Syringomas are benign neoplasms derived from eccrine sweat glands. Eruptive syringomas are a subtype of syringomas and are typically located on the chest, neck, and abdomen during puberty or childhood. Herein, JDD authors Jennifer Wang BA, Nyousha Yousefi MD, Edward Heilman MD FAAD FCAP, and Jared Jagdeo MD MS present a 20-year-old African American female with an atypical case of eruptive syringomas, characterized by an unusual distribution on her chest, abdomen, and anterior and posterior bilateral extremities. This case underscores the importance of recognizing diverse presentations of skin conditions in patients with skin of color and adds to the limited reports of eruptive syringoma in these populations. The authors present and emphasize this atypical manifestation of eruptive syringomas in an individual with darker skin to promote awareness and improve diagnosis and patient outcomes.
INTRODUCTION
Syringomas are benign adnexal tumors originating from the eccrine sweat gland ducts.1 Syringomas are traditionally classified into four subtypes: localized, generalized, familial, and Down syndrome-associated.2 Eruptive syringomas fall under the generalized subtype of syringomas.2 Eruptive syringoma classically develops during puberty or childhood, predominantly in females, and typically localizes to the chest, neck, and upper abdomen.1,3 Lesions are often stable and benign, although there have been some instances of spontaneous resolution.3,4 Herein, the authors highlight an atypical case of eruptive syringoma occurring in a patient with a darker skin tone, adding to the dermatologic understanding of skin conditions in individuals with skin of color.
CASE DESCRIPTION
A 20-year-old African American female (Fitzpatrick skin type V) presented with dark skin lesions on her chest, abdomen, and bilateral upper and lower extremities. The lesions have been present for 15 years and are asymptomatic, with no associated pain or pruritus. The patient denies the development of new lesions over the years. However, the lesions have been progressively darkening. The patient’s maternal aunt had similar lesions that resolved without intervention at 26 years old.
The patient’s past medical history was significant for asthma but otherwise unremarkable. She had no history of Down syndrome or any relevant dermatologic conditions. No personal or family history of skin cancer.
Physical examination revealed scattered light to dark brown papules and plaques on the chest, abdomen, and flexure surfaces of the upper extremities greater than the extensor surfaces of the upper extremities and anterior thighs. Lesions were most concentrated and pigmented on the extremities, gradually diminishing in density and intensity towards the central body. No lesions were noted on her face, neck, palms, and soles. No nail changes were noted, and oral mucosa was clear on the exam (Figures 1-3). Due to the patient’s distribution of hyperpigmented lesions, the differential diagnosis included reticulate acropigmentation of Kitamura, reticulate acropigmentation of Dohi, and lichen planus.
A 4 mm skin punch biopsy from the left upper thigh was taken. There was a subtle proliferation of ductal epithelial elements and thin cords composed of cuboidal epithelial cells embedded in a perfectly normal stroma. The ductal elements exhibited an outer layer of cuboidal epithelial cells and a luminal layer containing pale staining cytoplasm. The ducts contained eosinophilic secretion-like material. These findings are diagnostic of a syringoma (Figures 4 and 5).
DISCUSSION
Herein, the authors present an atypical case of eruptive syringoma in an African American patient. Eruptive syringomas are a rare subtype of syringomas, with a higher incidence in women and African American and Asian patients.1,5,6 Eruptive syringomas typically present as multiple 2 to 5 mm yellow or brown, non-scaly, flat-topped papules.1,5,7 Dermoscopy may reveal fine reticulate brown lines on a light brown background.8 Histopathologically, eruptive syringomas consist of a distinctive pattern of small, “comma” or “tadpole-like””sweat ducts within a fibrotic stroma in the dermis, without extension into the subcutaneous layer.1,5,7 Histological evaluation is required for the diagnosis of eruptive syringoma.3
This report highlights a novel case of eruptive syringomas with an atypical distribution in an African American woman, presenting symmetrically on the chest, abdomen, and bilateral upper and lower extremities. Eruptive syringomas are typically present in the neck, chest, and abdomen areas.1,5,7 One meta-analysis of 90 patients with eruptive syringoma found that 86 patients had lesions on the trunk, the most common site.1 Eruptive syringoma is also rarely present in the posterior body; this patient had both anterior and posterior involvement.9 The distribution of lesions in our patient represents an atypical inverse presentation of this already rare condition. An interesting additional finding noted by one of our authors is that in our diverse population, the majority of patients with eruptive syringomas exhibit little or no fibrosis within the stroma of the neoplasm, whereas the classic features of syringomas include stromal fibrosis.
The pathogenesis of eruptive syringomas remains unclear. Several studies associate their development with inflammatory processes.10-12 Some studies hypothesize that eruptive syringomas develop as reactive hyperplasia from inflammatory triggers, instead of being a true neoplasm.10 Hormones such as progesterone are also hypothesized to play a role, due to eruptive syringomas’ increased incidence in women.13 Additionally, a correlation with immunosuppression has been proposed, with one case report describing an eruptive syringoma that developed post-liver transplantation.14 Our patient, however, exhibited no identifiable inflammatory or immunosuppressive triggers.
