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Dear Editor: Sebaceous hyperplasia (SH) is a benign proliferation of the sebaceous glands that develops as a result of intrinsic aging, photo-aging, exposure to ultraviolet radiation, and genetic predisposition. Organ transplant recipients are susceptible to SH particularly on the face, where multiple large lesions may cause cosmetic concern. Several studies in the literature report SH being induced by cyclosporine due to immunosuppression of patients undergoing organ transplant. Oral isotretinoin and topical photodynamic therapy has previously been reported as a treatment for SH in immunocompetent individuals1,2,3. Other options include electrodesiccation, shave excision and carbon dioxide laser. However, only three cases of cyclosporine-induced SH in a kidney transplant population treated with oral isotretinoin have been reported in the English literature2,3. Therefore, we report a case of cyclosporine-induced SH in a renal transplant recipient successfully treated with oral isotretinoin, along with a review of the literature. A 40-year old Korean man presented in 2013 with multiple skin-colored papules on his face. He had undergone renal transplantation surgery in 1996, following which, he was immunosuppressed with oral cyclosporine and prednisolone for 11 years. He started to notice the facial lesions during this period. The initial doses were cyclosporine 350 mg (5.0 mg/kg body weight) and prednisolone 7.5 mg. The initial dosage was tapered and the patient eventually stopped taking the immunosuppressants in 2007. The patient then started taking tacrolimus 6 mg and prednisolone 5 mg for 4 years. Examination of his face revealed approximately a hundred skin-colored, umbilicated papules, 2 to 4 mm in size, which had increased in number for several years (Fig. 1A). Histological examination of the lesion demonstrated a peculiar superficial localization of the enlarged sebaceous glands in the upper dermis. The patient was diagnosed with SH. He was treated with daily oral isotretinoin 20 mg (0.29 mg/kg) for two months which resulted in near-complete remission without any side effect (Fig. 1B). Two months after discontinuing oral isotretinoin, a few new lesions started to develop. Oral isotretinoin 20 mg was restarted for two months. The lesions cleared without recurrence for nine months. Fig. 1 (A) Prominent multiple hyperplastic sebaceous glands seen as skin-colored papules (arrows) scattered on the right side of the face after treatment of cyclosporine for 11 years and tacrolimus for 4 years. (B) Sebaceous hyperplasia almost completely cleared ... Cyclosporine-induced SH has been reported in several series of organ transplant recipients. Among renal transplant recipients, 7 out of 67 (10%) and 5 out of 82 patients (6%) developed SH. In all cases, the patients were taking cyclosporine4. In an earlier report of 151 kidney transplant recipients who were not taking cyclosporine, SH did not occur5. These studies suggest that cyclosporine is a direct and causative factor of SH. Both tacrolimus and cyclosporine are calcineurin inhibitors sharing similar physicochemical properties and a common mechanism of action - inhibition of proinflammatory cytokines. In addition, both drugs are highly soluble in lipids allowing for cutaneous accumulation of the drugs and leading to dysplastic epithelial proliferation. Therefore, in this patient, it is possible to that oral tacrolimus might have played a role in developing SH. Sebaceous glands are mostly considered by dermatologists in association with acne and seborrhea; thus, the antiproliferative and sebostatic effects of isotretinoin have been extensively studied. Isotretinoin causes cell cycle arrest in human staphylococcal enterotoxin B-1 sebocytes in vitro, and apoptosis in human sebaceous glands in vivo2. To our knowledge, there are two other reports of renal transplant recipients receiving treatment for SH with isotretinoin (Table 1)2,3. Other reported effective treatments for cyclosporine-induced SH in patients undergoing renal transplant include carbon dioxide laser and topical photodynamic therapy. Table 1 Summary of previously reported cases of kidney transplant recipient receiving treatment for sebaceous hyperplasia with isotretinoin In conclusion, our case provides additional support for the safe and effective use of oral isotretinoin for cyclosporine-induced SH in patients undergoing renal transplant. However, further studies are needed to establish a treatment protocol for cyclosporine-induced SH in patients undergoing renal transplant.

Sebaceous hyperplasia (SH) is a proliferative abnormality of sebaceous glands, most often seen in elderly individuals. It consists of single or multiple, asymptomatic, small yellow papules with a central depression. The face is most commonly affected, but there have been reports of SH on the chest or genitalia. A lobular array of well-differentiated mature sebaceous lobules is noted on histological preparations. In this report, we describe a patient with SH on the penile shaft and parts of the scrotum.

