal carcinoma, pneumothorax, and colon polyps as well as cutaneous markers that include fibrofolliculomas, acrochordons, and trichodiscomas; the trichodiscomas tend to manifest as numerous smooth, flesh-colored or grayish-white papules on the face, ears, neck, and/or upper trunk.1
Trichodiscomas are benign lesions and do not require treatment2; however, if they are cosmetically bothersome to the patient, surgical excision is an option for single lesions. For more widespread cutaneous disease, combination therapy with a CO2 laser and erbium-doped yttrium aluminum garnet laser may be utilized.3 The differential diagnosis for trichodiscoma includes basal cell carcinoma, fibrous papule, dermal nevus, and trichofolliculoma.
Basal cell carcinoma is the most common type of skin cancer.4 Clinically, it typically manifests as pink or flesh-colored papules on the head or neck, often with overlying ulceration or telangiectasia. Due to its association with chronic sun exposure, the median age of diagnosis for basal cell carcinoma is 68 years. Histopathologically, basal cell carcinoma is characterized by islands or nests of atypical basaloid cells with palisading cells at the periphery.4 Treatment depends on the location and size of the lesion, but Mohs micrographic surgery is the most common intervention on the face and ears.5
In contrast, fibrous papules are benign lesions that manifest clinically as small, firm, flesh-colored papules that most commonly are found on the nose.6,7 On dermatopathology, classic findings include fibrovascular proliferation and scattered multinucleated triangular or stellate cells in the upper dermis.7 Due to the benign nature of the lesion, treatment is not required6; however, shave excision, electrodessication, and laser therapies can be attempted if the patient chooses to pursue treatment.8
Dermal nevus is a type of benign acquired melanocytic nevus that manifests clinically as a light-brown to flesh-colored, dome-shaped or papillomatous papule.9 It typically develops in areas that are exposed to the sun, including the face.10 There also have been cases of dermal nevi on the ear.11 Histopathology shows melanocytic nevus cells that have completely detached from the epidermis and are located entirely in the dermis.12 While dermal nevi are benign and treatment is not necessary, surgical excision is an option for patients who request removal.13
Trichofolliculoma is a benign tumor of the adnexa that shows follicular differentiation on histopathology.14 On physical examination, it manifests as an isolated flesh-colored papule or nodule with a central pore from which tufted hairs protrude. These lesions usually appear on the face or scalp and occur more commonly in women than in men. While these may be clinically indistinguishable from trichodiscomas, the absence of protruding hair in our patient’s case makes trichofolliculoma less likely. When biopsied, histopathology classically shows a cystically dilated hair follicle with keratinous material and several mature and immature branched follicular structures. Preferred treatment for trichofolliculomas is surgical excision, and recurrence is rare.14
- Toro JR, Glenn G, Duray P, et al. Birt-Hogg-Dubé syndrome: a novel marker of kidney neoplasia. Arch Dermatol. 1999;135:1195-202. doi:10.1001/archderm.135.10.1195
- Tong Y, Coda AB, Schneider JA, et al. Familial multiple trichodiscomas: case report and concise review. Cureus. 2017;9:E1596. doi:10.7759/cureus.1596
- Riley J, Athalye L, Tran D, et al. Concomitant fibrofolliculoma and trichodiscoma on the abdomen. Cutis. 2018;102:E30-E32.
