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Trichilemmoma Clinical Presentation

  • Author: William P Baugh, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jul 24, 2014
 

History

Patients with trichilemmomas usually give a history of a slow-growing, asymptomatic papule and/or plaque on the face. Such lesions may be solitary or multiple. Patients often desire reassurance that they do not have a skin cancer and/or seek an evaluation for cosmetic removal of the lesions.

If presenting in a nevus sebaceous of Jadassohn, a trichilemmoma may appear as a new growth within the lesion. No single feature allows the clinical diagnosis of a trichilemmoma, but rather this diagnosis is usually rendered histologically. However, if multiple lesions are present on the face, trichilemmomas associated with Cowden syndrome may be suspected. Once the diagnosis of trichilemmoma has been given, reevaluating the patient for clinical features of Cowden syndrome may be prudent.

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Physical

Patients with trichilemmomas usually present with either a single papule or multiple, small, flesh-colored papules that are 1-5 mm in diameter on the face or the neck. When these lesions grow in size, small plaques may be found, particularly in the nasolabial fold region. As trichilemmomas slowly enlarge, they often produce a hyperkeratotic surface suggestive of a verruca or a cutaneous horn. Besides the central part of the face, the ears, the forearms, the hands, or within a nevus sebaceous of Jadassohn are other typical sites that are examined for these cutaneous lesions.

If a diagnosis of trichilemmoma is rendered, the patient should be completely examined for evidence of Cowden syndrome. (See images below.) Ten key physical features to look for in establishing the diagnosis of Cowden syndrome include the following:

  • Adenoid facies with facial trichilemmomas
  • Craniomegaly
  • High arched palate
  • Oral papillomas producing a cobblestone appearance on the lips and the mucosal surfaces
  • Goiter or palpable thyroid nodules/tumors
  • Gynecomastia in men
  • Fibrocystic breast disease and/or palpable breast nodules or tumors in women
  • Acral keratoses on the dorsum of the hands and the wrists
  • Palmoplantar translucent punctate keratoses
  • Sclerotic fibromas on the extremities

In 1983, Salem and Steck[16] proposed diagnostic criteria for Cowden syndrome. See Cowden Disease (Multiple Hamartoma Syndrome) for a more definitive discussion in this area.

Clinical image of the face of a patient with Cowde Clinical image of the face of a patient with Cowden syndrome.
Clinical image of the oral mucosa of a patient wit Clinical image of the oral mucosa of a patient with Cowden syndrome.
Clinical image of palmar keratoses in a patient wi Clinical image of palmar keratoses in a patient with Cowden syndrome.
Clinical image of sclerotic fibroma in a patient w Clinical image of sclerotic fibroma in a patient with Cowden syndrome.
Clinical image of multiple trichilemmomas in a pat Clinical image of multiple trichilemmomas in a patient with Cowden syndrome.

Patients with desmoplastic trichilemmomas usually present with lesions less than 1 cm in diameter found predominantly on the face, the neck, the scalp, and, sometimes, on the chest or the vulva. Several reports have described desmoplastic trichilemmomas occurring on the upper eyelid.[17, 18] They may be indurated, with a depressed central region and a raised, annular border. Desmoplastic trichilemmomas, although not associated with Cowden disease, have been described arising from a nevus sebaceous.[2, 19]

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Causes

The cause of a trichilemmoma is unknown. Some researchers have postulated that a virus may induce these lesions because of morphologic and histologic features that they share with a verruca.

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Contributor Information and Disclosures
Author

William P Baugh, MD Assistant Clinical Professor of Dermatology, Western University of Health Sciences; Medical Director, Full Spectrum Dermatology; Consulting Staff, Department of Dermatology, St Jude Medical Center

William P Baugh, MD is a member of the following medical societies: American Academy of Dermatology, American Society for Laser Medicine and Surgery, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Coauthor(s)

David Barnette, Jr, MD Voluntary Associate Clinical Professor, University of California San Diego School of Medicine

David Barnette, Jr, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology

Disclosure: Nothing to disclose.

James H Kerr, MD Former Head (Retired), Department of Dermatology, Naval Medical Center at San Diego

James H Kerr, MD is a member of the following medical societies: American Academy of Dermatology, Pacific Dermatologic Association

Disclosure: Nothing to disclose.

Walter D Kucaba, DO Private Family Practice, Simpsonville, South Carolina

Walter D Kucaba, DO is a member of the following medical societies: Aerospace Medical Association, American Medical Association, American Osteopathic Association, Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Cynthia L Chen, DO, DO Intern, Pacific Hospital of Long Beach, California

Cynthia L Chen, DO, DO is a member of the following medical societies: American Osteopathic Association, California Medical Association, American Osteopathic College of Dermatology, Los Angeles County Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

David P Fivenson, MD Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan

David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Michigan State Medical Society, Society for Investigative Dermatology, Photomedicine Society, Wound Healing Society, Michigan Dermatological Society, Medical Dermatology Society

Disclosure: Nothing to disclose.

References
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A patient with trichilemmoma papules on the face.
Low-power histologic view of a trichilemmoma.
Mid-power histologic view of a trichilemmoma.
Low-power histologic view of a desmoplastic trichilemmoma.
High-power histologic view of a desmoplastic trichilemmoma.
Tumor of the follicular infundibulum.
Clinical image of the face of a patient with Cowden syndrome.
Clinical image of the oral mucosa of a patient with Cowden syndrome.
Clinical image of palmar keratoses in a patient with Cowden syndrome.
Clinical image of sclerotic fibroma in a patient with Cowden syndrome.
Clinical image of multiple trichilemmomas in a patient with Cowden syndrome.
 
 
 
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