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Bristol
Medico-Chirurgical
Journal,
February
1986
Eruptive
vellus
hair
cysts
C.
E.
H.
Grattan
MB,
BChir,
MRCP.
and
R. R.
M.
Harman
MB,
BS,
FRCP.
Department
of
Dermatology,
Bristol
Royal
Infirmary,
Bristol,
BS2
8HW.
SUMMARY
A
case
of
sporadic
eruptive
vellus
hair
cysts
occurring
in
a
young
Chinese
woman
is
described.
Many
of the
le-
sions
had
an
unusual
and
distinctive
dark
blue
discol-
ouration.
Resolution,
by
spontaneous
discharge
of
the
encysted
vellus
hairs to
the
surface,
was
observed.
INTRODUCTION
Eruptive
vellus
hair
cysts
were
first
reported
by
Esterly,
Fretzin
and
Pinkus
in
1977.
They
described
two
children
who
developed
asymptomatic
papular
eruptions
over
the chest
and
mentioned
two
other
cases,
also
children,
who
presented
after
submission of the
original
manu-
script.
Histology
revealed
a
mid-dermal
cyst
lined
by
squamous
epithelium
containing
keratinous
material
and
vellus
hairs.
Lee,
Kim
and
Kang
(1984)
have
recently
reported
11
cases
from
Korea
and
have
reviewed the
literature.
Typically
multiple
flesh-coloured,
red
or
dark
brown
papules
erupt
on
presternal
skin,
although
other
sites
may
be
affected.
The
condition
occurs
in
both
sexes
but
appears
to
be
confined
to
children
and
young
adults.
An
autosomal
dominant
pattern
of inheritance
has
been
recorded
in
two
kindreds
(Piepkorn,
Clark
and
Lombardi,
1981;
Stiefler
and
Bergfeld,
1980).
Burns
and
Calnan
(1981)
described
a
case
in
a
Negro
but there
have
been
no
reports
of
this
condition
in
the
Chinese.
CASE
REPORT
A
20
year
old
Chinese
woman
presented
with
multiple
asymptomatic
papules,
measuring
1
to 3
mm
in
dia-
meter,
concentrated
on
the
presternal
and
inframam-
mary
skin
(Figure
1).
Scattered
lesions
were
also
present
on
her
abdomen
and
lumbosacral
area.
She
had
noticed
them
several
years
earlier
but
only
sought
medical
advice
when
they
increased
in
number
and
depth
of
pigmentation.
No
other
member
of her
family
was
affected.
The
papules
varied
from
the
normal
skin
colour
to
deep
blue
and
were
palpable
as
tiny
hard
intradermal
papules
with
some
similarity
to
epidermal
cysts
or
closed
comedones.
Histology
of
a
lesion
from
the lumbo-
sacral
area
showed
a
typical
mid-dermal
cyst
lined
with
squamous
epithelium
containing
vellus
hair
shafts
(Fi-
gure
2).
Hair bulb
remnants
and
appendigeal
structures
were
not
identified
on
serial
sections.
Spontaneous
im-
provement
occurred
over
several
months.
Tufts of
inter-
woven
fine
pigmented
hairs
were
observed
by
the pa-
tient
to
extrude
on
to the skin surface
when
the
cysts
ruptured.
The
hairs
were
easily
extracted
and
did
not
recur.
DISCUSSION
Bovenmyer
(1979)
observed
communication
of a
cyst
with the skin
surface
and
postulated
that the
contents
had
been
expelled
by
a
process
similar
to
transepithelial
elimination,
which
occurs
in
pathological
states
such
as
elastosis
perforans
serpiginosa,
perforating
folliculitis
Figure
1
Multiple
papules
on
presternal
skin
Figure
1
Multiple
papules
on
presternal
skin.
Figure
2
Cross-section
of
mid-dermal
cyst
showing
squamous
epithelial
lining
and
vellus
hair
shafts.
(Haematoxylin
and
Eosinx204).