- McDaniel B, Badri T, Steele RB. Basal cell carcinoma. StatPearls [Internet]. Updated March 13, 2024. Accessed December 19, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482439/
- Bittner GC, Kubo EM, Fantini BC, et al. Auricular reconstruction after Mohs micrographic surgery: analysis of 101 cases. An Bras Dermatol. 2021;96:408-415. doi:10.1016/j.abd.2020.12.008
- Damman J, Biswas A. Fibrous papule: a histopathologic review. Am J Dermatopathol. 2018;40:551-560. doi:10.1097/DAD.0000000000001083
- Jacyk WK, Rütten A, Requena L. Fibrous papule of the face with granular cells. Dermatology. 2008;216:56-59. doi:10.1159/000109359
- Macri A, Kwan E, Tanner LS. Cutaneous angiofibroma. StatPearls [Internet]. Updated July 19, 2024. Accessed December 19, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482470/
- Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103. doi:10.2147/CCID.S57782
- Conforti C, Giuffrida R, Agozzino M, et al. Basal cell carcinoma and dermal nevi of the face: comparison of localization and dermatoscopic features. Int J Dermatol. 2021;60:996-1002. doi:10.1111/ijd.15554
- Alves RV, Brandão FH, Aquino JE, et al. Intradermal melanocytic nevus of the external auditory canal. Braz J Otorhinolaryngol. 2005;71:104-106. doi: 10.1016/s1808-8694(15)31295-7
- Muradia I, Khunger N, Yadav AK. A clinical, dermoscopic, and histopathological analysis of common acquired melanocytic nevi in skin of color. J Clin Aesthet Dermatol. 2022;15:41-51.
- Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103. doi:10.2147/CCID.S57782
- Massara B, Sellami K, Graja S, et al. Trichofolliculoma: a case series. J Clin Aesthet Dermatol. 2023;16:41-43.
- Toro JR, Glenn G, Duray P, et al. Birt-Hogg-Dubé syndrome: a novel marker of kidney neoplasia. Arch Dermatol. 1999;135:1195-202. doi:10.1001/archderm.135.10.1195
- Tong Y, Coda AB, Schneider JA, et al. Familial multiple trichodiscomas: case report and concise review. Cureus. 2017;9:E1596. doi:10.7759/cureus.1596
- Riley J, Athalye L, Tran D, et al. Concomitant fibrofolliculoma and trichodiscoma on the abdomen. Cutis. 2018;102:E30-E32.
- McDaniel B, Badri T, Steele RB. Basal cell carcinoma. StatPearls [Internet]. Updated March 13, 2024. Accessed December 19, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482439/
- Bittner GC, Kubo EM, Fantini BC, et al. Auricular reconstruction after Mohs micrographic surgery: analysis of 101 cases. An Bras Dermatol. 2021;96:408-415. doi:10.1016/j.abd.2020.12.008
- Damman J, Biswas A. Fibrous papule: a histopathologic review. Am J Dermatopathol. 2018;40:551-560. doi:10.1097/DAD.0000000000001083
- Jacyk WK, Rütten A, Requena L. Fibrous papule of the face with granular cells. Dermatology. 2008;216:56-59. doi:10.1159/000109359
- Macri A, Kwan E, Tanner LS. Cutaneous angiofibroma. StatPearls [Internet]. Updated July 19, 2024. Accessed December 19, 2024. https://www.ncbi.nlm.nih.gov/books/NBK482470/
- Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103. doi:10.2147/CCID.S57782
- Conforti C, Giuffrida R, Agozzino M, et al. Basal cell carcinoma and dermal nevi of the face: comparison of localization and dermatoscopic features. Int J Dermatol. 2021;60:996-1002. doi:10.1111/ijd.15554
- Alves RV, Brandão FH, Aquino JE, et al. Intradermal melanocytic nevus of the external auditory canal. Braz J Otorhinolaryngol. 2005;71:104-106. doi: 10.1016/s1808-8694(15)31295-7
- Muradia I, Khunger N, Yadav AK. A clinical, dermoscopic, and histopathological analysis of common acquired melanocytic nevi in skin of color. J Clin Aesthet Dermatol. 2022;15:41-51.
- Sardana K, Chakravarty P, Goel K. Optimal management of common acquired melanocytic nevi (moles): current perspectives. Clin Cosmet Investig Dermatol. 2014;7:89-103. doi:10.2147/CCID.S57782
- Massara B, Sellami K, Graja S, et al. Trichofolliculoma: a case series. J Clin Aesthet Dermatol. 2023;16:41-43.
