CLINICAL A man with an itchy auricular mass lesion Yang Ho Lee, Kang Duk Suh, a large cystic follicle lined by squamous Question 4 Seog-Kyun Mun epithelium were found in the biopsy specimen (Figure 2). The follicles were What other differential diagnoses surrounded by a well-circumscribed should be considered in this case? dense stroma. The secondary follicles CASE showed various stages of differentiation, Question 5 A man aged 47 years presented with a six- and an inner and outer root sheath was month history of an itchy and enlarging seen. In the inner root sheath, a darkly What diagnostic tests need to be mass on his left auricle. The patient staining eosinophilic trichohyaline considered to confirm the diagnosis? remembered that the itching sensation granule was observed (Figure 3). first began about six months earlier and Question 6 the mass had enlarged gradually over the last two months. He did not recall Question 1 What treatment is required for this any trauma or piercing history at the diagnosis? site prior to the onset of the lesion. The What is the most likely diagnosis? patient had no past medical history, had Answer 1 never been exposed to toxic substances Question 2 and had not experienced any excessive This case shows characteristics of sun exposures. On physical examination, How does the diagnosed condition trichofolliculoma, a rare adnexal tumour there was a 2 x 1.5 cm flesh-coloured hard typically present? that shows follicular differentiation and mass with a smooth surface and central occurs solitarily on the face or scalp. It is pore on the antihelix of the patient’s left Question 3 usually considered to be a benign tumour, auricle (Figure 1). In order to confirm but there is one report of perineural the diagnosis, skin biopsy was done. Which demographic does this condition invasion of trichofolliculoma.1 All stages Numerous small follicles radiating from usually affect? of follicular differentiation may be seen Figure 1. A solitary 1.5 cm well-demarcated Figure 2. The central dilated primary hair Figure 3. The secondary hair follicles show an skin-coloured mass in the left auricle follicle is filled with keratin, and secondary hair outer and inner root sheath with eosinophilic follicles are radiating from this primary hair trichohyaline granules (H&E, x100) follicle (H&E, x40) © The Royal Australian College of General Practitioners 2018 REPRINTED FROM AJGP VOL. 47, NO. 11, NOVEMBER 2018 | 785 CLINICAL AN ITCHY AURICULAR MASS LESION in the lesion, and it shows differentiation Keloid Kang Duk Suh MD, Department of • Otorhinolaryngology – Head and Neck Surgery, College of middle stage trichoepithelioma, in The clinical features of keloid are a of Medicine, Chung-Ang University, Seoul, Korea which the hair follicle nevus and follicular flat, sharply margined, red or brown Seog-Kyun Mun MD, PhD, Department of maturation are not seen.2 elevation caused by proliferation of Otorhinolaryngology – Head and Neck Surgery, College of Medicine, Chung-Ang University, Seoul, connective tissue following an injury.5 Korea. [email protected] Answer 2 No pre-existing scar was present in Competing interests: None. this patient. Funding: None. In clinical findings, trichofolliculoma Provenance and peer review: Not commissioned, externally peer reviewed. is variable in size, with a hard, dome- • Chondroma shaped, skin-coloured papule. In typical Histologically, a well-circumscribed References trichofolliculoma lesions, a central pore tumour with lobules of mature 1. Mizutani H, Senga K, Ueda M. Trichofolliculoma with a whitish immature hair is observed, chondrocytes or chondroblasts of the upper lip: Report of a case. Int J Oral which has diagnostic value.3 In some surrounded by hyaline matrix is seen.6 Maxillofac Surg 1999;28(2):135–36. 2. Wu YH. Folliculosebaceous cystic hamartoma or cases, sebum or similar materials are trichofolliculoma? A spectrum of hamartomatous secreted from the central pore. There • Dilated pore of Winer changes inducted by perifollicular stroma in the follicular epithelium. J Cutan Pathol are generally no subjective or systemic This condition is similar to 2008;35(9):843–48. doi: 10.1111/j.1600- symptoms, but the patient in this case trichofolliculoma in that they both 0560.2007.00914.x. complained of an itching sensation.4 This contain cystic spaces filled with 3. Misago N, Kimura T, Toda S, Mori T, Narisawa Y. A revaluation of trichofolliculoma: The symptom is probably caused by continuous keratin and are formed by squamous histopathological and immunohistochemical stimulation to the skin lesion caused by the epithelium formed from the epidermis. features. Am J Dermatopathol 2010;32(1):35–43. loss of immature hair. However, in a dilated pore of Winer, doi: 10.1097/DAD.0b013e3181a77414. 4. Lim P, Kossard S. Trichofolliculoma with mucinosis. proliferation of the follicle epithelium Am J Dermatopathol 2009;31(4):405–06. Answer 3 into adjacent tissue is less severe and doi: 10.1097/DAD.0b013e3181a09960. shows finger-shaped proliferation.2 5. Shimizu H. Benign skin tumors. In: Shimizu’s textbook of dermatology. Japan: Department of Trichofolliculoma may occur at any age Dermatology Hokkaido University, 2006; p. 439–80. 1 but typically affects adults. • Pilar sheath acanthoma 6. Podder D, Monappa V, Shetty P. Soft tissue This condition also shows cystic spaces chondroma: A rare tumor presenting as a cutaneous nodule. New Zealand: Our Dermatology Answer 4 filled with keratin and squamous Online/Nasza Dermatologia Online, 2015. epithelium from epidermis, but it shows 7. Srivastava RN, Ajwani KD. Trichofolliculoma. Ear As there were no significant findings a low level of differentiation. Hair shaft Nose Throat J 1979;58(4):159–60. involving skin problems in other locations, in the cyst is not seen, and it rarely 8. O’Mahony JJ. Trichofolliculoma of the external auditory meatus. Report of a case and a review of differential diagnoses should include the involves fibrovascular proliferation of the literature. J Laryngol Otol 1981;95(6):623–25. following. adjacent tissues.3 • Epidermal cyst Answer 5 These cysts are elastic but firm, with a surface colour of normal skin or a light Biopsy should be considered to confirm blue and a black punctate opening at the the diagnosis and exclude other conditions centre. They are asymptomatic. When such as epidermal cyst, soft fibroma, pressed after excision, the cyst exudes chondroma. a putrid-smelling, white, gruel-like discharge, which was not seen in this Answer 6 particular case. Pathologically, the wall of the cyst has the same structure as Simple excision is recommended for normal epidermis. However, instead of treatment, although there have been reports the horny cell layer, there are gruel-like, of recurrence after surgery.7 However, layered keratinous contents.5 as there have been reports of tumour cell invasion into surrounding nerves, • Soft fibroma histological confirmation must be made. In The primary condition of soft fibroma cases where invasion has been confirmed, is proliferation of collagen bundles radical excision must be considered.8 with few fibroblasts. In soft fibroma, fat cells are contained in tumours in many Authors 5 Yang Ho Lee MD, Department of Otorhinolaryngology cases. There were no collagen bundles – Head and Neck Surgery, College of Medicine, with fibroblasts in this case. Chung-Ang University, Seoul, Korea correspondence [email protected] 786 | REPRINTED FROM AJGP VOL. 47, NO. 11, NOVEMBER 2018 © The Royal Australian College of General Practitioners 2018.