Case Report
Dermatology 2007;215:354358
Dermoscopic and Reflectance Confocal
Microscope Findings of Trichoepithelioma
Marco Ardigo a Jonathon Zieff b Alon Scope c Melissa Gill d Philip Spencer c
Liang Deng c Ashfaq A. Marghoob c
a
San Gallicano Dermatological Institute, IRCCS, Rome, Italy; b Department of Dermatology, Stony Brook University
Hospital, Stony Brook, N.Y., and Departments of c Dermatology and d Pathology, Memorial Sloan-Kettering Cancer
Center, New York, N.Y., USA
Key Words
Familial trichoepithelioma  Desmoplastic
trichoepithelioma  Reflectance confocal
microscopy  Dermoscopy
Abstract
Background: Trichoepitheliomas (TE) are
benign neoplasms of follicular differentia-
tion. Solitary lesions are often confused with
basal cell carcinoma (BCC). Reflectance con-
focal microscopy (RCM) and dermoscopy are
imaging tools for in vivo, noninvasive evalu-
ation of skin lesions. To date, there has been
no description of their findings in the evalu-
ation of TE. Objective: Our aim is to describe
the dermoscopic and RCM findings of histo-
pathologically confirmed TE. Methods: Four
TE were evaluated, 2 each of the desmoplas-
tic and nondesmoplastic variants. RCM was
performed on 1 of the desmoplastic and
both of the nondesmoplastic lesions. Re-
sults: Dermoscopically, all of the lesions
showed arborizing telangiectasias. The des-
moplastic lesions also had an ivory-white
background throughout. RCM showed oval,
darker-appearing tumor islands that con-
tained brightly refractile material, consis-
tent with keratin horn cysts at the center, as
well as parallel bundles of highly refractile
dermal collagen surrounding the tumor is-
2007 S. Karger AG, Basel
10188665/07/21540354$23.50/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/drm
Received: January 26, 2007
DOI: 10.1159/000107631
lands. Conclusion: The ivory-white back-
ground throughout the lesion seen on der-
moscopy may be helpful in distinguishing
desmoplastic TE from BCC. The RCM find-
ings in TE of keratin-filled cysts in tumor is-
lands and attachment of the tumor to follic-
ular structures have not been previously
observed in BCC, and thus may also be diag-
nostically helpful. Further study is necessary
for validation of these findings.
Copyright 2007 S. Karger AG, Basel
Introduction
Trichoepitheliomas (TE) are benign
cutaneous neoplasms that reveal features
of follicular differentiation on histopa-
thology. In fact, the cells in TE have similar
immunohistochemical staining patterns
to that of cells in the outer root sheath [1].
Three distinct subtypes of TE are rec-
ognized, namely solitary, multiple and
desmoplastic TE [2]. The solitary variant,
seen in adults, usually presents as a skin-
colored papule 58 mm in diameter, locat-
ed on the central face with a predilection
for the perinasal area [3]. Infrequently, sol-
itary TE can obtain a diameter greater
than 1 cm or can be located on the neck,
scalp or trunk [4, 5].
Ashfaq A. Marghoob, MD
Dermatology Service, Memorial Sloan-Kettering Cancer Center
160 East 53rd Street, New York, NY 10022 (USA)
Tel. +1 212 610 0780 or +1 631 863 5150, Fax +1 212 308 0739
E-Mail marghooa@mskcc.org
Accepted: April 5, 2007
Patients with the second variant of TE
present with multiple lesions, with each le-
sion exhibiting similar clinical character-
istics as seen in the solitary variant. This
variant is often transmitted as an autoso-
mal dominant trait. Multiple TE first ap-
pears during adolescence as small papules
on the central face, with predilection for
the skin near the nasolabial folds, fore-
head, chin and periauricular area [6]. The
combination of multiple TE with cylindro-
mas and/or spiradenomas can be seen in
the Brooke-Spiegler syndrome [7, 8].