Dome-Shaped White Papules on the Earlobe
Dome-Shaped White Papules on the Earlobe
A 70-year-old man presented to the dermatology clinic for a routine full-body skin examination that revealed multiple asymptomatic, dome-shaped, white papules on the left posterior earlobe. The patient had a personal and family history of spontaneous pneumothorax and no history of cancer. A shave biopsy of one of the papules was performed.
Oval Brown Plaque on the Palm
The Diagnosis: Poroma
Histopathology showed an endophytic expansion of the epidermis by bland, uniform, basaloid epithelial cells with focal ductal differentiation and an abrupt transition with surrounding epidermal keratinocytes (Figure), consistent with a diagnosis of poroma. The patient elected to monitor the lesion rather than to have it excised.
Eccrine poroma, used interchangeably with the term poroma, is a rare benign adnexal tumor of the eccrine sweat glands resulting from proliferation of the acrosyringium.1,2 It often occurs on the palms or soles, though it also can arise anywhere sweat glands are present.1 Eccrine poromas often appear in middle-aged individuals as singular, well-circumscribed, red-brown papules or nodules.3 A characteristic feature is a shallow, cup-shaped depression within the larger papule or nodule.1
Because the condition is benign and often asymptomatic, it can be safely monitored for progression.1 However, if the lesion is symptomatic or located in a sensitive area, complete excision is curative.4 Eccrine poromas can recur, making close monitoring following excision important.5 The development of bleeding, itching, or pain in a previously asymptomatic lesion may indicate possible malignant transformation, which occurs in only 18% of cases.6
The differential diagnosis includes basal cell carcinoma, circumscribed acral hypokeratosis, Kaposi sarcoma, and pyogenic granuloma. Basal cell carcinoma is the most common type of skin cancer.7 In rare cases it has been shown to present on the palms or soles as a slowgrowing, reddish-pink papule or plaque with central ulceration. It typically is asymptomatic. Histopathology shows dermal nests of basaloid cells with peripheral palisading, stromal mucin, and peritumoral clefts. Treatment is surgical excision.7
Circumscribed acral hypokeratosis presents on the palms or soles as a solitary, shallow, well-defined lesion with a flat base and raised border.8 It often is red-pink in color and most frequently occurs in middle-aged women. Although the cause of the condition is unknown, it is thought to be the result of trauma or human papillomavirus infection.8 Biopsy results characteristically show hypokeratosis demarcated by a sharp and frayed cutoff from uninvolved acral skin with discrete hypogranulosis, dilated blood vessels in the papillary dermis, and slightly thickened collagen fibers in the reticular dermis.9 Surgical excision is a potential treatment option, as topical corticosteroids, retinoids, and calcipotriene have not been shown to be effective; spontaneous resolution has been reported.8
Kaposi sarcoma is a vascular neoplasm that is associated with human herpesvirus 8 infection.10 It typically presents on mucocutaneous sites and the lower extremities. Palmar involvement has been reported in rare cases, occurring as a solitary, well-demarcated, violaceous macule or patch that may be painful.10-12 Characteristic histopathologic features include a proliferation in the dermis of slitlike vascular spaces and spindle cell proliferation.13 Treatment options include cryosurgery; pulsed dye laser; and topical, intralesional, or systemic chemotherapy agents, depending on the stage of the patient’s disease. Antiretroviral therapy is indicated for patients with Kaposi sarcoma secondary to AIDS.14
Pyogenic granuloma presents as a solitary red-brown or bluish-black papule or nodule that bleeds easily when manipulated.15 It commonly occurs following trauma, typically on the fingers, feet, and lips.6 Although benign, potential complications include ulceration and blood loss. Pyogenic granulomas can be treated via curettage and cautery, excision, cryosurgery, or pulsed dye laser.15
- Wankhade V, Singh R, Sadhwani V, et al. Eccrine poroma. Indian Dermatol Online J. 2015;6:304-305.
