Cutaneous Cysts

Cysts with a lining of stratified squamous epithelium: Epidermoid cyst
Milium
Trichilemmal cyst
Vellus hair cyst
Steatocystoma
Dermoid cyst
Cysts lined with non-stratified squamous epithelium: Hidrocystoma, Eccrine or Apocrine
Cysts without an epithelial lining: Mucocele
Digital mucous cyst
Ganglion

1. CUTANEOUS CYSTS ALLPPT.com _ Free PowerPoint Templates, Diagrams and Charts facebook.com/groups/ dermatologycourseonline

2. Cutaneous Cysts A cyst is a circumscribed dermal or subcutaneous papule or nodule that contains fluid or semi-fluid material, so a cyst is fluctuant . Cysts can be classified by anatomic location (as they may occur in virtually any organ of the body), by embryologic derivation , or by histologic features ( of the cyst lining). True cysts have an epithelial lining that may be composed of stratified squamous epithelium or other forms of epithelia . Some “ cysts ” have no epithelial lining at all ( pseudocysts ).

3. Structure of Hair Follicle

4. Cutaneous Cysts CLASSIFICATION OF CYSTS ACCORDING TO LINING : Cysts with a lining of stratified squamous epithelium Cysts lined with non-stratified squamous epithelium Cysts without an epithelial lining

5. THE THREE MAIN CATEGORIES OF CUTANEOUS CYST STRATIFIED SQUAMOUS EPITHELIUM NON-STRATIFIED SQUAMOUS EPITHELIUM ABSENCE OF EPITHELIUM Epidermoid cyst Milium Trichilemmal cyst Proliferating trichilemmal cyst Proliferating epidermoid cyst Vellus hair cyst Steatocystoma Cutaneous keratocyst Pigmented follicular cyst Dermoid cyst Verrucous cyst Ear pit cyst Pilonidal cyst Hidrocystoma Eccrine Apocrine Bronchogenic cyst Thyroglossal duct cyst Branchial cleft cyst Cutaneous ciliated cyst Ciliated cyst of the vulva Median raphe cyst Omphalomesenteric duct cyst Mucocele Digital mucous cyst Ganglion Pseudocyst of the auricle Cutaneous metaplastic synovial cyst

6. CYSTS LINED WITH STRATIFIED SQUAMOUS EPITHELIUM

7. Epidermoid Cyst

8. Epidermoid Cyst SYNONYMS : Epidermoid inclusion cyst Epidermal cyst Epidermal inclusion cyst Infundibular cyst It is the most common cutaneous cyst. Tiny superficial epidermoid cysts are known as milia .

9. Pathogenesis of Epidermoid Cyst It is derived from the follicular infundibulum . They may be primary , or they may arise from disrupted follicular structures or traumatically implanted epithelium (hence the synonym epidermal “inclusion” cyst ).

10. Epidermoid cyst Typical clinical appearance

11. Epidermoid Cysts

12. Puncti of Epidermoid Cysts Dark color keratin plug overlying cyst cavity tether the cyst to the overlying epidermis

13. Epidermoid Cyst commonly present on the face

14. Epidermoid Cysts yellowish dermal nodules

15. Palpation of Epidermoid Cyst

16. C/P of Epidermoid Cyst These lesions are firm to fluctuant well-demarcated , skin-colored to yellowish mobile dermal nodules , and they may have a clinically visible punctum representing the follicle from which the cyst is derived range from a few millimeters to several centimeters in diameter. These cysts may be flat or flush to the surface of the skin or elevated well above the surface. In either case, they are easily palpable . It can occur anywhere on the skin, but are most common on the face, scalp , post auricular , neck , scrotum and upper trunk . Non-inflamed epidermoid cysts are usually asymptomatic , but, with pressure , cyst contents may be expressed that may have an foul odor .

