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Eccrine Hidrocystoma Successfully Treated with Topical Synthetic Botulinum Peptide Sir, Eccrine hidrocystomas (EHs) are benign cystic lesions of eccrine ducts that are associated with a chronic course and seasonal variations. They are more frequent in females than in males.[1] Solitary EH can be treated easily by surgical excision; however, the treatment of multiple lesions is problematic. We report a case of multiple eccrine hydrocystomas over the face, which responded completely after 4 weeks of treatment with topical Botulinum Toxin (Boxtlak-BL) like preparation. A 60-year-old Indian lady presented with multiple papules over the cheeks since last 5–6 years, which were persistent and aggravated in summer and on exposure to heat. On local examination, there were shiny, translucent papules of 1–3 mm in diameter on the centrofacial area. On puncturing with a disposable needle, clear watery fluid came out. A skin biopsy stained with haematoxylin and eosin showed dilated cystic spaces in upper dermis [Figure 1], which were unilocular and lined by flattened squamous epithelial cells in two layers. There were no myoepithelial cells in the cyst wall. There was no evidence of decapitation secretions in the lining cells.[2] Based on clinical features and histopathology, a diagnosis of multiple EHs was made. The patient was treated with topical Boxtlak-BL twice daily and there was almost complete clearance of lesions after 4 weeks of treatment [Figures 2 and 3 ]. EH is a benign cystic condition of eccrine sweat ducts.[3] The
Figure 1: Dilated unilocular cystic spaces lined by two layers of squamous epithelial cells without any evidence of decapitation secretions, (H and E, ×40)
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aetiopathogenesis is still debatable. Electron microscopy has established that the cyst wall is composed of ductal cells. It is likely that obstruction of eccrine duct leads to retention of sweat causing flattening of the lining cells and cystic dilatation. Treatment of EH is recommended for cosmetic reasons. Different modalities have been proposed with variable results, which include puncture and drainage of the cyst that gives transient improvement with an early recurrence,[4] surgical excision,[4] microdermabrasion and electrodessication with high risk of scarring,[5] pulse dye laser,[6] topical atropine[7] and scopolamine.[8] Recently
Figure 2: Multiple eccrine hydrocystomas over the left cheek before treatment
Figure 3: After 4 weeks of topical treatment with Boxtlak-BL cream
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EH has been treated with botulinum toxin (injectable) with good results.[9] Botulinum toxin (Boxtlak-BL) is a potent neurotoxin that blocks cholinergic nerve terminals. It has been used in the treatment of blepharospasm, strabismus, torticollis, hemifacial spasm and other dystonias.[10] It has also been used in the treatment of hyperhidrosis[11] and facial wrinkles. Boxtlak-BL containing BoNT_L peptide significantly inhibits SNAP-25 (synaptosomeassociated protein of 25 kd)[12] of SNARE complex thereby inhibiting the release of acetylcholine from vesicle within the cytoplasm of the motor nerve endings. The end result is chemodenervation of cholinergic nerves targeting the autonomic control of eccrine sweat glands. We propose topical Botulinum toxin like peptide as a painless, non-invasive, cost-effective and safe technique for the treatment of multiple EH with excellent results.
Vijay Gandhi, Geetanjali Naik, Prashant Verma Departments of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Shahadara, Delhi, India. E-mail:
[email protected]
REFERENCES 1.
Hashimoto K, Lever WF. Tumors of skin appendages. In: Fitzpatrick TB, Eisen AZ, Wolf K Freedberg IM, Austen K. Dermatology in General Medicine. 4th ed. New york: Mc Graw-Hill; 1983. p. 550-1.
2.
Klein W, Chan E, Seykora JT. Tumours of epidermal appendages. In: Eldn DE, editor. Levers histopathology of skin. 9th ed. Philadelphia USA; Lippincott Williams and Wilkins; 2005. p. 867-926. 3. Robinson AR. Hidrocystoma. J Cutan Genitourinary Dis 1893;11: 292-303. 4. Fariña MC, Piqué E, Olivares M, Escalonilla P, Martín L, Requena L, et al. Multiple hidrocystomas of face; Three cases. Clin Exp Dermatol 1995;20:323-7. 5. Blugerman G, Sehavelzon D, D’Angelo S. Multiple eccrine hidrocystomas, A new therapeutic option with Botulinum Toxin. Dermatol Surg 2003;29:557-9. 6. Tanzi E, Alster TS. Pulsed dye laser treatment of multiple eccrine hidrocystomas: A novel approach. Dermatol Surg 2001;27:898-900. 7. Khunger N, Mishra S, Jain RK, Saxena S. Multiple eccrine hidrocystomas. Report of 2 cases treated unsuccessfully with atropine ointment. Indian J Dermatol Venereol Leprol 2004;70:367-9. 8. Clever HW, Shal WJ. Multiple eccrine Hidrocystomas: A nonsurgical treatment. Arch Dermatol 1991;127:422-4. 9. Correia O, Duarte A, Barros A, Rocha N. Multiple Eccrine HidrocystomasFrom Diagnosis to Treatment: The role of Dermatoscopy and Botulinum Toxin: Dermatology 2009;219:77-9. 10. Carruthers A, Carruthers J. History of cosmetic use of Botulinum A exotoxin. Dermatol Surg 1998;24:1168-70. 11. Glogou RG. Use of hyperhidrosis with botulinum toxin. Dermatol Clin 2004;22:177-85,vii. 12. Aoki KR. Pharmacology and immunology of botulinum toxin serotypes. J Neurol 2001;248:3-10. Access this article online Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.85048
Female Genital Cosmetic Surgery Sir, The World Health Organisation’s (WHO) definition of female genital mutilation is, all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural, religious, or other non-therapeutic reasons.[1] Women’s concerns about their appearance, fuelled by commercial pressure for surgical fixes, now include the genitalia. A lot more women are stated to be troubled by the shape, size, or proportions of their vulvas, hence, elective genitoplasty is apparently a demanding cosmetic procedure. The latest survey by the British Association of Aesthetic Plastic Surgeons reported that the staggering 31% increase in the uptake of cosmetic surgery in UK women accounted for 92% of this uptake.[2] The
increased demand for cosmetic genitoplasty may reflect a narrow social definition of normal, or a confusion of what is normal and what is idealised. The provision of genitoplasty could narrow acceptable ranges further and increase the demand for surgery even more. Research involving women with atypical genitalia has shown that clitoral surgery is associated with the inability to reach an orgasm and has emphasised the role of the vulvar epithelium in sensuality and arousability.[3,4] Women who seek cosmetic genital surgery fall into two main categories. First, women with congenital conditions such as intersex for which the current standard practice advises feminizing genitoplasty procedures, with the objective of reducing the clitoral size and opening the vaginal introitus.[5,6] Second, some women with no underlying
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