Desmoplastic TE, the third variant, of-
ten presents as a firm, annular, asymptom-
atic, white to yellow papule or plaque vary-
ing in size from 3 to 8 mm. However, it is
not uncommon to encounter desmoplastic
TE that are larger than 12 cm. The center
of a desmoplastic TE is frequently de-
pressed; however, ulceration is not en-
countered [9]. The borders are frequently
raised and can exhibit a rolled appear-
ance, a feature characteristically associat-
ed with basal cell carcinoma (BCC). How-
ever, unlike BCC, desmoplastic TE tend to
enlarge very slowly over many years to de-
cades, and the lesions tend not to develop
ulcerations.
Histologically, solitary and multiple
TE are seen as relatively symmetric and
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Fig. 1. Case 1. a Skin-colored to pearly,
translucent and well-demarcated papule
on the forehead. b Dermoscopy shows
short, thin telangiectasias (arrow) on a
shiny-white background.
Fig. 2. Case 1. a Histology reveals islands
of basaloid tumor cells (T) embedded in a
fibrotic stroma (S). HE. !20, horizontal
section. b Corresponding RCM mosaic
(3 ! 2.5 mm) at the level of the dermis
shows a circumscribed lesion (dashed line)
composed of relatively darker-appearing
tumor islands (T) in a brightly refractive
stroma (S).
sharply circumscribed epithelial prolifera-
tions characterized by a predominance of
follicular germinative cells arrayed as
small clusters or as reticulate and cribri-
form cords of basaloid cells. The tumor
cell aggregates are enveloped by a fibrotic,
conspicuous stroma that typically main-
tains tight adherent contact to the neoplas-
tic cells [2, 10]. Brownstein and Shapiro [9]
provided histopathological criteria for
desmoplastic TE. They attributed three
features to desmoplastic TE: (1) narrow
strands of tumor cells, (2) keratinaceous
cysts and (3) desmoplastic stroma. Fur-
thermore, they also listed features that
help differentiate desmoplastic TE from
conventional TE, syringomas, morphei-
form BCC and metastatic breast cancer
[9]. Another differential diagnosis that has
to be considered is the microcystic adnex-
al carcinoma [11].
TE can closely mimic BCC, clinically
and dermoscopically. In this paper we de-
scribe cases of TE which in clinical and
dermoscopic examinations were sugges-
tive of BCC; however, the patients reported
long-standing, completely unchanged le-
sions, the final histopathological diagnosis
being indeed TE. We describe the dermo-
Dermoscopic and RCM Findings of
Trichoepithelioma
scopic and reflectance confocal microsco-
py (RCM) attributes of a small case series
of TE, as a first step toward being able to
better discriminate it from BCC.
Case Report
Case 1
A 60-year-old white woman with a pre-
vious history of multiple BCC on the face
presented for routine dermatological fol-
low-up. She denied any familial syndromes.
On clinical examination she had multiple
skin-colored papular lesions, ranging in
size from 2 to 4 mm, located predomi-
nately on the forehead and central face. A
3-mm dome-shaped lesion on her fore-
head, representative of her other lesions,
was selected for clinical, dermoscopic and
RCM analysis and biopsy. The selected le-
sion consisted of a skin-colored, translu-
cent and well-defined papule (fig. 1a). By
dermoscopy, small and thin arborizing tel-
angiectasias were observed on a shiny white
background (fig. 1b). RCM examination
revealed the presence of a sharply demar-
cated lesion composed of tumor islands lo-
cated in a highly refractile (bright) stroma
Dermatology 2007;215:354358
(fig. 2). At higher-magnification RCM the
tumor islands showed morphology similar
to that seen in BCC (fig. 3). In the dermis,
RCM examination revealed brightly re-
fractile collagen, arranged in parallel
bundles, encasing the tumor islands. In ad-
dition, round black spaces filled with
brightly refractile material were seen in
the center of several tumor islands, cor-
responding to early horn cysts seen on
histology. The lesion was surgically re-
moved, and histopathological examination
revealed the presence of basaloid tumor is-
lands composed of branching and budding
nests, recapitulating follicular germs and
producing horn cysts, wrapped in a fi-
brotic stroma.