17. Large sized Epidermal Cyst

18. Epidermal cyst in the epigastric region of > 10 years duration the skin overlying the cyst has been atrophied with some dilated vessels due to the pressure effect produced by the cyst. The punctum in the central part of the cyst is so evident.

19. C/P of Epidermoid Cyst Unlike pilar cysts, the epidermal cyst wall is fairly delicate and thus prone to rupture . Rupture of the cyst wall can result in an intensely painful inflammatory reaction , and this is a common reason for presentation to a physician . Rupture is followed by foreign body reaction to keratin extruded into the dermis and acute inflammation .

20. Inflamed Epidermoid Cyst Such painful inflammatory reactions to cyst rupture are a frequent cause for presentation to a physician

21. C/P of Epidermoid Cyst Development of a BCC or SCC within an epidermoid cyst is a very rare event . Multiple epidermoid cysts may occur in the following settings: Individuals with a history of significant acne vulgaris . Multiple scrotal cysts may lead to scrotal calcinosis via dystrophic calcification. Gardner syndrome (familial adenomatous polyposis). Nevoid BCC syndrome.

22. Multiple Postauricular Epidermoid Cysts

23. Multiple Epidermal Cysts Of The Scrotum

24. Multiple Epidermal Cysts Of The Scrotum

25. HP of Epidermoid Cyst Cystic cavity filled with lamellated keratin lined by a flattened stratified squamous epithelium including a granular layer . A surrounding inflammatory response with both acute and chronic granulomatous inflammation may be seen as evidence of prior rupture and resolves with scarring . In individuals with Gardner syndrome , some cysts show, as a characteristic feature, columns of pilomatricoma -like shadow cells projecting into the cyst cavity .

26. Histopathology of Epidermoid Cyst

27. Histopathology of Epidermoid Cyst

28. Histopathology of Epidermoid Cyst showing the cyst wall lined by stratified squamous epithelium with a granular cell layer ( arrow). The central portion of the cyst is filled with keratinaceous debris (star).

29. Histopathology of Epidermoid Cyst of the scrotum epidermal cyst wall with thin layer of benign stratified squamous epithelium (small solid arrows) and keratinous debris present in cyst (open arrows). Scrotal skin with basal pigmentation (large solid arrows) is also noted.

30. Treatment of Epidermoid Cyst Assurance: Small cysts (e.g. less than 5 mm) don't usually need treatment. Surgical excision: Removal may be accomplished by simple excision , or incision and expression of the cyst contents and wall through the defect . Other techniques of removal include punch biopsy aspiration followed by curettage and avulsion of the cyst wall . If the entire cyst wall is not removed , the cyst may recur . Cysts are more difficult to remove once they have ruptured . Inflamed epidermoid cysts: It is best to avoid surgery while the cyst is actively inflamed due to higher risk of infection, wound dehiscence and cyst recurrence . Following the resolution of the infection, the lesion is excised. Incision and drainage . Antibiotic therapy, occasionally. Intralesional triamcinolone may be helpful in speeding the resolution of the inflammation.

31. Epidermoid Cyst Removal

32. Macroscopic appearance of a resected cyst

33. MILIA

34. Milia They are small epidermoid cysts containing keratin usually multiple and are quite common , occurring in individuals of all ages and both sexes . These harmless cysts present as tiny pearly-white papules. Between 40% and 50% of infants will have milia usually resolve during the 1st four weeks of life while in adults tend to be persistent .

35. C/P of Milia Present as 1–2 mm pearly-white to yellow fixed subepidermal papules . Present most commonly on the face usually on the cheeks , eyelids and forehead .

