Syringomata

Published on 18/03/2015 by admin

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Syringomata

James A.A. Langtry

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Syringomata are benign appendageal tumors of the intraepidermal eccrine sweat duct which have a characteristic histologic appearance. The typical clinical presentation is of individual skin- or tan-colored papules, with a rounded or flat surface, 1–5 mm in diameter. Single tumors can occur, but more commonly they are multiple and symmetric, more common in females, and from adolescence onwards. Syringomata most often involve the lower eyelids, although they may occur at other sites, including the cheeks, axillae, abdomen, and vulva. A linear distribution, familial occurrence, a variant associated with Down syndrome, as well as generalized forms have all been described. Frequent onset around puberty and reports of symptoms during pregnancy or menstruation have led to immunohistochemical studies of estrogen and progesterone receptors, with varying results and uncertain relevance.

Management strategy

Syringomata of the eyelids and cheeks are in a prominent site, may appear conspicuous, and treatment may be sought to improve appearance. The syringomata are situated in the upper to mid dermis. Available treatments aim to remove or flatten the papule produced by each syringoma. The majority of treatments are ablative in nature. Some patients may be troubled by only a few individual lesions, whereby excision of these is an option. Ablative modalities include: scissor excision with secondary intention healing; surgical excision of the entire cosmetic unit of the lower eyelids in patients who would also benefit from lower eyelid blepharoplasty; electrocautery; electrodesiccation; intralesional electrodesiccation; dermabrasion; cryotherapy; ablation with CO2 or erbium : YAG laser; and radiofrequency ablation.

Local anesthesia is needed prior to treatment, and this may be topical, or by local injections with or without nerve blocks. Local anesthetic injections producing a field block are most commonly employed, as good anesthesia is helpful when using ablative treatments near the eye. Patients should be warned about the possibility of postoperative bruising. Eye protection is of paramount importance, and specific precautions relevant to the use of lasers must be taken if laser treatment is used.

Ablative treatments will produce some degree of scarring and the aim is to make this imperceptible and produce an excellent cosmetic result. Possible sequelae, including scarring and hypo- or hyperpigmentation (especially with increasing skin pigmentation), should always be discussed prior to treatment.

There are no studies comparing different treatment modalities for syringomata, and a dearth of long-term follow-up data on which to base recommendations for treatment. On the basis of experience and the limited evidence available, it is not necessary to have the latest and most expensive technology to achieve good results. Expertise and good outcomes with simple, ‘low-tech’ methods are as important as with ‘high-tech’ modalities. Each has benefits as well as pitfalls for the novice or unwary. It is more important to be expert in the use and application of one or more modalities than to ‘have a go’ at them all.

First-line therapies

image Surgical excision E
image Snip excision and secondary intention healing E
image Electrocautery E
image Intralesional electrodesiccation D
image CO2 laser D

Second-line therapies

image Electrodesiccation and curettage E
image Cryotherapy E
image Combination of CO2 laser and trichloroacetic acid D

Third-line therapies

image Dermabrasion E
image Trichloroacetic acid E
image Topical atropine E
image Topical tretinoin E

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Syringomata

James A.A. Langtry

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Syringomata are benign appendageal tumors of the intraepidermal eccrine sweat duct which have a characteristic histologic appearance. The typical clinical presentation is of individual skin- or tan-colored papules, with a rounded or flat surface, 1–5 mm in diameter. Single tumors can occur, but more commonly they are multiple and symmetric, more common in females, and from adolescence onwards. Syringomata most often involve the lower eyelids, although they may occur at other sites, including the cheeks, axillae, abdomen, and vulva. A linear distribution, familial occurrence, a variant associated with Down syndrome, as well as generalized forms have all been described. Frequent onset around puberty and reports of symptoms during pregnancy or menstruation have led to immunohistochemical studies of estrogen and progesterone receptors, with varying results and uncertain relevance.

Management strategy

Syringomata of the eyelids and cheeks are in a prominent site, may appear conspicuous, and treatment may be sought to improve appearance. The syringomata are situated in the upper to mid dermis. Available treatments aim to remove or flatten the papule produced by each syringoma. The majority of treatments are ablative in nature. Some patients may be troubled by only a few individual lesions, whereby excision of these is an option. Ablative modalities include: scissor excision with secondary intention healing; surgical excision of the entire cosmetic unit of the lower eyelids in patients who would also benefit from lower eyelid blepharoplasty; electrocautery; electrodesiccation; intralesional electrodesiccation; dermabrasion; cryotherapy; ablation with CO2 or erbium : YAG laser; and radiofrequency ablation.

Local anesthesia is needed prior to treatment, and this may be topical, or by local injections with or without nerve blocks. Local anesthetic injections producing a field block are most commonly employed, as good anesthesia is helpful when using ablative treatments near the eye. Patients should be warned about the possibility of postoperative bruising. Eye protection is of paramount importance, and specific precautions relevant to the use of lasers must be taken if laser treatment is used.

Ablative treatments will produce some degree of scarring and the aim is to make this imperceptible and produce an excellent cosmetic result. Possible sequelae, including scarring and hypo- or hyperpigmentation (especially with increasing skin pigmentation), should always be discussed prior to treatment.

There are no studies comparing different treatment modalities for syringomata, and a dearth of long-term follow-up data on which to base recommendations for treatment. On the basis of experience and the limited evidence available, it is not necessary to have the latest and most expensive technology to achieve good results. Expertise and good outcomes with simple, ‘low-tech’ methods are as important as with ‘high-tech’ modalities. Each has benefits as well as pitfalls for the novice or unwary. It is more important to be expert in the use and application of one or more modalities than to ‘have a go’ at them all.

First-line therapies

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image Surgical excision E
image Snip excision and secondary intention healing E
image Electrocautery