Case 2
A 68-year-old woman with a previous
diagnosis of multiple familial TE was seen
for routine follow-up. She presented with
multiple, dome-shaped, whitish to skin-
colored papules, ranging from 2 to 6 mm
in diameter located on her forehead,
cheeks, chin, and in the perinasal, perocu-
lar and zygomatic areas. After clinical
evaluation, she underwent dermoscopic
and RCM examination of 2 papular le-
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Fig. 3. Case 1. a Histology shows a fibrotic
stroma (S) concentrically ramifying the
tumor islands (T). HE. !400. b Corre-
sponding RCM (0.5 ! 0.5 mm) shows
brightly refractile collagen arranged in
parallel bundles (S) which encases the rel-
atively darker-appearing tumor islands
(T).
Fig. 4. Case 3. a A hard, annular, scar-like
plaque, 14 mm in diameter with telangiec-
tasias and a central depression was ob-
served on the right chin. b Dermoscopy
shows an ivory-white, scar-like lesion with
arborizing telangiectatic vessels (arrows).
This dermoscopic pattern is usually diag-
nostic for BCC.
sions, a 4-mm lesion located on the right
cheek and a 5-mm lesion on the chin. In
both lesions, dermoscopy disclosed the
presence of well-defined lesions with fine
arborizing telangiectasias and numerous
milia-like structures. RCM examination
revealed a normal epidermal architecture;
however, in the dermis one could identify
islands and cords of tumor cells. These tu-
mor structures were embedded in a stroma
of brightly refractile collagen arranged in
parallel bundles. Numerous dilated blood
vessels were evident throughout the stro-
ma. In some areas, the tumor cords were
connected to follicular structures. At the
center of several tumor islands, round,
black areas filled with brightly refractile
material with RCM features of keratin ma-
terial were seen corresponding on histopa-
thology to pseudo-horn cysts.
Case 3
An 83-year-old male with no history of
skin cancer presented for routine derma-
tological screening examination. During
356 Dermatology 2007;215:354358
the examination, a 14-mm atrophic plaque
was noted on his right chin. The lesion had
a scar-like appearance, but its edge re-
vealed a rolled border (fig. 4a). The patient
stated that this lesion was a scar that re-
sulted after attempts to remove a skin cyst
60 years ago. He was also convinced that
the scar had not changed in appearance
over time. On dermoscopy, the lesion
showed an ivory-white color, reflecting
an underlying fibrotic process, as well
as prominent arborizing telangiectasias
(fig. 4b) that were significantly different as
compared to the vessels in the surround-
ing actinically damaged skin. A shave bi-
opsy of a portion of this lesion was per-
formed, and histopathology revealed mul-
tiple, narrow strands of basaloid cells
without atypia or mitotic figures. The
strands were surrounded by a desmoplas-
tic stroma, and there was no clefting be-
tween the strands and the stroma. Multi-
ple keratinaceous cysts were also present.
The diagnosis of desmoplastic TE was ren-
dered. RCM examination was performed
Ardigo /Zieff /Scope /Gill /Spencer /Deng /
on the remainder of the lesion. RCM mo-
saic revealed the presence of dark, small,
round and elongated tumor nests in a
brightly refractile stroma arranged in par-
allel bundles (fig. 5). The stroma tightly
wrapped around the tumor islands. In
some foci, tumor nests showed a small,
round, dark central structure containing
brightly refractile material, corresponding
on histopathology to horn cysts (fig. 6).
Case 4
A 77-year-old man with a history of
multiple actinic keratoses was seen for
skin cancer screening. On his left medial
cheek, he had a 2 ! 1 cm sharply demar-
cated ivory-colored firm plaque, which he
stated had been present for over 50 years.
The lesion was slightly raised at the pe-
ripheral margin. Dermoscopically, there
were prominent and sharply focused ar-
borizing telangiectasias visible within the
central white area, and the lesion had
sharply defined borders. The arborizing
vessels were markedly different from the
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Fig. 5. Case 3. a Histology shows small
nests and cords of tumor cells (white ar-
rows) embedded in a sclerotic stroma.