36. CLINICAL TYPES OF MILIA 1. Primary Milia 2. Secondary Milia 3. Milia En Plaque 4. Neonatal Milia 5. Juvenile Milia 6. Multiple Eruptive Milia - Found on the face especially around eyelids, cheeks, forehead and genitalia - May clear in a few weeks or persist for months or longer. - Following blistering processes or superficial ulceration from trauma, burn or cosmetic procedures. - May also occur in areas of topical drugs e.g. corticosteroid, hydroquinone . - Multiple milia within an erythematous edematous plaque especially in middle-aged women. - Most often occurs in the postauricular area, but may also occur eyelid, cheeks or jaw. - Affect 40-50% of newborns. - Few to multiple. - Often seen on the nose, but may also arise inside the mouth on gum margins (Epstein pearls) or palate (Bohn nodules). - Usually resolve within 1 st four wk. - Persistent widespread milia may be congenital or appear later in life. - Associated with Rombo , basal cell naevus, Gardner, Bazex syndromes and other genetic disorders. - Crops of numerous milia appear over a few weeks to months. - Lesions may be asymptomatic or itchy. - Most often affect face, upper arms and upper trunk.

37. Milia

38. Milia on the Eye Lids

39. Palatal Cyst Of Newborn

40. Gingival Cysts Of Newborn

41. Bilateral Retro-auricular Milia En Plaque

42. Periorbital Bilateral Milia En Plaque

43. Milia en Plaque In a Traumatic Scar

44. Milia Following Bullous Pemphigoid

45. Histopathology of Milia Histologic features are exactly similar to those of a small epidermoid cyst .

46. Treatment of Milia They often clear up spontaneously within a few months . Elective removal for cosmesis . Medical: Topical retinoid: For multiple facial milia, may be helpful in reducing the number of milia and aiding in the ease of removal . Minocycline: may improve milia en plaque . Surgical: Milia may be de-roofed by incising the epidermis over the milium with a needle , scalpel or lancet and expressing the milium (may be aided by the use of a comedo extractor ). They may be destroyed using and curettage , cryotherapy , laser ablation or electrodesiccation .

47. Treatment of Milia Nick the surface with an 11 blade or an 18 gauge needle , then gently express the entire cyst, lining and contents . Dress with a dab of petrolatum.

48. Removal of Milia

49. PILAR ( Trichilemmal) CYST

50. Pilar Cyst Pilar Cysts are usually clinically indistinguishable from epidermoid cysts , but they are fourfold to fivefold less common . They may be inherited as an autosomal dominant trait. More frequent in middle-aged females . 90 % of trichilemmal cysts are located on the scalp . They may be solitary , but frequently they are multiple .

51. C/P of Pilar Cyst May look similar to epidermoid cysts present as one or more firm , mobile , subcutaneous nodules measuring 0.5 to 5 cm in diameter. There is no central punctum , unlike an epidermoid cyst.

52. Pilar Cysts

53. Main Differences Between Pilar Cyst and Epidermoid Cyst EPIDERMOID CYST PILAR CYST Most common site Face, neck, trunk Scalp (90% of pilar cysts), scrotum Central punctum Present Absent Origin Epithelium or hair follicle infundibulum Outer root sheath Cyst wall Delicate and prone to rupture Thick and less prone to rupture Histology Granular layer present Granular layer absent Excision More difficult They deliver themselves through an incision easily without rupture

54. Histopathology of Pilar Cyst Cyst walls lined by stratified squamous epithelial cells that show keratinization that has a palisaded outer layer , analogous to that of the outer root sheath of the hair follicle at the isthmus and the sac surrounding catagen and telogen hairs become swollen and pale close to the cystic cavity and show abrupt keratinization without an intervening granular layer . The cyst contents consist of homogeneous very brightly eosinophilic keratinaceous debris that commonly shows foci of calcification in 25% of cases. A foreign body giant cell response may surround the cyst if prior wall rupture has occurred .

55. Histopathology of Pilar Cyst Wall

56. Histopathology of Pilar Cyst

57. Focal Calcification

58. Treatment of Pilar Cyst Elective excision before rupture prevents scarring. Surgical treatment involves either of the following methods: Enucleation of the cyst. Typically, they “ deliver ” themselves through an incision without rupture more easily than do epidermoid cysts , and, therefore, the distinction between a trichilemmal cyst and an epidermoid cyst can often be correctly made at the time of excision . Incision followed by expression of contents and removal of cyst wall – this is often best achieved with a surgical punch with the cyst expressed through the hole.

