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Table of Contents 
CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 4  |  Page : 403-405
Reactive eccrine syringofibroadenomatosis presenting as bilateral plantar hyperkeratosis


1 Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication10-Jul-2015

Correspondence Address:
Dr. Laxmisha Chandrashekar
Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.160497

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   Abstract 

Eccrine syringofibroadenoma (ESFA) is a rare cutaneous tumor with eccrine differentiation with varied clinical manifestations. We report a case of reactive eccrine syringofibroadenomatosis associated with chronic bilateral plantar ulcers in a patient with diabetes mellitus presenting as plantar hyperkeratosis and verrucous growth at margins.


Keywords: Eccrine, diabetes mellitus, syringofibroadenomatosis


How to cite this article:
Singh N, Chandrashekar L, Shakthi P, Thappa DM, Badhe BA, Sylvia MT. Reactive eccrine syringofibroadenomatosis presenting as bilateral plantar hyperkeratosis. Indian J Dermatol 2015;60:403-5

How to cite this URL:
Singh N, Chandrashekar L, Shakthi P, Thappa DM, Badhe BA, Sylvia MT. Reactive eccrine syringofibroadenomatosis presenting as bilateral plantar hyperkeratosis. Indian J Dermatol [serial online] 2015 [cited 2019 Sep 23];60:403-5. Available from: http://www.e-ijd.org/text.asp?2015/60/4/403/160497

What was known?
Patients of diabetes mellitus with long standing plantar ulcers may develop reactive eccrine syringofibroadenomatosis.



   Introduction Top


Eccrine syringofibroadenoma (ESFA) is a rare cutaneous tumor with eccrine differentiation with varied clinical manifestations. [1] ESFA was first described by Mascaro [2] in 1963 as a solitary nodule characterized histopathologically by anastomosing strands of epithelial cells embedded in a fibrovascular stroma. Starink [1] classified ESFA into four subtypes, which includes solitary ESFA, multiple ESFA with hidrotic ectodermal dysplasia, multiple ESFA without associated cutaneous findings and nevoid (nonfamilial, unilateral) ESFA. This classification has been modified by French [3] to include reactive ESFA associated with inflammatory or neoplastic dermatoses as the fifth subtype of ESFA. Reactive ESFA is better termed as "reactive eccrine syringofibroadenomatosis (ESFa)" to highlight that it is a reactive process and not a neoplasm. ESFA may present as solitary nodule or multiple papules, nodules, and plaques, in a "streusel bread"-like appearance usually on extremities of an elderly. [4] But, it may present on face, trunk and rarely nails. We report a case of reactive eccrine ESFa associated with chronic ulcers of bilateral feet in a patient with long-standing diabetes mellitus.


   Case Report Top


A 65-year-old female presented with non-healing ulcers over bilateral soles of 1 year duration and surrounding skin thickening of 6 months duration. She had been a known case of diabetes mellitus on oral hypoglycemic agents for the past 10 years. She gave history of repeated plantar ulcers and reduced sensation over bilateral feet up to the ankle region (diabetic neuropathy). There was no evidence of leprosy or past history of antileprosy treatment. Physical examination revealed two ulcers of size 1 × 2 cm and 2 × 3.5 cm over plantar aspect of bilateral feet. The skin surrounding the ulcers was hyperkeratotic and at the margin of hyperkeratotic area, multiple, coalescing, firm, flesh-colored nodules in "streusel bread"- like appearance were seen, more prominent on medial border of right sole [Figure 1] and [Figure 2]. Atrophic scars were present on plantar aspect of bilateral feet due to repeated multiple traumatic events and due to incision and drainage done before. There was no clinical or radiological evidence of osteomyelitis. A skin biopsy was taken from the flesh-colored nodule over right sole which on histopathological examination revealed hyperkeratosis, acanthosis, anastomosing thin cords of cuboidal epithelial cells extending from epidermis to dermis and a fibrovascular stroma [Figure 3]. Ductal structures were seen within the thin epithelial cords [Figure 4]. Immunohistochemistry revealed staining of ducts by S100 [Figure 5] but not by carcinoembryonic antigen (CEA) and cytokeratin 19 (CK19). These clinico-histopathological findings were characteristic of ESFa. The patient was offered treatment options - surgical excision and CO 2 laser ablation of ESFa lesions but she refused both the procedures. She was advised regular cleaning and dressing of the ulcers, foot care measures and regular follow up.
Figure 1: Bilateral plantar ulcers with surrounding skin hyperkeratosis and a pink verrucous growth at medial border of bilateral sole