- Yorulmaz A, Aksoy GG, Ozhamam EU. A growing mass under the nail: subungual eccrine poroma. Skin Appendage Disord. 2020;6:254-257.
- Wang Y, Liu M, Zheng Y, et al. Eccrine poroma presented as spindleshaped plaque: a case report. Medicine (Baltimore). 2021;100:E25971. doi:10.1097/MD.0000000000025971
- Sharma M, Singh M, Gupta K, et al. Eccrine poroma of the eyelid. Indian J Ophthalmol. 2020;68:2522.
- Rasool MN, Hawary MB. Benign eccrine poroma in the palm of the hand. Ann Saudi Med. 2004;24:46-47.
- Sawaya JL, Khachemoune A. Poroma: a review of eccrine, apocrine, and malignant forms [published online April 2, 2014]. Int J Dermatol. 2014;53:1053-1061. doi:10.1111/ijd.12448
- López-Sánchez C, Ferguson P, Collgros H. Basal cell carcinoma of the palm: an unusual presentation of a common tumour [published online August 6, 2019]. Australas J Dermatol. 2020;61:69-70. doi:10.1111/ajd.13129
- Berk DR, Böer A, Bauschard FD, et al. Circumscribed acral hypokeratosis [published online April 6, 2007]. J Am Acad Dermatol. 2007;57:292-296. doi:10.1016/j.jaad.2007.02.022
- Majluf-Cáceres P, Vera-Kellet C, González-Bombardiere S. New dermoscopic keys for circumscribed acral hypokeratosis: report of four cases. Dermatol Pract Concept. 2021;11:E2021010. doi:10.5826/dpc.1102a10
- Simonart T, De Dobbeleer G, Stallenberg B. Classic Kaposi’s sarcoma of the palm in a metallurgist: role of iron filings in its development? Br J Dermatol. 2003;148:1061-1063. doi:10.1046/j.1365-2133.2003.05331.x
- Radu O, Pantanowitz L. Kaposi sarcoma. Arch Pathol Lab Med. 2013;137:289-294. doi:10.5858/arpa.2012-0101-RS
- Al Zolibani AA, Al Robaee AA. Primary palmoplantar Kaposi’s sarcoma: an unusual presentation. Skinmed. 2006;5:248-249. doi:10.1111/j.1540-9740.2006.04662.x
- Cesarman E, Damania B, Krown SE, et al. Kaposi sarcoma. Nat Rev Dis Primers. 2019;5:9. doi:10.1038/s41572-019-0060-9
- Etemad SA, Dewan AK. Kaposi sarcoma updates [published online July 10, 2019]. Dermatol Clin. 2019;37:505-517. doi:10.1016/j. det.2019.05.008
- Murthy SC, Nagaraj A. Pyogenic granuloma. Indian Pediatr. 2012;49:855. doi:10.1007/s13312-012-0184-4
The Diagnosis: Poroma
Histopathology showed an endophytic expansion of the epidermis by bland, uniform, basaloid epithelial cells with focal ductal differentiation and an abrupt transition with surrounding epidermal keratinocytes (Figure), consistent with a diagnosis of poroma. The patient elected to monitor the lesion rather than to have it excised.