There are horn cysts inside some of the tu-
mor islands (yellow arrows). HE. !40.
b RCM mosaic (4 ! 4 mm) reveals small,
dark, round and elongated areas (white ar-
rows), corresponding to tumor nests in a
brightly refractile stroma (S) arranged in
parallel bundles. Highly refractile materi-
al is seen at the center of some of the dark
areas (yellow arrows), corresponding to
the horn cysts in the tumor islands.

Fig. 6. Case 3. a Histology shows small

nests and cords of basaloid tumor cells (T)
encased in a sclerotic stroma (S). A horn
cyst inside one nest is visible (arrow). HE.
!400. b RCM (0.5 ! 0.5 mm) reveals a
darker, oval area (asterisks) containing
central refractile material (arrow), corre-
sponding to a tumor island with an early
horn cyst. The stroma is composed of
brightly refractile parallel bundles which
tightly wrap around the tumor islands
(S).

vessels in the surrounding actinically
damaged skin. A shave biopsy of a portion
of the lesion was performed, and the ini-
tial pathological diagnosis favored that
of a morpheiform BCC. However, based
on the presence of multiple strands of
basaloid cells without surrounding cleft-
ing, atypia or mitotic figures, and due to
the presence of multiple keratinaceous
cysts and focal calcification, the diagno-
sis was subsequently amended to a des-
moplastic TE.
Discussion
The clinical diagnosis of familial mul-
tiple TE is generally straightforward. How-
ever, solitary and desmoplastic TE vari-
ants may be difficult to differentiate from
BCC [12]. The addition of dermoscopy to
the unaided eye examination may aid in
reaching the correct diagnosis. It has be-
come evident that dermoscopy is not lim-
ited to the evaluation of pigmented lesions
[13].
Thus, dermoscopy has the potential to
be useful in the diagnosis of TE, especially
the desmoplastic variant, which is chal-
lenging to distinguish from BCC. Arboriz-
ing telangiectasias and focal shiny-white
areas are features commonly seen in BCC,
and we observed similar findings in des-
moplastic TE. However, the distinguish-
ing feature in desmoplastic TE was the
presence of a pearl-white to ivory-white
background color throughout the entire
lesion with prominent, large arborizing
vessels. These lesions lack any other der-
moscopic feature of BCC, such as leaf-like
structures and ovoid nests. Ivory-white
color seen on dermoscopy is usually indic-
ative of a sclerotic stroma [14], and this
correlated well with the desmoplastic stro-
ma seen under histology.
In addition to the 2 desmoplastic TE
cases, we also evaluated 2 patients with
classical TE, presenting with dome-
shaped, white lesions with superficial ar-
borizing telangiectasias. These lesions also
had similar arborizing telangiectasias and
a shiny white color like BCC. However, un-
like desmoplastic TE, the lesions did not
have the ivory-white background through-
out the lesion, rendering them dermoscop-
ically indistinguishable from BCC.
RCM allows for the visualization of mi-
croscopic features in vivo [15]. Gaining in-
sight into the RCM appearance of lesions
may help us to improve our bedside clini-
cal diagnostic accuracy and reduce unnec-
essary excisions of benign lesions [16, 17].
In all 4 TE lesions analyzed with RCM, we
observed features that were previously de-
scribed for BCC [18, 19] such as the pres-
ence of islands or cords of tumor cells com-
posed of basaloid epithelial cells with elon-
gated nuclei. However, some features of
TE, not previously described for BCC,
were noted on RCM. In familial TE, der-
mal tumor proliferations were shown to
be connected with follicular structures;
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Dermoscopic and RCM Findings of Dermatology 2007;215:354358 357

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Table 1. Dermoscopically and RCM prom-
inent features of TE
Dermoscopy
Arborizing vessels
Pearl-white to ivory-white background
RCM
Dermal basaloid tumor cell islands and
cords
Brightly refractile stroma arranged in
parallel bundles and tightly wrapped
around the tumor islands
Horn cysts within tumor islands as
small, round, dark central structure
containing brightly refractile material
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