59. Vellus Hair Cysts

60. Vellus Hair Cysts Quite rare asymptomatic small , dome-shaped papules . They may be inherited in an autosomal dominant pattern when they occur in early childhood . Sporadic forms tend to develop later in teenage years. Occasionally, solitary cysts are seen. Multiple lesions are known as “ERUPTIVE” VELLUS HAIR CYSTS ( may be seen in conjunction with steatocystoma multiplex or pachyonychia congenita ).

61. Eruptive Vellus Hair Cysts

62. Eruptive Vellus Hair Cysts

63. Eruptive Vellus Hair Cysts

64. C/P of Vellus Hair Cysts They are asymptomatic except for cosmetic concerns . Most commonly present as numerous , small , dome-shaped papules , ranging from skin-colored to darkly pigmented. They may be dimpled or umbilicated . Most commonly located on the trunk especially the anterior chest . Most lesions persist indefinitely .

65. Dx of Vellus Hair Cysts The diagnosis of eruptive vellus hair cysts is often made clinically , because of typical age of onset, the site of the lesions, and their appearance . Incision or puncture of the cyst and examination of the contents under a microscope will reveal the vellus hairs . Skin biopsy may confirm the diagnosis.

66. HP of Vellus Hair Cysts Small cystic structure lined by stratified squamous epithelium with epidermoid keratinization . The cysts contain loose laminated keratin and numerous vellus hairs . A follicle may be found entering the lower portion of the cyst.

67. Histopathology of Vellus Hair Cyst Within the dermis there is a cyst lined by squamous epithelium with a granular layer and containing laminated keratin and numerous vellus hairs.

68. Treatment of Vellus Hair Cysts Medical : Topical retinoic, salicylic acid or lactic acid ( long term). Surgical: Incision and drainage. Needle evacuation. Puncture followed by forceps assisted extraction. Cryotherapy. Laser.

69. Steatocystoma

70. Steatocystoma Steatocystomas occur as: Single ( STEATOCYSTOMA SIMPLEX) or; Multiple ( STEATOCYSTOMA MULTIPLEX ) . Steatocystoma multiplex is rare and can be inherited as an autosomal dominant condition , and is due to mutations in the KRT17 gene . It may occur in association with eruptive vellus hair cysts and pachyonychia congenita . It is due to hamartomatous malformations of the pilosebaceous duct junction.

71. Steatocystoma Multiplex n umerous cystic nodules on the neck

72. Steatocystoma Multiplex

73. Steatocystoma Multiplex A yellow creamy discharge after puncture of a yellow cyst.

74. C/P of Steatocystoma Multiplex They tend to be small ( 2-20 mm ) but they may be several centimetres in diameter and appear as soft to firm semi-translucent cysts in the dermis that drain oily fluid if punctured . They are most numerous on the chest and in the axillae, abdomen, upper arms and groin . There are unusual facial and acral variants as well as a rare congenital linear form. Steatocystomas develop at puberty presumably due to hormonal stimulus of the pilosebaceous unit and persist indefinitely . They are usually asymptomatic except for cosmetic concerns .

75. HP of Steatocystoma Dermal cyst lined by a thin stratified squamous epithelium , without a granular layer and surmounted by a characteristic thin , irregular , corrugated eosinophilic lining ( cuticle) . Small sebaceous lobules are found in or immediately adjacent to the cyst wall .

76. Histopathology of Steatocystoma The cyst wall is characterized by an undulated, thin stratified epithelium lacking a stratum granulosum and lined by an eosinophilic cuticle. A search may be required to identify small sebaceous lobules in or immediately adjacent to the cyst wall (insert)

77. Treatment of Steatocystoma Medical: Oral isotretinoin is not curative but may temporarily shrink the cysts and reduce inflammation. Oral antibiotics ; to reduce the inflammation if present. Surgical: Excision ; If it is tethered to the underlying skin. Incision with removal of the cyst wall; In most cases, small incisions allow the cyst and its contents to be extracted through the opening . Cryotherapy . Electrosurgery . Laser .

