Dermatology Online Journal

Tazarotene 0.1 percent cream fares better than erbium:YAG laser or incision and drainage in a patient with eruptive vellus hair cysts
Karen Saks¹, Jacob O Levitt MD²
Dermatology Online Journal 12 (6): 7

1. University of California at Santa Barbara2. Department of Dermatology, The Mount Sinai School of Medicine, New York, NY

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Introduction

Eruptive vellus hair cysts (EVHC), first reported in 1977, are characterized by 1-3 mm, skin-colored papules on the chest and extremities [1]. The cyst walls are composed of a keratinized epithelium that surrounds keratin and many thin hairs [2]. Eruptive vellus hair cysts appear most frequently in children and young adults and equally among men and women [3]. Vellus hairs, unlike terminal hairs, are small in diameter and lack pigment.

Clinical synopsis

Figure 1
Eruptive vellus hair cysts in a 6 year old girl

A 6-year-old girl, Fitzpatrick skin-type IV, presented with a 2 year history of a non-pruritic eruption. The child had no other medical problems. Her family history was negative for this problem. Examination revealed small, skin-colored papules and cysts on the anterior trunk and proximal extremities (Fig. 1). Several months of therapy with triamcinolone 0.1 percent cream compounded with 5 percent salicylic acid yielded no improvement. In search of the most effective way to treat the cysts, we sectioned the patient's abdomen into four quadrants to be treated with different modalities as follows:

• upper left quadrant: incision and drainage (I&D) with an 11-blade
• lower left quadrant: tazarotene 0.1 percent cream bid
• upper right quadrant: erbium:YAG laser vaporization
• lower right quadrant: control

Figure 2A	Figure 2B
Right upper quadrant of the abdomen before and after treatment with erbium:YAG laser

Figure 3A	Figure 3B
Left lower quadrant of the abdomen before and after treatment tazarotene 0.1% cream

Tazarotene 0.1% cream application was associated with inflammation of the treated cysts at 2 weeks (Fig. 2) with subsequent resolution of many lesions (Fig. 3). Erbium:YAG laser did resolve the cysts but was associated with excessive post-inflammatory hyperpigmentation (Fig. 3). Incision and drainage failed to demonstrate superiority over control, demonstrating no more inflammation or hyperpigmentation than lesions undergoing their natural course. The tazarotene-treated cysts healed with post-inflammatory hyperpigmentation that was less severe than the hyperpigmentation associated with erbium:YAG laser treatment (Fig. 3). The patient was lost to followup after 1 month, so the effects of a longer treatment course with tazarotene could not be assessed.

Discussion

Eruptive vellus hair cysts may be attributed to abnormal development of vellus hair follicles, either making them susceptible to blockage or leading to a disruption of the attachment between the proximal and distal ends of the follicle [1]. Eruptive vellus hair cysts are reported occasionally with steatocystoma multiplex. It was once thought that they were variable expressions of the same disorder [4], however, Tomkova et al. revealed through staining with K10 and K17 that EVHC and steatocystoma multiplex were in fact two distinct entities [5]. Eruptive vellus hair cysts have been noted also in patients with pachyonychia congenita [6], anhidrotic ectodermal dysplasia [7, 8], Lowe syndrome [9], and chronic renal failure [10].

The least invasive method for diagnosis of EVHC is needle evacuation rather than biopsy [2]. Therapy for EVHC is challenging. Success has been reported anecdotally with needle evacuation [2], topical tretinoin [11, 12], systemic isotretinoin [13], CO₂ laser [14], and erbium:YAG laser [15]. We compared Incision and drainage, erbium:YAG laser, and topical tazarotene 0.1 percent cream in the treatment of EVHC in our patient. Tazarotene 0.1 percent cream proved to be both the least invasive and most (albeit not completely) effective method of treatment. Although erbium:YAG laser has been reported as a safe modality [15], we found it should be reserved for lighter skin types and only after less-invasive topical retinoids have been tried.

References

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