Open Access Original

Article DOI: 10.7759/cureus.45548

Benign Cutaneous Cysts: A Comprehensive

Analysis of 1160 cases
Review began 09/08/2023
Anila Chughtai 1 , Muhammad Moseeb Ali Hashim 1 , Rashida Saleem 1 , Ghazi Zafar 1 , Rafeya Yasin 1 , Omar
Review ended 09/15/2023 Chughtai 1 , Akhtar S. Chughtai 1 , Asma Zafar 1
Published 09/19/2023

© Copyright 2023 1. Histopathology, Chughtai Institute of Pathology, Lahore, PAK

Chughtai et al. This is an open access
article distributed under the terms of the
Corresponding author: Rashida Saleem, [email protected]
Creative Commons Attribution License CC-
BY 4.0., which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original author and
source are credited. Abstract
Background
Cysts are common skin abnormalities that are mostly benign; however, sometimes malignant lesions may
present clinically as cystic manifestations. Benign cutaneous cysts can be of different morphological types
and their diagnosis relies on histological evaluations. The most common mode of treatment is surgical
excision, which is curative.

Methodology
This is a retrospective cross-sectional study conducted at the Department of Histopathology, Chughtai
Institute of Pathology, Lahore, Pakistan from 1st January 2020 to 31st December 2022. Non-probability
consecutive sampling was done, and all the cases of benign cutaneous cysts were included. All cases were
microscopically reviewed by two histopathologists, and variables like age, gender, site of the lesion, and
histological diagnosis were noted. The data were analyzed using IBM SPSS Statistics for Windows, Version 29
(Released 2022; IBM Corp., Armonk, New York, United States).

Results
A total of 1160 recorded cases of benign cutaneous cysts were included. Overall gender distribution revealed
males (n=489, 42.1%) and females (n=671, 57.8%). The age range was 3 to 91 years with a mean age of 37.56 ±
16.05 years. The three most common cysts were epidermal inclusion cysts (74.3%), trichilemmal cysts
(15.1%), and dermoid cysts (6.3%). Other cysts were uncommon including hidrocystoma (1.9%),
steatocystoma (0.3%), verrucous cysts (0.3%), comedones (0.6%), hybrid cysts (0.2%), milia (0.3%), and vellus
hair cysts (0.2%). The most common site was back (23.5%) for epidermal inclusion cysts, scalp (74.4%) for
trichilemmal cysts, and eye (33.8%) for dermoid cysts.

Conclusion
Benign cutaneous cysts have a broad morphological spectrum with a wide age range. Epidermal inclusion
cysts, trichilemmal cysts, dermoid cysts, and hidrocystoma account for the four most common types. For
each of the other cyst type, the prevalence was under 1%. Female gender predominated in epidermal
inclusion cysts, trichilemmal cysts, and dermoid cysts while male gender was common in other cysts.
Overall majority of the cysts presented in the head and neck area.

Categories: Pathology
Keywords: steatocystoma, comedones, benign cutaneous cysts, hidrocystoma, trichilemmal cyst, dermoid cyst,
epidermal inclusion cyst

Introduction
Benign cutaneous cysts are prevalent skin abnormalities that can lead to aesthetic and medical issues,
eliciting significant concern among both patients and their healthcare providers. Cysts are fluid-filled
cavitary lesions, lined by different types of epithelium [1]. The cutaneous cysts are mostly benign; however,
sometimes malignant lesions may also present as cystic lesions. Benign cutaneous cysts can be of various
morphological types. These may present as either dermal or subcutaneous nodules [2]. These cysts are
mostly painless; however, they can be painful if ruptured or infected. Surgical excision is the primary mode
of treatment and is curative [3]. The diagnosis of cysts relies on the clinical characteristics of the lesions
followed by histopathological examination to determine the exact morphological type and to exclude the
possibility of malignancy [3-6]. To the best of our knowledge, there are no detailed studies related to benign
cutaneous cysts conducted in the Pakistani population. The aim of this study was to assess the prevalence of
different types of benign cutaneous cysts in the Pakistani population and describe their detailed clinical and
pathological characteristic.

Materials And Methods

How to cite this article

Chughtai A, Hashim M, Saleem R, et al. (September 19, 2023) Benign Cutaneous Cysts: A Comprehensive Analysis of 1160 cases. Cureus 15(9):
e45548. DOI 10.7759/cureus.45548
 Study design
This is a retrospective cross-sectional study conducted at the Department of Histopathology, Chughtai
Institute of Pathology, Lahore, Pakistan from 1st January 2020 to 31st December 2022. The study was
conducted after approval by the institutional review board (CIP/IRB/1151). The non-probability consecutive
sampling technique was applied.