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Figure 2: Pink verrucous growth over medial border of right sole

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Figure 3: Photomicrograph showing anastomosing strands of epithelial cells embedded in a fibrovascular stroma (H and E, × 100)

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Figure 4: Higher magnification photomicrograph showing thin epithelial strands with ductal structures (H and E, × 400)

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Figure 5: Photomicrograph showing staining of eccrine ducts by S100 (S100, × 400)

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   Discussion Top


Reactive ESFa accounts for approximately a quarter of reported cases of ESFA. [5] Reactive ESFa occurs in cases with repeated tissue damage and repair which results in reactive hyperplasia of eccrine ducts. It has been proposed that reactive ESFA represents a hyperplastic and hamartomatous process and hence, "reactive eccrine syringofibroadenomatosis" may be the more appropriate terminology. [5] Reactive ESFa presents as a response to inflammatory and neoplastic dermatoses like chronic ulceration of feet (related to diabetes mellitus, [6] leprosy [7] ), burn scars, [8] peristomal dermopathy, [9] erosive palmoplantar lichen planus, [10] bullous pemphigoid, [11] nail trauma, [12] nevus sebaceous [13] and squamous cell carcinoma. [14] Diabetes mellitus typically causes diabetic neuropathy and these patients frequently sustain traumatic injuries resulting in frequent skin repair and remodeling, which may result in abnormal epithelial changes and eccrine ductal proliferation, thus resulting in ESFa. [6],[7] Scarring after recurrent infections may also predispose the skin to ESFa. It has also been postulated that reactive ESFa may be related to altered sympathetic nerve function possibly affecting regeneration of traumatized eccrine tissues and thus contributing to cellular proliferation. [7] Both diabetes mellitus and leprosy are known to affect autonomic nerves and lead to neuropathy. Our case had ESFa bilaterally which could be related to the diabetic neuropathy predisposing to frequent and recurrent plantar ulceration and alteration in sympathetic nerve function due to diabetes. Clinically, reactive ESFa usually presents as erythematous lesions unlike other types of ESFA. But, in our case the erythematous verrucous growth consisting of multiple, coalescing, firm, flesh-colored nodules in a "streusel bread"- like appearance was visible only along the medial border of right sole and instead there was predominant plantar hyperkeratosis which could be due to pressure effect of weight bearing of the sole. The histologic features of ESFA are diagnostic, which includes multiple thin anastomosing cords of cuboidal epithelial cells which forms a lattice and are embedded in fibrovascular stroma. These anastomosing cords of epithelial cells are connected to the undersurface of epidermis and characteristically show ductal differentiation. On immunohistochemistry, S100 stains the outer layer of eccrine ducts as was seen in our case. [15] CEA stains the luminal surface of eccrine ducts. [16] Cytokeratin 19 positivity has been reported to be confined to luminal ductal cells of ESFA. [17] But in our case it did not stain the luminal surface probably due to scarring. The clinical course of ESFA is benign, although malignant transformation to eccrine syringofibrocarcinoma and the association with squamous cell carcinoma has been reported. But there has been no report of malignancy in reactive ESFa yet, so probably the risk of malignant transformation in reactive ESFa is lower than other subtypes. Regular monitoring of reactive ESFa is preferable to surgical excision. [5] An alternative to surgical excision is CO 2 laser ablation for ESFa lesions at difficult to treat anatomical sites or in cases of refusal of surgical excision. [18] Radiotherapy is also an option that can be considered for ESFa at difficult to treat locations. [19]


   Conclusion Top


Reactive ESFA has been reported with diabetes mellitus but bilateral reactive ESFA presenting as plantar hyperkeratosis with verrucous growth at margins in a patient with diabetes mellitus is unique and an interesting finding.