Eccrine poroma, used interchangeably with the term poroma, is a rare benign adnexal tumor of the eccrine sweat glands resulting from proliferation of the acrosyringium.1,2 It often occurs on the palms or soles, though it also can arise anywhere sweat glands are present.1 Eccrine poromas often appear in middle-aged individuals as singular, well-circumscribed, red-brown papules or nodules.3 A characteristic feature is a shallow, cup-shaped depression within the larger papule or nodule.1
Because the condition is benign and often asymptomatic, it can be safely monitored for progression.1 However, if the lesion is symptomatic or located in a sensitive area, complete excision is curative.4 Eccrine poromas can recur, making close monitoring following excision important.5 The development of bleeding, itching, or pain in a previously asymptomatic lesion may indicate possible malignant transformation, which occurs in only 18% of cases.6
The differential diagnosis includes basal cell carcinoma, circumscribed acral hypokeratosis, Kaposi sarcoma, and pyogenic granuloma. Basal cell carcinoma is the most common type of skin cancer.7 In rare cases it has been shown to present on the palms or soles as a slowgrowing, reddish-pink papule or plaque with central ulceration. It typically is asymptomatic. Histopathology shows dermal nests of basaloid cells with peripheral palisading, stromal mucin, and peritumoral clefts. Treatment is surgical excision.7
Circumscribed acral hypokeratosis presents on the palms or soles as a solitary, shallow, well-defined lesion with a flat base and raised border.8 It often is red-pink in color and most frequently occurs in middle-aged women. Although the cause of the condition is unknown, it is thought to be the result of trauma or human papillomavirus infection.8 Biopsy results characteristically show hypokeratosis demarcated by a sharp and frayed cutoff from uninvolved acral skin with discrete hypogranulosis, dilated blood vessels in the papillary dermis, and slightly thickened collagen fibers in the reticular dermis.9 Surgical excision is a potential treatment option, as topical corticosteroids, retinoids, and calcipotriene have not been shown to be effective; spontaneous resolution has been reported.8
Kaposi sarcoma is a vascular neoplasm that is associated with human herpesvirus 8 infection.10 It typically presents on mucocutaneous sites and the lower extremities. Palmar involvement has been reported in rare cases, occurring as a solitary, well-demarcated, violaceous macule or patch that may be painful.10-12 Characteristic histopathologic features include a proliferation in the dermis of slitlike vascular spaces and spindle cell proliferation.13 Treatment options include cryosurgery; pulsed dye laser; and topical, intralesional, or systemic chemotherapy agents, depending on the stage of the patient’s disease. Antiretroviral therapy is indicated for patients with Kaposi sarcoma secondary to AIDS.14
Pyogenic granuloma presents as a solitary red-brown or bluish-black papule or nodule that bleeds easily when manipulated.15 It commonly occurs following trauma, typically on the fingers, feet, and lips.6 Although benign, potential complications include ulceration and blood loss. Pyogenic granulomas can be treated via curettage and cautery, excision, cryosurgery, or pulsed dye laser.15
The Diagnosis: Poroma
Histopathology showed an endophytic expansion of the epidermis by bland, uniform, basaloid epithelial cells with focal ductal differentiation and an abrupt transition with surrounding epidermal keratinocytes (Figure), consistent with a diagnosis of poroma. The patient elected to monitor the lesion rather than to have it excised.
Eccrine poroma, used interchangeably with the term poroma, is a rare benign adnexal tumor of the eccrine sweat glands resulting from proliferation of the acrosyringium.1,2 It often occurs on the palms or soles, though it also can arise anywhere sweat glands are present.1 Eccrine poromas often appear in middle-aged individuals as singular, well-circumscribed, red-brown papules or nodules.3 A characteristic feature is a shallow, cup-shaped depression within the larger papule or nodule.1
Because the condition is benign and often asymptomatic, it can be safely monitored for progression.1 However, if the lesion is symptomatic or located in a sensitive area, complete excision is curative.4 Eccrine poromas can recur, making close monitoring following excision important.5 The development of bleeding, itching, or pain in a previously asymptomatic lesion may indicate possible malignant transformation, which occurs in only 18% of cases.6
