Multiple trichoepitheliomas: A rare occurrence
A 52-year-old male reported with the chief complaint of multiple growths on the face for 25 years. On examination multiple dome shaped growths of varying sizes from 5 mm to 2 cm, soft to firm in consistency, non tender, non indurated were observed. In addition the patient had multiple brownish black pigmentations on the hands and back [Figure -]. No other contributory medical history was reported by the patient. The patient was moderately built and vital signs were within the clinically acceptable range. With the above features a clinical differential diagnosis of neurofibromatosis was considered. Two lesions, one from region lateral to the left ala of the nose and one lesion from above the right eyebrow, were excised. The gross specimen was 1.2 × 1 × 1 cm in size and brownish black in color []. Histopathological examination of the lesion revealed cystic areas that consist of central keratinaceous material surrounded by basophilic cells resembling basal cell carcinoma []. Tumor islands composed basaloid cells showing peripheral palisading arranged in solid islands, adenoid and lace-like pattern, surrounded by a moderately cellular stroma and condensation of mesenchymal cells around tumor islands in some areas [] Cystic areas contain keratin surrounded by basophilic cells and proliferations from the wall of the horn cyst [Figure and ]. Due to the varying histopathological features of the specimens obtained during the initial biopsy procedure, surgical excision of the lesions located on the right eyebrow and forehead region were carried out []. The gross specimens which measured approximately 1 × 1 × 0.5 cm contained cheesy material within [Figures and ]. Histopathological examination of the lesion on the eyebrow revealed solid areas resembling basal cell epithelioma with cribriform pattern [Figures and ] and central melanin pigmentation []. Whereas hisopathological examination of the lesion on the forehead revealed central keratin filled cystic areas, lined by stratified squamous epithelium with cells with eosinophilic cytoplasm and a vesicular nuclei, basal cells with hyperchromatic nuclei and a granular layer []. Cord-like proliferation of basaloid cells was seen in one area of the lining [Figures and ]. Based on the above histopathological findings a diagnosis of multiple trichoepithelioma was made.\nDifferential diagnosis considered in this case were TE, Trichofolliculoma and basal cell carcinoma (BCC). Trichofolliculoma represents aborted and disrupted attempt at follicle formation, which commonly affects adults and presents as a solitary lesion on the face. Usually a dome-shaped nodule showing a central pore with wool like tuft of immature, usually white hair is highly diagnostic. The present case presented multiple lesions and none showed the central pore with immature hair and hence the diagnosis of trichofolliculoma was ruled out.\nBCC may show similar features but the characteristic retraction artifact seen in BCC was absent and the presence of papillary–mesenchymal bodies, which is characteristic of TE was seen in the present case.