Pilar Cysts

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A Pilar Cyst, aka a trichilemmal cyst, an isthmus-catagen cyst, or a “wen”, looks identical on examination to the more common epidermoid cyst, except that 90% of them occur on the scalp. They tend to be more mobile and firmer than epidermoid cysts, and are derived from a different part of the hair follicle/skin. The internal content tend to be more “homogenous”/ smooth (looks different under the microscope), but it is also a benign growth. It is not uncommon to have multiple pilar cysts on the scalp and to have other family members to have these cysts (tend to run in families). Treatment is for cosmetic reasons usually (people don’t like the appearance of them), and excision with removal of the cyst and it’s contents is curative.

Trichilemmal or pilar cysts are common intradermal or subcutaneous cysts, occurring in 5-10% of the population.[1] Greater than 90% occur on the scalp, where trichilemmal cysts are the most common cutaneous cyst.[2, 3] Trichilemmal cysts are almost always benign. They may be sporadic or they may be autosomal dominantly inherited.[4, 5] They contain keratin and its breakdown products and are lined by walls resembling the external (outer) root sheath of the hair.

In 2% of trichilemmal cysts, single or multiple foci of proliferating cells lead to tumors called proliferating trichilemmal cysts.[6] Proliferating trichilemmal cysts are gradually enlarging (up to 25 cm in diameter), exophytic nodules that occasionally ulcerate.[2] Although biologically benign tumors, they may be locally aggressive. Recurrences and metastases have been observed, with rare malignant transformation.[5, 6]

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