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Background:  Pilomatricoma (PM) is one of the most common benign tumours in children. However, the inaccuracy of preoperative diagnosis and evaluation is high. Non-invasive examinations, including dermoscopy and ultrasound are helpful for diagnosing and evaluating PM. To date, ultra-high-frequency ultrasonographic features of PM have been rarely studied.   Objective:  We aimed to investigate the ultra-high frequency ultrasonographic features of PM in a large paediatric cohort and to determine the associations of these features with the clinical features of different histological subtypes of PM.   Methods:  This was a retrospective study. Patients who had both preoperative ultra-high-frequency ultrasonographic evaluation and pathological diagnosis of PM were enrolled. A series of infantile haemangiomas and cutaneous cysts during the same period were included as controls. Histological findings, including the stage, calcifying type, and ultrasonographic features of each lesion, were described.   Results:  A total of 133 patients with PM were included, and 147 PM lesions were analysed. The male-to-female ratio was 1:1.58, and the median age of onset was 91 (range: 10–188) months. On ultra-high-frequency ultrasonography, PM presented as heterogeneous (144/147, 98.0%), well-demarcated (143/147, 97.3%), and hypoechoic (126/147, 85.7%) tumours located between the deep dermis and subcutaneous tissue (139/147, 94.6%). The most common features were internal echogenic foci (135/147, 91.8%), hypoechoic rim (133/147, 90.5%), and posterior acoustic shadowing (94/147, 63.9%). Fourteen (9.5%) lesions were histologically categorized in the early stage, 58 (39.5%) in the fully developed stage, 65 (44.2%) in the early regressive stage and 10 (6.8%) in the late regressive stage. Three calcifying types, including scattered dots, clumps and arcs, were observed on histologic examination, which corresponded well with grey-scale imaging on ultra-high-frequency ultrasonography. Each calcifying type was significantly different in various histological stages ( P  = 0.001), among which scattered dots were mainly present in the early and fully developed stage and arc-shaped calcifying were present in the regressive stages. Calcification was observed in skin cysts, while there was more frequent posterior enhancement, less frequent posterior shadowing, and hypoechoic rim than PM. Haemangioma also presented as a hypoechoic tumour on grey-scale imaging. However, haemangioma was homogeneous and rarely calcifying.   Conclusions:  PM is a heterogeneous, well-demarcated, hypoechoic tumour located between the deep dermis and the subcutis on ultra-high-frequency ultrasonography. The most common features are internal echogenic foci (calcifying) and hypoechoic rim. Calcifying types can help in the staging of PM. Ultra-high-frequency ultrasound is a useful tool for the diagnosis and evaluation of PM.

Ultra-High-Frequency Ultrasound in the Evaluation of Paediatric Pilomatricoma Based on the Histopathologic Classification