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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 214-216

Trichilemmal cyst of eyelid: A case report and review of literature

1 Ophthalmic Plastic Surgery and Ocular Oncology Services, The Operation Eyesight Universal Institute for Eye Cancer, LV Prasad Eye Institute, Vijayawada, Andhra Pradesh, India
2 Ophthalmic Pathology Laboratory, LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission07-Apr-2021
Date of Acceptance31-Jul-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Kavya M Bejjanki
The Operation Eyesight Universal Institute for Eye Cancer, Ophthalmic Plastic Surgery and Ocular Oncology Services, LV Prasad Eye Institute, Vijayawada, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_783_21

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Trichilemmal cyst is a rare benign tumor of the skin, with distinct keratinisation and a predilection for the scalp. In the eyelid, these benign hair follicle lesions clinically mimic chalazion and recurrences occur with incomplete removal of cyst wall. To the best of authors' knowledge, only 7 cases of eyelid trichilemmal cysts have been described in English literature. Herein, we report a case of a 56-year-old lady with a nodule on the upper eyelid, with typical clinical features and characteristic histopathological findings aiding the diagnosis of trichilemmal cyst. Complete resection was performed to prevent recurrence. The authors also reviewed the cases of eyelid trichilemmal cyst reported in literature to highlight the demography, clinical features, and management of this rare eyelid tumor.

Keywords: Chalazion, eye cancer, eyelid cyst, pilosebaceous follicle, trichilemmal cyst

How to cite this article:
Bejjanki KM, Mishra DK, Kapoor AG. Trichilemmal cyst of eyelid: A case report and review of literature. Indian J Ophthalmol Case Rep 2022;2:214-6

How to cite this URL:
Bejjanki KM, Mishra DK, Kapoor AG. Trichilemmal cyst of eyelid: A case report and review of literature. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 16];2:214-6. Available from: https://www.ijoreports.in/text.asp?2022/2/1/214/334979

Cysts of eyelid skin adnexae are of wide spectrum in origin, arising from epidermal appendages such as sweat glands, sebaceous glands, and hair follicles with varied distribution. Trichilemmal cyst, also called pilar cyst, is one of the eyelid cysts that arises from the outer root sheath of hair follicles. These cysts commonly affect the hair-bearing region of the body with eyelid involvement being extremely rare. To the best of the author's knowledge, till date, only 7 cases have been reported in the literature.[1],[2],[3],[4],[5],[6] It is often misdiagnosed as chalazion with incomplete removal, leading to recurrences. Complete excision of the cyst is the treatment of choice. Histopathological examination is essential for confirming the diagnosis.[2] Herein, we report a rare case of trichilemmal cyst arising from the eyelid and review the relevant literature.

  Case Report Top

A 56-year-old lady presented with slowly progressive painless swelling of the left upper eyelid of 1-year duration. She was diagnosed as chalazion elsewhere, for which conservative management was given. The lesion was persistent with a gradual increase in size. There was no history of similar lesions elsewhere in the body or any other significant family history. On clinical examination, there was a firm immobile nontender nodule on the left upper eyelid (10 × 7 × 5 mm) fixed to the underlying tarsus [Figure 1]a with an overlying nevus of (3 × 2 × 1 mm) [Figure 1]b. Eversion of the eyelid revealed a translucent region in tarsus corresponding to the lesion. The meibomian gland orifices along the eyelid margin were healthy and normal. The rest of ocular examination and right eye was normal. The patient underwent excision biopsy of the lesion. Histopathological evaluation revealed a cyst that is surrounded by fibrocollagenous tissue and lined by stratified squamous epithelium without keratohyalin granules. These lining epithelial cells have abundant eosinophilic cytoplasm with trichilemmal keratinization [Figure 1]c and [Figure 1]d, which suggest trichilemmal cyst. There was no recurrence after a follow-up of 6 months.
Figure 1: (a): Clinical image showing a 10 × 7 × 3 mm3 size nodular mass with mild drooping of the lateral part of the left upper eyelid. (b): Magnified clinical photograph in downgaze showing nevus overlying the nodule. (c): Photomicrograph shows a cyst (marked with black arrow) surrounded by fibrocollagenous tissue (Hematoxylin and Eosin stain, 20×). (d): Photomicrograph showed cyst wall lined by stratified squamous epithelium with trichilemmal keratinization (black arrow) and there were no keratohyalin granules (Hematoxylin and Eosin stain, 400×)

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  Discussion Top

Trichilemmal cysts are pilosebaceous follicular cysts involving mostly the hairy regions of the body, with the scalp being the most common location.[7] It is rarely seen in the eyelids. Historically, these cysts were referred to the common name of wen.[8] For many years, they were considered as sebaceous or epidermoid cysts until Pinkus introduced the term “trichilemmal” for the outer sheath of the hair root in 1969 and “trichilemmal cyst” as a more appropriate designation. Later, Maurer further strengthened this by describing the mode of keratinization in the middle portion of the hair root sheath in 1985.[9]