Eruptive syringomas are typically asymptomatic, as is the case in this patient. As such, patients seek treatment primarily for cosmetic reasons. Treatments include retinoids, trichloroacetic acid, atropine, chemical peels, laser, dermabrasion, botulinum toxin A, electrodesiccation, and surgery.3,7,15-17 However, treatment can be costly and often unsuccessful.1,17 In patients with darker skin tones, treatment is challenging due to the increased risk of post-inflammatory hyperpigmentation.5,18
This case demonstrates an atypical presentation of eruptive syringomas, adding to the current understanding of skin conditions in darker-skinned populations, a population in which dermatology conditions are commonly misdiagnosed and underrepresented in dermatological literature.19,20 This is particularly significant given the higher prevalence of eruptive syringomas in Asian and Black individuals.5 The recognition of skin diseases in darker skin types is essential, as the presentation can significantly differ from those in lighter skin, potentially leading to misdiagnosis or delayed treatment.
In conclusion, this case report highlights a clinical presentation of eruptive syringomas and adds to the current understanding of dermatological manifestations in patients with skin of color. The authors hope this case will promote awareness and improve diagnosis and clinical outcomes in the skin of color patients.
DISCLOSURES
The authors have no conflicts of interest to disclose.
REFERENCES
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- Lei H, Wang Z, Ma X, et al. Eruptive syringomas: summary of ninety cases and a brief literature review. J Cosmet Dermatol. 2023;22(3):1128-1133.
- Friedman SJ, Butler DF. Syringoma presenting as milia. J Am Acad Dermatol. 1987;16(2 Pt 1):310-314.
- Jamalipour M, Heidarpour M, Rajabi P. Generalized eruptive syringomas. Indian J Dermatol. 2009;54(1):65-67.
- Teixeira M, Ferreira M, Machado S, et al. Eruptive syringomas. Dermatol Online J. 2005;11(3):34.
- Huang A, Taylor G, Liebman TN. Generalized eruptive syringomas. Dermatol Online J. 2017;23(9).
- Medscape. Syringoma. Available at: https://emedicine.medscape.com/ article/1059871-overview#a7. Accessed November 2, 2023.
- Avhad G, Ghuge P, Jerajani HR. Generalized eruptive syringoma. Indian J Dermatol. 2015;60(2):214.
- Aleissa M, Aljarbou O, AlJasser MI. Dermoscopy of eruptive syringoma. Skin Appendage Disord. 2021;7(5):401-403.
- Lee AY, Kawashima M, Nakagawa H, et al. Generalized eruptive syringoma. J Am Acad Dermatol. 1991;25(3):570-1.
- Guitart J, Rosenbaum MM, Requena L. ‘Eruptive syringoma’: a misnomer for a reactive eccrine gland ductal proliferation? J Cutan Pathol. 2003;30(3):202-205.
- Hassab-El-Naby HMM, Nouh AH. Syringomatous dermatitis: a myth or an existing entity? Arch Dermatol Res. 2023;315(6):1649-1654.
- Husein-El Ahmed H, Aneiros-Fernandez J, Aneiros-Cachaza J. “Eruptive” facial syringomas: an inflammatory skin reaction? Skinmed. 2012;10(3):186-187.
- Wallace ML, Smoller BR. Progesterone receptor positivity supports hormonal control of syringomas. J Cutan Pathol. 1995;22(5):442-445.
- Maeda T, Natsuga K, Nishie W, et al. Extensive eruptive syringoma after liver transplantation. Acta Derm Venereol. 2018;98(1):119-120.
- Gómez MI, Perez B, Azana JM, et al. Eruptive syringoma: treatment with topical tretinoin. Dermatology. 1994;189(1):105-106.
- Frazier CC, Camacho AP, Cockerell CJ. The treatment of eruptive syringomas in an African American patient with a combination of trichloroacetic acid and CO2 laser destruction. Dermatol Surg. 2001;27(5):489-492.
- Zaldivar-Fujigaki JL, Achell Nava L. Botulinum toxin A as monotherapy for syringoma. J Cosmet Dermatol. 2021;20(5):1393-1395.
- Markiewicz E, Karaman-Jurukovska N, Mammone T, et al. Post-inflammatory hyperpigmentation in dark skin: molecular mechanism and skincare implications. Clin Cosmet Investig Dermatol. 2022;15:2555-2565.
- Lyman M, Mills JO, Shipman AR. A dermatological questionnaire for general practitioners in England with a focus on melanoma; misdiagnosis in Black patients compared to White patients. J Eur Acad Dermatol Venereol. 2017;31(4):625-628.
- Diao JA, Adamson AS. Representation and misdiagnosis of dark skin in a large-scale visual diagnostic challenge. J Am Acad Dermatol. 2022;86(4):950-951.
SOURCE
Wang, Jennifer, et al. “Inverse Eruptive Syringoma in a Skin of Color Patient.” Journal of Drugs in Dermatology: JDD 23.7 (2024): 564-566.
Content and images used with permission from the Journal of Drugs in Dermatology.
Adapted from original article for length and style.
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