Inclusion criteria
All the biopsy cases with a diagnosis of benign cutaneous cysts reported in the designated time window were
included in the study.

Exclusion criteria
The cases with poor preservation due to fixation artifacts of the tissue were excluded from the study.

Data collection
The tissue slides for all the reported cases within the study period were retrieved from archives. These slides
were prepared from paraffin embedded tissue blocks which were formed after routine tissue processing. The
slides were stained with hematoxylin and eosin tissue stains. All the case slides were reviewed by two
histopathologists with special interest in dermatopathology and findings were noted. The variables like age,
gender, site of the lesion, and histological diagnosis were noted.

Statistical analysis
The data were analyzed using IBM SPSS Statistics for Windows, Version 29 (Released 2022; IBM Corp.,
Armonk, New York, United States).

Results
A total of 1160 recorded cases of benign cutaneous cysts were included in the study. Overall gender
distribution revealed males (n=489, 42.1%) and females (n=671, 57.8%). The age range was 3 to 91 years with
a mean age of 37.56 ± 16.05 years. The most prevalent morphological type was epidermal inclusion cysts
(n=862, 74.3%) followed by trichilemmal cysts (n=176, 15.1%), dermoid cysts (n=74, 6.3%), hidrocystoma
(n=23, 1.9%), comedones (n=7, 0.6%), steatocystoma (n=4, 0.3%), verrucous cysts (n=4, 0.3%), milia (n=4,
0.3%), vellus hair cysts (n=3, 0.2%), and hybrid cysts (n=3, 0.2%) as shown in Table 1.

Cyst type Frequency (n) Percentage (%)

Epidermal inclusion cyst 862 74.3%

Trichilemmal cyst 176 15.1%

Dermoid cyst 74 6.3%

Hidrocystoma 23 1.9%

Comedones 7 0.6%

Steatocystoma 4 0.3%

Verrucous cyst 4 0.3%

Milia 4 0.3%

Vellus hair cyst 3 0.2%

Hybrid cyst 3 0.2%

TABLE 1: Prevalence of different morphological types of benign cutaneous cysts

For epidermal inclusion cysts, the majority of the cases presented in the fourth decade of life, and gender
distribution revealed males (n=358, 41.5%) and females (n=504, 58.4%). Gender distribution and the most
common age range for other cysts are shown in Table 2.

2023 Chughtai et al. Cureus 15(9): e45548. DOI 10.7759/cureus.45548 2 of 9

 Cyst type Male Female Most common Age range (years) Most common location

Epidermal inclusion cyst 358 (41.5%) 504 (58.4%) 31-40 (27.9%) Back (23.5%)

Trichilemmal cyst 69 (39.2%) 107 (60.8%) 31-40 (31.3%) Scalp (74.4%)

Dermoid cyst 35 (47.3%) 39 (52.7%) 11-29 (40.5%) Eye (33.8%)

Hidrocystoma 12 (52.2%) 11 (47.8%) 31-50 (43.4%) Eye (78.3%)

Comedone 7 (100%) 0 11-20 (57%) Face (71.4%)

Steatocystoma 3 (75%) 1 (25%) 21-30 (50%) Eye (75%)

Verrucous cyst 4 (100%) 0 41-50 (50%) Scalp (75%)

Milia 3 (75%) 1 (25%) 21-30 (50%) Face (75%)

Vellus hair cyst 3 (100%) 0 11-20 (100%) Face (66%)

Hybrid cyst 1 (33%) 2 (66%) 21-30 (66%) Back (66%)

TABLE 2: Distribution of cysts according to gender predilection, most common age range, and
most common location

The most common site of presentation is back (23.5%) in epidermal inclusion cysts, scalp (74.4%) in
trichilemmal cysts, eye (33.8%) in dermoid cysts, eye (78.3%) in hidrocystoma, face (71.4%) in comedones,
eye (75%) in steatocystoma, scalp (75%) in verrucous cysts, face (75%) in milia, face (66%) in vellus hair
cysts, and back (66%) in hybrid cysts as depicted in Table 2.