Dear Editor: Syringomas are benign adnexal tumors of eccrine sweat duct origin. Clinically, they usually present as multiple, soft, skin-colored or yellowish papules and generally measure 1 to 2 mm in diameter. The sites of predilection are the face (especially the lower eyelids), cheeks, thigh, and axilla in a symmetrical or bilateral fashion1. A 39-year-old female patient presented with asymptomatic multiple flesh-colored papules on her trunk. The lesions had developed in crops about a month previously. Without spontaneous regression or improvement, the lesions had increased in number gradually. The patient's medical history was unremarkable, and she was not on any medication. She had no family history of similar skin lesions. Physical examination revealed multiple, flesh-colored to light-brownish, 2 to 4-mm-diameter papules across the right side of the trunk (Fig. 1). The lesions had a zosteriform distribution along the right T8 and T9 dermatomes. No other lesions were observed elsewhere on the whole body. Histopathological examination of the abdomen revealed numerous epithelial strands and small ducts in a fibrous stroma of the upper dermis (Fig. 2). Taking the clinicopathological features into consideration, the lesions were diagnosed as zosteriform syringomas and were successfully treated with carbon dioxide laser. The patient was followed for 6 months after the treatment, without any sign of recurrence and new lesion formation elsewhere on the whole body. Fig. 1 (A, B) Multiple, flesh-colored to light-brownish papules across the right side of the trunk in a zosteriform distribution (arrows). (C) Close-up view of the lesion. Fig. 2 Histopathological findings showing numerous epithelial strands and ductal differentiation in a fibrous stroma of the upper dermis (HE A: ×40, B: ×100). Syringomas usually present with a bilateral or symmetrical distribution. Although Hayashi et al.2 and Goday et al.3 reported about unilateral linear syringomas on the arm, until now cases of zosteriform syringomas have not been reported in the Korean literature. There was only one case report by Ceulen et al.4 in 2008 in Europe. In that case, the syringomas were distributed on the left side of the chest of an 18-year-old Caucasian male patient. Here, we report the first case of unilateral zosteriform syringomas on the right side of the abdomen. Typical periorbital syringomas may be easy to diagnose; however, when they show an unusual clinical manifestation, they could be misdiagnosed as sebaceous hyperplasia, milia, acne vulgaris, or lichen planus5. When encountering unilateral, zosteriform, popular dermatosis, dermatologists should consider syringomas in the differential diagnosis. The case presented here is a rare clinical form of syringomas that occurred in a zosteriform fashion. Although further investigations of the cellular and molecular levels are needed to uncover the precise pathogenesis of syringomas, we suggest that unilateral zosteriform patterns may well provide clues to the pathogenesis of syringomas with unknown etiology.

Dear Editor: Sebaceous hyperplasia (SH) is a common benign skin lesion composed of sebaceous glands. It is characterized by a yellow or flesh-toned papule that is commonly found on the face1. Treatment of SH is usually for the cosmetic reasons only. Although many kinds of treatment modalities have been applied to treat SH, a successful, long-standing eradication of SH remains difficult2. A 55-year-old man presented with a several-year history of multiple papules on the face. Physical examination revealed multiple yellow or flesh-toned papules on both cheeks and lateral canthus (Fig. 1A). Magnification with dermatoscopy showed yellowish papules with overlying telangiectasias. He did not present with subjective symptoms that are frequently associated with skin lesions. On the basis of clinical findings, the patient's condition was diagnosed as SH. After 1-hour application of topical anesthesia (EMLA cream, AstraZeneca AB, Sodertalje, Sweden), we made a small, ~1 mm diameter opening in each papule using the carbon dioxide laser, then squeezed the papules using an acne extractor to induce shrinkage of the sebaceous lobules. Sebaceous contents were easily discharged through the small papule openings, and the size of the lesions decreased after squeezing. After squeezing, the small papule openings were shot by the carbon dioxide laser to remove the shrunken sebaceous lobules. The treatment was tolerable to the patient, and there were no bleeding or other signs of severe tissue damage. Most of the lesions were flattened after the procedure, and small crusts made by the carbon dioxide laser disappeared after 10 days of the treatment (Fig. 1B). After 3 months of the treatment, there were neither signs of recurrence nor specific side-effects related to the treatment. Fig. 1 (A) Multiple yellow or flesh-toned papules on both cheeks and lateral canthus. (B) Most lesions disappeared after 10 days of treatment. Various treatment modalities for SH have been used such as isotretinoin, cryosurgery, the pulsed-dye laser, and the carbon dioxide laser2-5. However, a long duration of down-time between treatments is necessary, as various kinds of laser therapy and cryosurgery inevitably cause epidermal damage. In addition, adverse effects such as persistent erythema, edema, infection, and persistent hyperpigmentation are not uncommon. Although the non-ablative lasers and isotretinoin can be used to avoid these limitations, the high cost may be a burden to patients. In this case, we used a simple method that required making an opening in the multiple SHs, using a carbon dioxide laser, with the subsequent squeezing by an acne extractor. Different from the conventional uses of the carbon dioxide laser, we used the laser only to make very small openings and to eradicate the shrunken sebaceous lobules. Because we made minimal epidermal changes, there were no side-effects related to the laser treatment such as persistent erythema, edema, infection, and persistent hyperpigmentation. In addition, the patient did not feel discomfort during the procedure. In summary, we report a case of SH that was effectively improved by the pin-hole technique with the carbon dioxide laser. We think that this method may be used as an alternative therapy for the treatment of SH. Further study is warranted to determine the longevity of the clinical results observed.