78. Dermoid Cyst

79. Dermoid Cyst Cutaneous dermoid cyst typically present in an infant along an embryonic fusion plane as a discrete, subcutaneous nodule . It results from sequestration of ectodermal tissue along embryonic fusion planes during development . Although dermoid cysts are congenital defects and may be recognized at birth, these lesions often escape notice until they become enlarged , infected or inflamed . This typically occurs by early childhood . Dermoid cysts in other parts of the body, such as within the skull , spine or abdominal cavity particularly the ovaries , may present at any time in people of all ages.

80. Common Sites Of Dermoid Cysts

81. Dermoid cyst This dermoid cyst presented in an infant as a firm subcutaneous nodule superior to the lateral left eyebrow.

82. Dermoid Cyst

83. Medial Dermoid Cyst Note the fullness below the head of the right brow. This lesion must be imaged to confirm the diagnosis and to distinguish it from an encephalocoele or mucocele.

84. Dermoid Cyst A subcutaneous mass at the lateral aspect of the right upper eyelid, under the tail of the brow. Note that the overlying skin is not erythematous, edematous or discolored.

85. C/P of Dermoid Cyst Present as firm , non-compressible , non-pulsatile subcutaneous nodules that often reach a size of 1–4 cm in diameter. The lesions usually do not transilluminate . They are most commonly located around the eyes , particularly the lateral eyebrow but may also occur anywhere in the body e.g. nose , scalp (often over the anterior fontanelle or the midline occiput), neck , sternum , sacrum and scrotum . They can be associated with a nearby pit and/or sinus tract to underlying tissues. Dermoid cysts on the nose or midline scalp have a much higher likelihood of intracranial extension than those in a periocular location.

86. HP of Dermoid Cyst Lined by keratinizing stratified squamous epithelium including a granular layer . They contain other normal mature adnexal cutaneous structures such as hair , sebaceous lobules , eccrine glands, apocrine glands , or smooth muscle .

87. Histopathology of Dermoid Cyst The cyst wall demonstrates a hair follicle (arrow), one of the adnexal structures that are commonly found in walls of dermoid cysts. Note the kertinized stratified squamous epithelium lining the cyst.

88. Treatment of Dermoid Cyst Surgical Excision. However , as there may be sinus tract or neural heterotopias , imaging studies may be appropriate prior to excision, to exclude a connection to the CNS .

89. Surgical Excision of Dermoid Cyst Before removal, one week and 1.5 years after removal.

90. CYSTS LINED WITH NON-STRATIFIED SQUAMOUS EPITHELIUM

91. Hidrocystoma

92. Hidrocystoma Hidrocystomas can traditionally divided by histologic features into; APOCRINE HIDROCYSTOMAS ECCRINE HIDROCYSTOMAS Also can divided according to number into; S OLITARY ( S MITH TYPE) MULTIPLE (ROBINSON TYPE) May be due to occlusion or blockage of the sweat duct apparatus , which results in the retention of sweat and a dilated cystic structure.

93. Hidrocystoma Apocrine hidrocystomas are relatively common benign cystic proliferations of the apocrine glands . In general, eccrine hidrocystomas are thought to develop from cystic dilation of eccrine ducts due to retention of eccrine secretions while apocrine hidrocystomas are thought to represent adenomas of apocrine secretory sweat gland coils .