Discussion
Benign cutaneous cysts are one of the most common skin lesions encountered clinically. The benign
cutaneous cysts have a broad morphological spectrum that correlates with the structures of origin, mainly
including the epidermis, pilosebaceous units, and eccrine/apocrine sweat ducts [1,2]. A vast majority of
cystic lesions of skin are benign; however, sometimes malignancies can perfectly imitate cystic clinical
presentation necessitating histological evaluation [3-6]. The most common type of benign cutaneous cyst
reported in the literature is the epidermal inclusion cyst (EIC) which correlates with our findings as it
accounted for 74.3% of all the cysts included in this study [7]. It was more prevalent in females with the
majority of cases presenting back in the fourth decade of life. These findings are discordant with the
findings of Nigam et al. [8]. Histologically, it showed benign stratified squamous epithelium with an intact
granular layer, flaky keratinous material within the luminal cavity, and associated inflammation in ruptured
cases, shown in Figure 1 [3,9].

FIGURE 1: Epidermal inclusion cyst

A and B: Cyst showing stratified squamous epithelium with an intact granular layer and flaky keratin in the lumen

The second most common cyst found in our study was the trichilemmal cyst (also known as the pilar cyst)
accounting for 15.1% with scalp as the most common site. These findings are concordant with findings
reported in the literature [2,10]. Female predilection was noted with the majority of the cases presenting in
the fourth decade of life. Histologically, trichilemmal cysts showed benign stratified squamous epithelium
without granular layer, abrupt trichilemmal type of keratinization, and associated inflammation in ruptured

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 cases as shown in Figures 2A, 2B [3,9].

FIGURE 2: Trichilemmal cyst

A: Low-power view of the cyst with abrupt trichilemmal type of keratinization. B: High-power view of the cyst
showing stratified squamous epithelium without a granular layer and trichilemmal type of keratin in the lumen.

The dermoid cyst was the third most prevalent cyst in our study accounting for 6.3% which is discordant
with the findings of Inbasekaran et al., and Singh et al. [1,9]. It showed female predominance, with eye as
the most common site and the majority of cases presenting in the second and third decade of life.
Histologically, dermoid cysts showed variable components for example different types of epithelial lining,
skin adnexal structures in the wall, keratinous debris, hair shafts, inflammation, and giant cell reaction, as
shown in Figures 3A, 3B. In our study, the most common type of epithelial lining documented in the dermoid
cyst was stratified squamous which is concordant with findings in the literature.

FIGURE 3: Dermoid cyst

A and B: Cyst with squamous lining, flaky keratin in the lumen, and pilosebaceous units in the wall.

Hidrocystoma was the fourth most prevalent cyst accounting for 1.9%. Male prevalence was noted with the
majority of the cases presenting in the fourth and fifth decade of life. Eye was the most common site of
presentation for these cysts. Hidrocystomas arise from dermal sweat glands and have two morphological
variants namely eccrine hidrocystoma and apocrine hidrocystoma [11-13]. Eccrine hidrocystomas showed
flattened to cuboidal double lining with cells having scant cytoplasm as shown in Figures 4A, 4B. Apocrine
hidrocystomas showed double lining with outer myoepithelial and inner epithelial cells having abundant
eosinophilic cytoplasm and apical snouts as shown in Figures 4C, 4D [12-15].

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 FIGURE 4: Eccrine and apocrine hidrocystomas
A: Low-power view of eccrine hidrocystoma. B: High-power view of eccrine hidrocystoma showing flattened to
cuboidal lining. C: Low-power view of apocrine hidrocystoma. D: High-power view of apocrine hidrocystoma
showing double lining with abundant cytoplasm and apical snouts

Comedones represent a form of acne vulgaris which are multiple small open or closed cystic lesions lined by
stratified squamous epithelium with luminal keratinous debris as shown in Figures 5A, 5B [16,17]. In this
study, a striking male predominance was noted for comedones and more than half of the cases were reported
in the second decade of life with face as the most common site. These results are concordant with findings in
the literature [17-19].

FIGURE 5: Comedone
A: Low-power view of comedones representing multiple small keratin containing cysts. B: High-power view
showing closed and open comedones with squamous lining and keratin in the lumen.

Verrucous cysts showed hyperplastic stratified squamous epithelium with hypergranulosis, prominent
keratohyalin granules, squamous eddies within the epithelial lining, and prominent luminal keratinous
debris as shown in Figures 6A, 6B [20-22]. These cysts are found to be associated with HPV infection
[20,21,23,24]. The most common site for verrucous cysts was scalp in our study which is discordant while the
age range in our study was concordant with the findings of Soyer et al. [24].

