A renal transplant recipient with multiple facial nodules

A 42-year-old male renal transplant recipient onciclosporin and steroid developed multiple enlargingnodulocystic lesions on face, neck and retroauricularregions. The lesions had never been present beforerenal transplant but occurred around 3 months afterthe operation and had increased in size in recentfew months. Examination revealed multiple soft non-tender cystic lesions on both sides of neck, retro-auricular areas and cheeks. The lesions ranged from0.3 to 3cm in diameter and some were pedunculated.Inflammation of the overlying skin and ulceration werenoted in some lesions (Figure 1A and B). Surgicalexcision revealed encapsulated cysts containing pastymaterial. Histological examination confirmed epider-mal cysts in the dermis, lined by stratified squamousepithelium containing laminated keratin. One excisedcyst was ruptured and associated with acute on chronicinflammation and a foreign body giant cell reaction.The eruption of the epidermoid cysts was temporallyrelated to renal transplantation and was most likelyassociated with ciclosporin use, which was, therefore,substituted by rapamycin. As the patient had a largenumber of epidermoid cysts of various sizes, selectiveexcision of the larger cysts was offered. The patient wasfollowed-up regularly for the progression of the cysticlesions and for surveillance of malignant cutaneoustumors. Graft function had remained stable afterswitching of immunosuppressive medications and nonew epidermoid cysts or further enlargement of theexisting lesions were noted.