A review of English literature revealed 7 cases of eyelid trichilemmal cysts [Table 1]. The mean age of presentation of all these cases was 54 years, with male preponderance (two cases being female). The duration of presentation ranged 1–10 years. Clinically, eyelid trichilemmal cyst presents as an asymptomatic, well-defined, nontender unilateral solitary nodule of the eyelid. The upper eyelid is the most common location. These cysts are usually immobile and fixed to the tarsus. However, freely mobile eyelid cyst has been reported by Karuppannan et al. in 2009.[1] The skin over the lesion has always been reported as normal, in contrast to the present case, where an overlying nevus was noted probably as a coincidental association. Ma et al. reported concomitant polycystic eyelid disease in a patient with prolactinoma.[5] Trichilemmal cysts masquerade as chalazion or epidermal cyst. All these cysts described in the eyelid are solitary, chronic in nature, whereas chalazion can be multiple with acute to subacute presentation. On eversion of the eyelid with trichilemmal cyst, translucent area is found in the present case with normal meibomian gland orifices, whereas in chalazion, dilated meibomian gland with diffused inspissation of yellowish material from the eyelid margin orifices are seen. The adjoining meibomian glands are normal in trichilemmal cysts while chronic inflammation is noted in chalazion secondary to leakage of sebaceous secretions [Table 2].[10],[11]
Table 1: Review of literature of trichilemmal cyst

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Table 2: Differentiating features between trichilemmal cyst and chalazion

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One of the patients reported in the literature had undergone multiple surgeries for chalazion before presentation, but the lesion recurred due to incomplete removal of the cyst wall and the contents leading to recollection of the keratinous material in the cyst cavity.[2] The majority of the patients underwent excisional biopsy of the cyst with no recurrences noted over a follow-up duration of 2–18 months.[1],[2],[3],[4],[5] It was a coincidental finding in post-mortem analysis of the eyelid of one patient with acquired immunodeficiency syndrome.[6]

It is important to distinguish these cysts from other benign eyelid lesions, and histopathological examination is mandatory to confirm the diagnosis. Approximately 20% of epithelial cysts are trichilemmal cysts and 80% are epidermal cysts.[10] On histopathological examination, these cysts exhibit stratified squamous epithelium lining without a granular layer. In cysts having breach or with metaplastic process, a granular layer may be noted. The inner layer of the cyst is lined by pale, corrugated cells, and the lumen is composed of pink, dense, homogeneous keratin with or without focal calcification [Table 1].[11] Trichilemmal cysts are essentially benign, though proliferating changes and malignant tumors have been reported.[12],[13],[14],[15]

  Conclusion Top

In conclusion, trichilemmal cyst is a solitary benign nodular lesion, rarely involving the eyelid. It is chronic in nature with normal meibomian gland orifices and complete excision is the treatment of choice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Karuppannan B, Shaharuddin B, Zunaina E. Trichilemmal cyst in the eyelid: A rare presentation. Int J Ophthalmol 2009;9:1451-2.  Back to cited text no. 1
Meena M, Mittal R, Saha D. Trichilemmal cyst of the eyelid: Masquerading as recurrent chalazion. Case Rep Ophthalmol Med 2012;261414.  Back to cited text no. 2
Anita P, Nandita C, Saita. Giant solitary trichilemmal cyst of the upper eye lid: Masquerading lacrimal gland tumor: A clinicoradio pathological case report. JOJ Ophthal 2017;4:555633. doi: 10.19080/JOJO.2017.04.555633.  Back to cited text no. 3
Suimon Y, Kase S, Ishijima K, Kanno-Okada H, Ishida S. Clinicopathological features of cystic lesions in the eyelid. Biomed Rep 2019;10:92-6.  Back to cited text no. 4
Ma L, Jakobiec FA, Wolkow N, Dryja TP, Borodic GE. Multiple eyelid cysts (Apocrine and eccrine hidrocystomas, trichilemmal cyst, and hybrid cyst) in a patient with a prolactinoma. Ophthalmic Plast Reconstr Surg 2018;34:83-5.  Back to cited text no. 5
Pecorella I, Ciardi A, Maedsco A, Di Tondo U. Histological findings in the eyelids of AIDS patients. Acta Ophthalmol Scand 1999;77:564-7.  Back to cited text no. 6
Adachi N, Yamashita T. Trichilemmal cyst of the scalp: MR imaging. AJR Am J Roentgenol 1990;154:423-4.  Back to cited text no. 7
Perrez LM, Bruce JW, Murrah VA. Trichilemmal cyst of the upper lip. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:58-60.  Back to cited text no. 8
Pinkus H. “Sebaceous cysts” are trichilemmal cysts. Arch Dermatol 1969;99:544-55.  Back to cited text no. 9
Butovich IA. Lipidomics of human meibomian gland secretions: Chemistry, biophysics, and physiological role of meibomian lipids. Prog Lipid Res 2011;50:278-301.  Back to cited text no. 10
Ozdal PC, Codere F, Callejo S, Caissie AL, Burnier MN. Accuracy of the clinical diagnosis of chalazion. Eye 2004;18:135-8.  Back to cited text no. 11
Satyaprakash AK, Sheehan DJ, Sangueza OP. Proliferating trichilemmal tumors: A review of the literature. Dermatol Surg 2007;9:1102-8.  Back to cited text no. 12
Leppard BJ, Sanderson KV. The natural history of trichilemmal cysts. Br J Dermatol 1976;4:379-90.  Back to cited text no. 13
Kang SJ, Wojno TH, Grossniklaus HE. Proliferating trichilemmal cyst of the eyelid. Am J Ophthalmol 2007;143:1065-7.  Back to cited text no. 14
Lee SJ, Choi KH, Han JH, Kim YD. Malignant proliferating trichilemmal tumor of the lower eyelid. Ophthal Plast Reconstr Surg 2005;21:349-52.  Back to cited text no. 15


  [Figure 1]

  [Table 1], [Table 2]


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