An Unusual 2-Tone Epidermal Cyst: Dermoscopy, Confocal Microscopy, and Histopathologic Correlations | Dermatology | JAMA Dermatology | JAMA Network
[Skip to Navigation]
Sign In
December 2015

An Unusual 2-Tone Epidermal Cyst: Dermoscopy, Confocal Microscopy, and Histopathologic Correlations

Author Affiliations
  • 1Dermatology Clinic, University of Catania, Catania, Italy
  • 2Department G.F. Ingrassia, Section of Anatomic Pathology, University of Catania, Catania, Italy
JAMA Dermatol. 2015;151(12):1386-1388. doi:10.1001/jamadermatol.2015.2505

Noninvasive techniques such as dermoscopy and reflectant confocal microscopy (RCM) may enhance the diagnosis in some unusual nodules, as illustrated by the present case.

Report of a Case

A woman in her 30s reported changes in the last 6 months to an originally asymptomatic nodule on her right thigh. The 2-tone lesion of about 0.5 × 1 cm appeared to be exophytic and well demarcated: half of the lesion appeared whitish, and the other half was black (Figure 1A). Polarized-light dermoscopy (DermLite hybrid; 3Gen) showed the presence of 2 well-defined areas; one of them had a homogeneous yellowish color, the other was irregularly bluish. Within the bluish area, a circular, keratin-filled pore was observed (Figure 1B).

Figure 1.  Clinical and Dermoscopic Views of Epidermal Cyst
Clinical and Dermoscopic Views of Epidermal Cyst

A, In the clinical image, a well-demarcated, 2-tone nodule of about 0.5 × 1 cm is apparent on the right thigh. B, Under dermoscopy (original magnification ×10, polarized light), the 2 well-defined areas can be seen, one of a homogeneous yellowish color, the other an irregular blue; within the bluish area, a circular, keratin-filled pore is evident (arrowhead).

Analysis by RCM, performed with the handheld VivaScope 3000 (Mavig GmbH), showed beyond the pore a keratin-filled duct extending below the epidermis. In addition, just beneath a thinned epidermis, highly reflectant, geometrical, platelike structures with notched corners were revealed (Figure 2A). Histopathologic analysis of the excised nodule demonstrated the presence of a superficial epidermal cyst with squamous epithelial lining containing several cholesterol clefts (Figure 2B). A large area of the lesion was filled by a foreign-body, giant-cell reaction and some red blood cell extravasations.

Figure 2.  Reflectance Confocal Microscopy (RCM) Visualization and Pathologic Analysis of Epidermal Cyst
Reflectance Confocal Microscopy (RCM) Visualization and Pathologic Analysis of Epidermal Cyst

A, Under RCM, highly reflectant, geometrical, platelike structures with notched corners are apparent. B, Histopathologically, a squamous epithelial lining contains an intact granular cell layer and cholesterol clefts (arrowheads) (hematoxylin-eosin, original magnification ×100).


An epidermal cyst is a common, keratin-filled, epithelial-lined cyst of the skin. It is usually a slow-growing, asymptomatic, dermal or subcutaneous elastic nodule that may be skin colored or yellowish white when located near the skin surface. The cyst may be connected to the surface by a duct, and the clinical identification of the corresponding pore represents a diagnostic clue. Two previous studies have highlighted the usefulness of dermoscopy in identifying the pore, described as a keratin-filled, roughly circular orifice that may be whitish, yellow, brown, or black.1,2

In our case, dermoscopy of the nodule revealed the presence of the pore along with 2 sharply demarcated areas, each showing a different color. Histopathologic analysis showed an epidermal cyst corresponding to the yellowish area along with a foreign-body giant-cell reaction and red blood cell extravasations, likely the result of the cyst rupture, responsible for the bluish color.3

A noninvasive technique, RCM is increasingly being used for several dermatologic conditions other than melanocytic tumors.4,5 Unlike conventional vertical histopathologic sections, it provides 2-dimensional pictures representing horizontal (en face) scans of the skin. Superficial laser depth penetration (250 μm) represents a limitation in the assessment of epidermal cysts, which are generally located deeper in the dermis and the subcutis. In our case, RCM allowed us to identify not only the pore but also the duct underneath, which appeared as a keratin-filled roundish canal penetrating down into the epidermis.

Also, RCM highlighted several unusual, geometrical, highly reflectant structures located underneath a thinned epidermis, likely related to empty needle-shaped cholesterol clefts, as observed by histopathologic analysis. The cholesterol clefts represent virtual structures frequently seen in biopsy specimens of dermoid, trichilemmal, and sometimes epidermal cysts, and they correspond to cholesterol crystals that dissolve during the fixation process. In our case, it was possible to detect the cholesterol crystals by RCM thanks to the superficial location of the cyst. Their appearance is similar to that of synovial fluid under polarized microscopy in some rheumatologic conditions.6

In conclusion, an epidermal cyst may undergo rupture that causes changes in its clinical presentation such that it shows an irregular bluish color under dermoscopy. To our knowledge, this is the first case report to describe in vivo cholesterol crystals within the cyst.

Back to top
Article Information

Corresponding Author: Giuseppe Micali, MD, Dermatology Clinic, University of Catania, AOU Policlinico-Vittorio Emanuele, Via Santa Sofia, 78-95123, Catania, Italy (

Published Online: September 9, 2015. doi:10.1001/jamadermatol.2015.2505.

Conflict of Interest Disclosure: None reported.

Ghigliotti  G, Cinotti  E, Parodi  A.  Usefulness of dermoscopy for the diagnosis of epidermal cyst: the ‘pore’ sign.  Clin Exp Dermatol. 2014;39(5):649-650.PubMedGoogle ScholarCrossref
Mun  JH, Park  SM, Kim  TW, Kim  BS, Ko  HC, Kim  MB.  Importance of keen observation for the diagnosis of epidermal cysts: dermoscopy can be a useful adjuvant tool.  J Am Acad Dermatol. 2014;71(4):e138-e140.PubMedGoogle ScholarCrossref
Lacarrubba  F, Pellacani  G, Verzì  AE, Pippione  M, Micali  G.  Extragenital lichen sclerosus: clinical, dermoscopic, confocal microscopy and histologic correlations.  J Am Acad Dermatol. 2015;72(1)(suppl):S50-S52.PubMedGoogle ScholarCrossref
Lacarrubba  F, Verzì  AE, Micali  G.  Detailed analysis of in vivo reflectance confocal microscopy for Sarcoptes scabiei hominis [published online September 9, 2014].  Am J Med Sci. doi:10.1097/MAJ.0000000000000336.PubMedGoogle Scholar
Oliveira  A, Arzberger  E, Massone  C, Zalaudek  I, Fink-Puches  R, Hofmann-Wellenhof  R.  Melanoma and satellite blue papule.  Dermatol Pract Concept. 2014;4(3):63-66.PubMedGoogle ScholarCrossref
DeMarco  PJ, Keating  RM.  Images in clinical medicine. Cholesterol crystals.  N Engl J Med. 1995;333(20):1325.PubMedGoogle ScholarCrossref