The differential diagnosis includes basal cell carcinoma, circumscribed acral hypokeratosis, Kaposi sarcoma, and pyogenic granuloma. Basal cell carcinoma is the most common type of skin cancer.7 In rare cases it has been shown to present on the palms or soles as a slowgrowing, reddish-pink papule or plaque with central ulceration. It typically is asymptomatic. Histopathology shows dermal nests of basaloid cells with peripheral palisading, stromal mucin, and peritumoral clefts. Treatment is surgical excision.7
Circumscribed acral hypokeratosis presents on the palms or soles as a solitary, shallow, well-defined lesion with a flat base and raised border.8 It often is red-pink in color and most frequently occurs in middle-aged women. Although the cause of the condition is unknown, it is thought to be the result of trauma or human papillomavirus infection.8 Biopsy results characteristically show hypokeratosis demarcated by a sharp and frayed cutoff from uninvolved acral skin with discrete hypogranulosis, dilated blood vessels in the papillary dermis, and slightly thickened collagen fibers in the reticular dermis.9 Surgical excision is a potential treatment option, as topical corticosteroids, retinoids, and calcipotriene have not been shown to be effective; spontaneous resolution has been reported.8
Kaposi sarcoma is a vascular neoplasm that is associated with human herpesvirus 8 infection.10 It typically presents on mucocutaneous sites and the lower extremities. Palmar involvement has been reported in rare cases, occurring as a solitary, well-demarcated, violaceous macule or patch that may be painful.10-12 Characteristic histopathologic features include a proliferation in the dermis of slitlike vascular spaces and spindle cell proliferation.13 Treatment options include cryosurgery; pulsed dye laser; and topical, intralesional, or systemic chemotherapy agents, depending on the stage of the patient’s disease. Antiretroviral therapy is indicated for patients with Kaposi sarcoma secondary to AIDS.14
Pyogenic granuloma presents as a solitary red-brown or bluish-black papule or nodule that bleeds easily when manipulated.15 It commonly occurs following trauma, typically on the fingers, feet, and lips.6 Although benign, potential complications include ulceration and blood loss. Pyogenic granulomas can be treated via curettage and cautery, excision, cryosurgery, or pulsed dye laser.15
- Wankhade V, Singh R, Sadhwani V, et al. Eccrine poroma. Indian Dermatol Online J. 2015;6:304-305.
- Yorulmaz A, Aksoy GG, Ozhamam EU. A growing mass under the nail: subungual eccrine poroma. Skin Appendage Disord. 2020;6:254-257.
- Wang Y, Liu M, Zheng Y, et al. Eccrine poroma presented as spindleshaped plaque: a case report. Medicine (Baltimore). 2021;100:E25971. doi:10.1097/MD.0000000000025971
- Sharma M, Singh M, Gupta K, et al. Eccrine poroma of the eyelid. Indian J Ophthalmol. 2020;68:2522.
- Rasool MN, Hawary MB. Benign eccrine poroma in the palm of the hand. Ann Saudi Med. 2004;24:46-47.
- Sawaya JL, Khachemoune A. Poroma: a review of eccrine, apocrine, and malignant forms [published online April 2, 2014]. Int J Dermatol. 2014;53:1053-1061. doi:10.1111/ijd.12448
- López-Sánchez C, Ferguson P, Collgros H. Basal cell carcinoma of the palm: an unusual presentation of a common tumour [published online August 6, 2019]. Australas J Dermatol. 2020;61:69-70. doi:10.1111/ajd.13129
- Berk DR, Böer A, Bauschard FD, et al. Circumscribed acral hypokeratosis [published online April 6, 2007]. J Am Acad Dermatol. 2007;57:292-296. doi:10.1016/j.jaad.2007.02.022
- Majluf-Cáceres P, Vera-Kellet C, González-Bombardiere S. New dermoscopic keys for circumscribed acral hypokeratosis: report of four cases. Dermatol Pract Concept. 2021;11:E2021010. doi:10.5826/dpc.1102a10
- Simonart T, De Dobbeleer G, Stallenberg B. Classic Kaposi’s sarcoma of the palm in a metallurgist: role of iron filings in its development? Br J Dermatol. 2003;148:1061-1063. doi:10.1046/j.1365-2133.2003.05331.x
- Radu O, Pantanowitz L. Kaposi sarcoma. Arch Pathol Lab Med. 2013;137:289-294. doi:10.5858/arpa.2012-0101-RS
- Al Zolibani AA, Al Robaee AA. Primary palmoplantar Kaposi’s sarcoma: an unusual presentation. Skinmed. 2006;5:248-249. doi:10.1111/j.1540-9740.2006.04662.x
- Cesarman E, Damania B, Krown SE, et al. Kaposi sarcoma. Nat Rev Dis Primers. 2019;5:9. doi:10.1038/s41572-019-0060-9
- Etemad SA, Dewan AK. Kaposi sarcoma updates [published online July 10, 2019]. Dermatol Clin. 2019;37:505-517. doi:10.1016/j. det.2019.05.008
- Murthy SC, Nagaraj A. Pyogenic granuloma. Indian Pediatr. 2012;49:855. doi:10.1007/s13312-012-0184-4
- Wankhade V, Singh R, Sadhwani V, et al. Eccrine poroma. Indian Dermatol Online J. 2015;6:304-305.