 
   References Top

1.
Starink TM. Eccrine syringofibroadenoma: Multiple lesions representing a new cutaneous marker of the Schöpf syndrome, and solitary nonhereditary tumors. J Am Acad Dermatol 1997;36:569-76.  Back to cited text no. 1
    
2.
Mascaro JM. Considerations on fibro-epithelial tumors. Exocrine syringofibradenoma. Ann Dermatol Syphiligr (Paris) 1963;90:143-53.  Back to cited text no. 2
    
3.
French LE. Reactive eccrine syringofibroadenoma: An emerging subtype. Dermatology 1997;195:309-10.  Back to cited text no. 3
    
4.
Cho E, Lee JD, Cho SH. A case of reactive eccrine syringofibroadenoma. Ann Dermatol 2011;23:70-2.  Back to cited text no. 4
    
5.
Tey HL. Characterizing the nature of eccrine syringofibroadenoma: Illustration with a case showing spontaneous involution. Clin Exp Dermatol 2009;34:e66-8.  Back to cited text no. 5
    
6.
Utani A, Yabunami H, Kakuta T, Endo H, Shinkai H. Reactive eccrine syringofibroadenoma: An association with chronic foot ulcer in a patient with diabetes mellitus. J Am Acad Dermatol 1999;41:650-1.  Back to cited text no. 6
    
7.
Tey HL, Chong WS, Wong SN. Leprosy-associated eccrine syringofibroadenoma of Mascaro. Clin Exp Dermatol 2007;32:533-5.  Back to cited text no. 7
    
8.
Ichikawa E, Fujisawa Y, Tateishi Y, Imakado S, Otsuka F. Eccrine syringofibroadenoma in a patient with a burn scar ulcer. Br J Dermatol 2000;143:591-4.  Back to cited text no. 8
    
9.
Mattoch IW, Pham N, Robbins JB, Bogomilsky J, Tandon M, Kohler S. Reactive eccrine syringofibroadenoma arising in peristomal skin: An unusual presentation of a rare lesion. J Am Acad Dermatol 2008;58:691-6.  Back to cited text no. 9
    
10.
French LE, Masgrau E, Chavaz P, Saurat JH. Eccrine syringofibroadenoma in a patient with erosive palmoplantar lichen planus. Dermatology1997;195:399-401.  Back to cited text no. 10
    
11.
Nomura K, Hashimoto I. Eccrine syringofibroadenomatosis in two patients with bullous pemphigoid. Dermatology 1997;195:395-8.  Back to cited text no. 11
    
12.
Theunis A, Andre J, Forton F, Wanet J, Song M. A case of subungual reactive eccrine syringofibroadenoma. Dermatology 2001;203:185-7.  Back to cited text no. 12
    
13.
Noguchi M, Akiyama M, Kawakami M, Nagashima T, Niizuma K, Matsuo I. Eccrine syringofibroadenoma developing in a sebaceous naevus. Br J Dermatol 2000;142:1050-1.  Back to cited text no. 13
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14.
Bjarke T, Ternesten-Bratel A, Hedblad M, Rausing A. Carcinoma and eccrine syringofibroadenoma: A report of five cases. J Cutan Pathol 2003;30:382-92.  Back to cited text no. 14
    
15.
Zhu L, Okano S, Takahara M, Chiba T, Tu Y, Oda Y, et al. Expression of S100 protein family members in normal skin and sweat gland tumors. J Dermatol Sci 2013;70:211-9.  Back to cited text no. 15
    
16.
Saga K. Histochemical and immunohistochemical markers for human eccrine and apocrine sweat glands: An aid for histopathologic differentiation of sweat gland tumors. J Investig Dermatol Symp Proc 2001;6:49-53.  Back to cited text no. 16
    
17.
Eckert F, Nilles M, Altmannsberger M. Eccrine syringofibroadenoma: A case report with analysis of cytokeratin expression. Br J Dermatol 1992;126:257-61.  Back to cited text no. 17
    
18.
Athanasiadis GI, Bobos M, Pfab F, Athanasiou E, Athanasiadis IE. Eccrine syringofibroadenoma treated with carbon dioxide laser. Clin Exp Dermatol 2009;34:261-3.  Back to cited text no. 18
[PUBMED]    
19.
Morganti AG, Martone FR, Macchia G, Carbone A, Massi G, De Ninno M, et al. Eccrine syringofibroadenoma radiation treatment of an unusual presentation. Dermatol Ther 2010;23(Suppl 1):S20-3.  Back to cited text no. 19
    

What is new?
Reactive eccrine syringofibroadenomatosis can present as plantar hyperkeratosis with verrucous growth at margins in a patient with diabetes mellitus, sometimes even bilaterally.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

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