94. Apocrine Hidrocystoma A single, slightly bluish, translucent papule on the lower eyelid near the lateral canthus .

95. Eccrine Hidrocystomas Numerous, tiny, translucent or bluish papules on the lower eyelid (A) or the cheek (B)

96. C/P of Apocrine Hidrocystoma Asymptomatic . No seasonal variation . Appear during adulthood , grow slowly , and usually persist indefinitely . Typically present as skin-colored to bluish and shiny cysts . They are usually solitary soft , dome-shaped , translucent papules or nodules and most frequently are located on the eyelids , especially the inner canthus also head, neck, and trunk. Consistency is fluctuant and cystic . Size varies from a few millimeters to approximately 1.5 cm . Walls, although translucent, are sufficiently thick & tense that they seldom rupture spontaneously.

97. Apocrine Hidrocystoma

98. Giant Multi- loculated Apocrine Hidrocystoma

99. C/P of Eccrine Hidrocystoma Typically present as translucent , clear , skin-colored cysts on the face although they may occur in other sites . May be solitary or multiple and are occasionally quite numerous and usually smaller in size and less bluish than apocrine hidrocystoma. They are associated with seasonal variations can enlarge with heat exposure or during the summer and regress with exposure to cold and winter . They are more frequent in females than in males.

100. Eccrine Hidrocystoma Puncture of a representative lesion with a sterile needle shows exudation of clear fluid

101. Eccrine Hidrocystoma

102. HP of Apocrine Hidrocystoma They are unilocular to multilocular dermal cysts lined by one to several layers of apocrine-type secretory epithelium cuboidal-to columnar that show bulbous protrusions (“ snouting ”) or papillary projections extend from the secretory layer into the cyst cavity representing luminal decapitation secretion . The outer layer of cells composing the cyst wall is formed by myoepithelial cells . Express human milk-fat globulin antigen , while “ true ” eccrine hidrocystomas do not .

103. Histopathology of Apocrine Hidrocystoma Cystic spaces appear empty because sweat is removed during processing . Decapitation secretion often is seen in the lining.

104. HP of Eccrine Hidrocystoma Unilocular cyst containing clear fluid , lined by ductal cells composed of one to two layers of cuboidal to flattened epithelium. Luminal protrusions (" apocrine snouts ") and myoepithelial cells are absent .

105. Histopathology of Eccrine Hidrocystoma

106. Treatment of Hidrocystoma Medical : Topical 1 % atropine in aqueous solution; Multiple eccrine hidrocystomas may be treated with daily application, although lesions reappear within days of discontinuing therapy. Botulinum toxin A injections may be helpful . Surgical : Excision ; punch , scissors , or elliptical . Electrodesiccation ; electrosurgical destruction of the cyst wall with a fine tipped probe often is recommended to prevent recurrence. Cryotherapy . Laser ; CO 2 or pulsed dye laser .

107. CYSTS WITHOUT AN EPITHELIAL LINING

108. Mucocele

109. Mucocele Mucocele are usually the result of trauma in the mouth  disruption of the ducts of minor salivary glands  an accumulation of mucinous material  a reactive inflammatory response , and the development of surrounding lining of granulation tissue.

110. Mucocele

111. Mucocele

112. C/P of Mucocele Mucoceles most frequently develop on the lower labial mucosa ( 75% of cases ), but they also occur on the floor of the mouth , buccal mucosa , and tongue . They appear as smooth , soft , dome-shaped , fluid-filled papules or nodules that are bluish or translucent and range in size from a few millimeters to over a centimeter . Single or multiple but usually single . In most cases of superficial mucocele lesions tend to persist for several days or weeks , rupture spontaneously (usually while eating).

113. HP of Mucocele It shows one or several spaces within the connective tissue filled with mucinous material , but without an epithelial lining . The spaces are surrounded by chronic inflammation , mucin containing macrophages , and granulation tissue . A salivary duct may be seen at the periphery of these findings . Adjacent minor salivary glands may show chronic inflammation and fibrosis . The mucinous material is sialomucin , and the latter contains both neutral and acid mucopolysaccharides , which stain with PAS ( diastase-resistant ) and with Alcian blue or colloidal iron , respectively.