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 FIGURE 6: Verrucous cyst
A: Low-power view of the cyst showing hyperplastic stratified squamous lining with keratin in the lumen B: High-
power view of the cyst showing hyperplastic stratified squamous epithelium with hypergranulosis and keratin in
the lumen

Steatocystomas showed cysts lined by stratified squamous epithelium with prominent surface corrugations
and an absent granular layer along with sebaceous units within the cyst wall. These cysts show empty lumen
on histology as shown in Figures 7A, 7B [25,26]. The most common site for steatocystoma in our study was
face which is discordant with the findings of Cho et al. [27,28].

FIGURE 7: Steatocystoma
A: Low-power view of the cyst showing stratified squamous epithelium, sebaceous units in the wall, and empty
lumen. B: High-power view of the cyst showing stratified squamous epithelium without a granular layer and
prominent surface corrugations.

Vellus hair cysts represented small multiple dermal-based cysts with stratified squamous epithelium and
keratinous luminal debris along with multiple hair shafts in the lumen as shown in Figures 8A, 8B [28-30].
The most common site for vellus hair cysts in our study was face which is discordant with findings of Anand
et al. [31].

FIGURE 8: Vellus hair cyst

A: Low-power view of the cyst showing stratified squamous epithelium and multiple vellus hair admixed with
luminal keratin. B: High-power view of the cyst showing stratified squamous epithelium, vellus hair shafts, and
keratinous debris in the lumen.

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 Milia were small multiple dermal-based cysts lined by squamous epithelium and contained keratin in the
lumina as shown in Figures 9A, 9B. These arise from hair follicles and have characteristic clinical
presentation [32,33]. Milia mostly present in newborns; however, they sometimes appear in adults. In our
study, all cases were presented in the adult age group as these lesions are rarely biopsied in newborns
[34,35]. The most common site reported in our study was face for milia which is concordant with the findings
of Pastukhova et al. [36].

FIGURE 9: Milia
A: Low-power view showing multiple small keratinous cysts. B: High-power view of the cyst showing stratified
squamous epithelium and luminal keratin.

Hybrid cysts represented a combination of any of the cyst types described above. All three hybrid cysts in our
study were a combination of epidermal inclusion cysts and trichilemmal cysts which is the most common
combination described in the literature [37].

Limitations
This was a single-center study with a limited sample size as no collaboration with central registries can be
established.

Conclusions
Benign cutaneous cysts have a broad morphological spectrum with a wide age range with an average age of
38 years. Epidermal inclusion cysts, trichilemmal cysts, dermoid cysts, and hidrocystoma account for the
four most common types of benign cutaneous cysts. Other cutaneous cyst types were uncommon. Overall
female gender predominance was noted for epidermal inclusion cysts, trichilemmal cysts, and dermoid
cysts, while male predilection was noted for other types of cysts. The overall majority of the cysts presented
in the head and neck area. In conclusion, as these lesions have a broad morphological spectrum and affect a
wide age range, histological assessment is mandatory for correct categorization and documentation of the
benign nature of these lesions.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Rashida Saleem, Anila Chughtai, Muhammad Moseeb Ali Hashim, Ghazi Zafar,
Rafeya Yasin, Akhtar S. Chughtai, Asma Zafar, Omar Chughtai

Acquisition, analysis, or interpretation of data: Rashida Saleem, Anila Chughtai, Muhammad Moseeb
Ali Hashim, Ghazi Zafar, Rafeya Yasin, Akhtar S. Chughtai, Asma Zafar, Omar Chughtai

Drafting of the manuscript: Rashida Saleem, Anila Chughtai, Muhammad Moseeb Ali Hashim, Ghazi
Zafar, Rafeya Yasin, Akhtar S. Chughtai, Asma Zafar, Omar Chughtai

Critical review of the manuscript for important intellectual content: Rashida Saleem, Anila Chughtai,
Muhammad Moseeb Ali Hashim, Ghazi Zafar, Rafeya Yasin, Akhtar S. Chughtai, Asma Zafar, Omar Chughtai

Supervision: Rashida Saleem, Anila Chughtai, Muhammad Moseeb Ali Hashim, Ghazi Zafar, Rafeya Yasin,
Akhtar S. Chughtai, Asma Zafar, Omar Chughtai

2023 Chughtai et al. Cureus 15(9): e45548. DOI 10.7759/cureus.45548 7 of 9

 Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review
Board of Chughtai Institute of Pathology, Lahore issued approval CIP/IRB/1151. Animal subjects: All
authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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