- Yorulmaz A, Aksoy GG, Ozhamam EU. A growing mass under the nail: subungual eccrine poroma. Skin Appendage Disord. 2020;6:254-257.
- Wang Y, Liu M, Zheng Y, et al. Eccrine poroma presented as spindleshaped plaque: a case report. Medicine (Baltimore). 2021;100:E25971. doi:10.1097/MD.0000000000025971
- Sharma M, Singh M, Gupta K, et al. Eccrine poroma of the eyelid. Indian J Ophthalmol. 2020;68:2522.
- Rasool MN, Hawary MB. Benign eccrine poroma in the palm of the hand. Ann Saudi Med. 2004;24:46-47.
- Sawaya JL, Khachemoune A. Poroma: a review of eccrine, apocrine, and malignant forms [published online April 2, 2014]. Int J Dermatol. 2014;53:1053-1061. doi:10.1111/ijd.12448
- López-Sánchez C, Ferguson P, Collgros H. Basal cell carcinoma of the palm: an unusual presentation of a common tumour [published online August 6, 2019]. Australas J Dermatol. 2020;61:69-70. doi:10.1111/ajd.13129
- Berk DR, Böer A, Bauschard FD, et al. Circumscribed acral hypokeratosis [published online April 6, 2007]. J Am Acad Dermatol. 2007;57:292-296. doi:10.1016/j.jaad.2007.02.022
- Majluf-Cáceres P, Vera-Kellet C, González-Bombardiere S. New dermoscopic keys for circumscribed acral hypokeratosis: report of four cases. Dermatol Pract Concept. 2021;11:E2021010. doi:10.5826/dpc.1102a10
- Simonart T, De Dobbeleer G, Stallenberg B. Classic Kaposi’s sarcoma of the palm in a metallurgist: role of iron filings in its development? Br J Dermatol. 2003;148:1061-1063. doi:10.1046/j.1365-2133.2003.05331.x
- Radu O, Pantanowitz L. Kaposi sarcoma. Arch Pathol Lab Med. 2013;137:289-294. doi:10.5858/arpa.2012-0101-RS
- Al Zolibani AA, Al Robaee AA. Primary palmoplantar Kaposi’s sarcoma: an unusual presentation. Skinmed. 2006;5:248-249. doi:10.1111/j.1540-9740.2006.04662.x
- Cesarman E, Damania B, Krown SE, et al. Kaposi sarcoma. Nat Rev Dis Primers. 2019;5:9. doi:10.1038/s41572-019-0060-9
- Etemad SA, Dewan AK. Kaposi sarcoma updates [published online July 10, 2019]. Dermatol Clin. 2019;37:505-517. doi:10.1016/j. det.2019.05.008
- Murthy SC, Nagaraj A. Pyogenic granuloma. Indian Pediatr. 2012;49:855. doi:10.1007/s13312-012-0184-4
A 43-year-old woman presented with a painful lesion on the palm of 30 years’ duration that had grown in size. Physical examination revealed an oval, brown, lobulated plaque with a hyperkeratotic rim on the left palm. She reported bleeding and pain. A shallow cup-shaped depression was noted within the plaque. A 4-mm punch biopsy was performed.
