Henry Journal of Clinical, Experimental & Cosmetic Dermatology

Background: Widespread asymptomatic papular eruption are common presentation to dermatology clinics. The differential diagnosis is wide and warrants a meticulous physical examination and complete history.

Objectives: Our aim is to differentiate clinically and on histopathology the diffuse eruption of asymptomatic papules that started on the abdomen.

Methods: We report a case of a 35-year-old female patient who presented for evaluation of a widespread asymptomatic papular eruption of about 10 years’ duration. Lesions started appearing on the abdomen, back and upper extremities, then, later on, the lower face and genitalia.

Conclusion: Syringoma is a benign sweat gland tumor formed by well-differentiated ductal elements of the eccrine glands. They are usually bilateral and symmetrically distributed, appearing mostly in crops as in our patient. They are flat topped, small skin colored or yellowish papules less than 3 mm in diameter. Many treatment modalities exist. Reassurance is best for generalized lesions.

Diffuse papular eruption; Eruptive syringoma; Syringomas

Histopathologic examination of one of the lesions revealed on H&E the presence of well-circumscribed, small comma-shaped tubular structures in the superficial dermis. The ducts were lined by two rows of flattened epithelial cells. The tubular structures were also surrounded by thickened collagen bundles. (Figure 3) Laboratory tests were done to rule out metabolic diseases which turned out to be normal. Unfortunately, the patient refused any medical or surgical treatment and she was lost to follow up.

Figure 3: High Power H&E photomicrograph showing tadpole shaped tubules supported by a fibroblastic schirrous stroma.

Syringoma is a benign sweat gland tumor formed by well-differentiated ductal elements of the eccrine glands [1].

Four variants have been recognized: a localized form, a form associated with Down’s syndrome, a familial form and a generalized form that encompasses multiple eruptive Syringomas. The development of syringomas, in crops and in large numbers is called eruptive Syringomas, and this type is a very rare variant of this kind of tumors [2]. The most common sites affected are the neck, axillae, anterior chest, upper abdomen, and periumbilical area [3]. A milium-like globoid structure overlies typical lesions of syringoma and this might be considered as a distinctive variant, reported by Zhong et al, which was the case in our patient.

Dermoscopically, fine pigment network with the typical rosette sign which is characterized by 4 white points arranged as a 4-leaf clover can be considered pathognomonic of this disease [4]. Syringomas affect 1% of the population and females are affected more often than males [2]. Lesions usually first appear at puberty; additional lesions develop later on [1].

They are usually bilateral and symmetrically distributed, appearing mostly in crops as in our patient. They are flat topped, small skin colored or yellowish papules less than 3 mm in diameter. Larger ones, which are the giant Syringomas, are rarely seen and in our patient, giant lesions are seen on the genitalia. They can be associated with pruritus which was absent in our case. They usually spare palms, soles and mucosal surfaces as our case demonstrated.

Eruptive syringomas might be associated with many diseases including Down’s syndrome, milium, elevation of carcinoembryonic antigen, diabetes, psychiatric disorders, Ehler Danlos syndrome, prurigo nodularis and sarcoidosis [5,6]. None of these was found in our patient.

On histopathology, lesions are located in the superficial dermis. They are composed of numerous small ducts in a sclerotic stroma. Some of the ducts have elongated tails of epithelial cells producing a characteristic comma-shaped or tadpole appearance.

In Urticaria Pigmentosa, the lesions are pruritic, exacerbated by friction (Darier Sign) [7]. In our patient, the lesions were asymptomatic and Darier sign was negative.

Disseminated papular granuloma annulare rarely involves genitalia and shows a lymphohistiocytic granuloma with connective tissue degeneration and mucin deposition unlike our patient [8].

Eruptive Xanthomas are reddish yellow papules arranged in crops on extensor surfaces, dorsum of the hands and buttocks and foamy macrophages are usually present on histopathology which were absent in our case [9].

For Syringomas, many modalities of treatment have been tried. For localized lesions; new techniques like microexcisions using Castroviejo scissors can minimize the risk of scarring [10], in addition to surgery, electrocautery and laser therapy which are usually used with different cosmetic results and possibility of scarring especially on the face. Reassurance is the best for generalized lesions.