114. Histopathology of Mucocele well-delineated cavity that contains free mucinous material ( blue arrow); this material is characteristic of these entities. The cavity wall lacks an epithelial lining and is considered a pseudocyst. The pseudocyst wall is composed of granulation tissue (red arrow).

115. Histopathology of Mucocele showing granulation tissue with collected mucin and inflammatory cells (A : mucous acini, G: granulation tissue, M: mucin).

116. Treatment of Mucocele Mucoceles may resolve spontaneously especially superficial mucocele and require no specific treatment . If they do not, treatment options include; Intralesional corticosteroid injection Surgical excision Marsupialization Electrodesiccation Cryosurgery Laser ablation e.g. CO2

117. Digital Mucous Cyst

118. Digital Mucous Cyst (Digital myxoid cyst) There appear to be two variations; The first is a form of focal mucinosis , a condition characterized by abnormal deposits of mucins in the skin. It shouldn't be called a cyst as it does not have a surrounding capsule , and is better termed a " pseudocyst ". The other variation arises from extension of the lining of the distal interphalangeal joint space and is due to osteoarthritis – a type of ganglion. A pedicle connecting the cyst to the adjacent joint space can usually be demonstrated.

119. Digital Mucous Cyst

120. Digital Mucous Cyst

121. Digital Mucous Cyst on the Toe

122. C/P of Digital Mucous Cyst Most commonly occur on the dorsal surface of the distal phalanx of the fingers . Toe lesions are less commonly observed. These cysts have smooth shiny surface and skin-colored to bluish and translucent that drain clear gelatinous material when punctured. A characteristic depressed nail deformity may be seen distal to the cyst .

123. Transillumination of a Mucous Cyst A cyst is translucent, so a light shines through it. Note a longitudinal groove in the nail.

124. HP of Digital Mucous Cyst Clefts are seen in the dermis without an epithelial lining . The clefts and the surrounding loose connective tissue contain abundant acid mucopolysaccharides , which can be highlighted by Alcian blue or colloidal iron stains.

125. Treatment of Digital Mucous Cyst Treatments which may be successful include: Repeatedly pressing firmly on the cyst. Intralesional injection of corticosteroids . Sclerosant injection Cryotherapy . Repeated puncture and drainage of a digital mucous cyst leads to resolution in up to 70% of patients. Surgical excision may give even higher success rates. Identification and ligature of the connection to the joint capsule.

126. Ganglion

127. Ganglion (Ganglion cyst/Synovial cyst) Ganglions are among the most common tumors of the hand and wrist . For the most part, they are asymptomatic masses that are primarily cosmetic rather than functional disturbances . Ganglia are frequently attached to a tendon sheath or the joint capsule , but usually do not communicate with the joint space.

128. Ganglion Cyst

129. Ganglion Cyst on The Palmar Side of The Wrist

130. Ganglion cyst in the foot

131. C/P of Ganglion They occur more commonly in women and may cause discomfort with activity , impairment of mobility , or cosmetic concerns. Soft cystic compressible , subcutaneous , transilluminating , and slightly mobile masses up to 4 cm in diameter without associated skin changes that most commonly occur on the dorsal aspect of the wrist ; they may also be found on the volar wrist or fingers , the dorsal aspect of the feet , or the knees .

132. HP of Ganglion Myxoid change is seen within the connective tissue that ultimately forms cystic spaces . These spaces coalesce into a dominant cystic space lined by fibrous tissue sometimes with a synovial lining .

133. Treatment of Ganglion Early lesions may respond to several weeks of compression therapy . Other options include aspiration plus intralesional corticosteroid injection or excision . Recurrences are common , even with excisional therapy.

134. References Bolognia 3 rd ed. dermnetnz.org http:// emedicine.medscape.com http:// www.globalskinatlas.com Google images AAD; Benign Skin Lesions (Presentation) Skin Tumors by Seyed Morteza Mahmoodi (Presentation)