Figure
2
Cross-section
of
mid-dermal
cyst
showing
squamous
epithelial
lining
and
vellus
hair
shafts.
(Haematoxylin
and
Eosinx204).
10
Bristol
Medico-Chirurgical
Journal,
February
1986
and
reactive
perforating
collagenosis
(Mehregan,
1970).
Mihara
(1984)
demonstrated
that
elastic
fibres
are
elimin-
ated
through
regenerated
epidermis
of
human
skin
using
histochemical,
immunofluorescent
and
electron
micros-
copic
techniques.
No
abnormality
was
detected
in
the
elastic
fibres
but
it
appeared
that
lymphocytes
and
his-
tiocytes
were
playing
an
important
role
in
their
recogni-
tion
and
removal.
As
Bovenmyer
has
shown
that
vellus
hairs
may
penetrate
a
cyst
wall
it
is
possible
that the
presence
of
this
foreign
material
in
the
dermis
triggers
rejection
of the
cyst
by
a
similar
process.
Unfortunately
we
were
not
able to
examine
an
extruding
cyst
histologi-
cally
as
our
patient
declined
further
biopsies.
However,
there
is
little
doubt
that the
cyst
contents
were
being
discharged
from
her
clear
description
of the
hair
tufts
which
appeared
as
the lesions resolved.
The
striking
blue
pigmentation
may
have
been
due
to
the
melanin
content
of the
encysted
vellus
hairs
in
the
mid
and
deep
dermis.
It
is
likely
that
this
physical
sign
would
not
be
seen
in
a
fair-haired
Caucasian
or
a
Negro
skin
as
it
would
require
both
a
darkly
pigmented
hair
and
a
light
skin
to be
apparent.
Although
the condition
has
been
described
only
once
before
in
the
British
medical
literature
(Burns
et
al.,
1981)
it
may
be
more
common
in
young
people
than
has
been
recognised.
The
asymptomatic
and
benign
nature
of
the
condition,
together
with the
tendency
towards
spon-
taneous
resolution,
no
doubt
deter
all
but the
most
determined
from
seeking
a
specialist
opinion
and
the
dearth of
textbook
references
hinder
the
clinician
from
making
the
correct
diagnosis.
ACKNOWLEDGEMENT
We
thank
J
W
B
Bradfield,
Consultant
Histopathologist,
Bristol
Royal
Infirmary,
for
preparation
of the
histology.
REFERENCES
BOVENMYER,
D.
A.
(1979)
Eruptive
vellus
hair
cysts.
Archives
of
Dermatology,
115,
338-339.
BURNS,
D. A. and
CALNAN,
C. D.
(1981)
Eruptive
vellus
hair
cysts.
Clinical
and
Experimental
Dermatology,
6,
209-213.
ESTERLY,
N.
B.,
FRETZIN, D.
F.
and
PINKUS,
H.
(1977)
Eruptive
vellus
hair
cysts.
Archives
of
Dermatology,
113,
500-503.
LEE,
S.,
KIM,
J-G.
and
KANG,
J.
S.
(1984)
Eruptive
vellus
hair
cysts.
Archives
of
Dermatology,
120,
1191-1195.
MEHREGAN,
A. H.
Transepithelial
elimination.
Current
Prob-
lems
in
Dermatology,
Basel,
Switzerland,
S.
Karger,
1970,
3,
124-147.
MIHARA,
M.
(1984)
Transepithelial
elimination
of
elastic
fibres
in
the
regenerated
human
epidermis.
British
Journal
of Der-
matology,
110,
No.
5,
547-554.
PIEPKORN,
M.
W.,
CLARK,
L.
and LOMBARDI, D.
L.
(1981)
A
kindred
with
congenital
vellus
hair
cysts.
Journal
of
the
Amer-
ican
Academy
of
Dermatology,
5,
661-665.
STIEFLER,
R.
E.
and
BERGFELD,
W.
F.
(1980)
Eruptive
vellus
hair
cysts?an
inherited disorder.
Journal of the
American
Academy
of
Dermatology,
3,
425-429.
