Dilated Pore of Winer

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Background

A dilated pore of Winer is a hair structure anomaly that appears as an enlarged solitary comedo.[1] Most commonly, it appears on the face of a middle-aged person. This condition is not associated with acne vulgaris. See the images below.



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Dilated pore of Winer on forehead.



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Dilated pores of Winer on forehead and lateral upper labial region.



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Dilated pore of Winer on lateral upper labial region.

Pathophysiology

A dilated pore of Winer is a tumor of the intraepidermal follicle and infundibulum of a pilosebaceous apparatus.[2] An immunohistochemical study using monoclonal antibodies against cytokeratins and involucrin confirmed differentiation toward the infundibulum and partly toward the isthmus.[3]

Epidemiology

Frequency

Most cases of dilated pore of Winer are reported in older adults in both the American and European literature.

Race

Most cases of dilated pore of Winer have been reported in white males.

Sex

Although dilated pores are found in both sexes, they appear to occur in men more often than in women.

Age

Most cases of dilated pore of Winer are diagnosed in individuals older than 40 years; however, many individuals report that they have had the lesions for many decades, usually starting when they are aged 20-60 years.

History

Most patients with dilated pore of Winer consult a dermatologist after many years of dealing with an unsightly, enlarged pore on the face.[4]

Patients with dilated pore of Winer usually have a past or present history of severe acne.

Patients report needing to repeatedly express a keratotic plug from the center of the dilated pore of Winer. The expression of this plug allows the further removal of caseous, white, soggy keratin from the deeper portion of the pore. Once the content of the dilated pore is expressed, a keratotic material similar to the original plug refills the pore within several weeks.

Physical

A dilated pore of Winer usually appears as a solitary large comedo on the face, predominantly on the upper lip, cheek, or forehead. The lesion can also be found on the trunk, most commonly the back. A rare incidence involving external ear canal has also been reported.[5]

The skin surrounding the pore appears to be unchanged, with no inflammation or induration.

Causes

The cause of a dilated pore of Winer is unknown. Winer suggested that an infection or an obstruction of the follicle ostium is the stimulus for the development of a dilated pore of Winer in a process similar to those of inflammatory cystic acne or other cystic conditions.

Procedures

Dermoscopic findings

Dermoscopic examination shows a pinkish nodule with peripheral vessels in a regular pattern. The individual vessels at the periphery of the lesion extend towards the center. The size of the vessels decreases with every progressive branching. The center of the lesion reveals a dilated ostium filled with terminal hairs.[8]

Biopsy

Histologic examination of a biopsy specimen from the lesion is the only way to make a definitive diagnosis.

Histologic Findings

A dilated follicular infundibulum extends deep into the dermis and, at times, into the subcutaneous tissue. The cavity is lined by the epidermis, which is atrophic near the follicular ostium. The epidermis is hypertrophic and proliferative in the deeper portion of the invagination where the numerous rete ridges project into the surrounding stroma. The cavity is filled with laminated keratin. Vellus hair follicles and small sebaceous lobules may be attached to the lower portion of the infundibulum.[9] Gonzalez-Guerra et al reported in 2008 that cutaneous adnexal tumors of the hair follicle can be identified using immunohistochemistry studies for calretinin, with differentiation towards cells of the outer root sheath.[10]



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Hematoxylin and eosin stain. Original magnification X40. Courtesy of Lawrence Machtinger, MD.



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Image shows an epidermal lining that is atrophic near the ostium but progressively hypertrophic and proliferative, with numerous rete ridges, in the d....



View Image

The cavity is filled with laminated keratin (hematoxylin and eosin, original magnification X100).

Medical Care

No medical treatment is available for a dilated pore of Winer.

Surgical Care

Excision of the entire lesion and closure of the resulting surgical defect are curative.

Superficial treatments, such as electrodesiccation, cauterization, coagulation, dermabrasion, or carbon dioxide laser surgery, are less effective because of the deeply invaginated base of a dilated pore of Winer.

Consultations

A dermatopathologist may be consulted.

Complications

Manipulation of a dilated pore of Winer may lead to infection and scarring.

Prognosis

Incomplete excision results in regeneration of the dilated pore from the residual infundibular lining. Prognosis is excellent with no known report of death. One case of trichoid basal cell carcinoma in a dilated pore has been reported.[11] More commonly, chronic manipulation and expression of the keratotic plug from inside the pore may lead to inflammation and infection of the surrounding tissue.

Author

Alyssa Y Kim, MD, Clinical Associate Professor, Department of Dermatology, Keck School of Medicine of the University of Southern California

Disclosure: Nothing to disclose.

Specialty Editors

Michael J Wells, MD, FAAD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD, Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Neil Shear, MD, Professor and Chief of Dermatology, Professor of Medicine, Pediatrics and Pharmacology, University of Toronto Faculty of Medicine; Head of Dermatology, Sunnybrook Women's College Health Sciences Center and Women's College Hospital, Canada

Disclosure: Nothing to disclose.

Acknowledgements

Author would like to thank Dr Lawrence Marchtinger for his contribution of the microscopic slides.

References

  1. Winer LH. The dilated pore, a tricho-epithelioma. J Invest Dermatol. 1954 Sep. 23(3):181-8. [View Abstract]
  2. Steffen C. Winer's dilated pore: the infundibuloma. Am J Dermatopathol. 2001 Jun. 23(3):246-53. [View Abstract]
  3. Morikawa T, Takizawa H, Ohnishi T, Watanabe S. Dilated pore: a case report and an immunohistochemical study of cytokeratin expression. J Dermatol. 2003 Jul. 30(7):556-8. [View Abstract]
  4. Jakobiec FA, Bhat P, Sutula F. Winer's dilated pore of the eyelid. Ophthal Plast Reconstr Surg. 2009 Sep-Oct. 25(5):411-3. [View Abstract]
  5. Ayoub OM, Timms MS, Mene A. Winer's dilated pore, rare presentation in the external ear canal. Auris Nasus Larynx. 2001 Nov. 28(4):349-52. [View Abstract]
  6. Walsh SN, Cruz DJ, Hurt MA. Hair cortex comedo: a series of 34 cases. Am J Dermatopathol. 2010 Dec. 32(8):749-54. [View Abstract]
  7. Lee JY, Hirsch E. Pilar sheath acanthoma. Arch Dermatol. 1987 May. 123(5):569-70. [View Abstract]
  8. Moreira A, Menezes N, Guedes R, Tente D, Baptista A, Varela P. Dermoscopy of a dilated pore of Winer. Eur J Dermatol. 2010 Mar-Apr. 20(2):229. [View Abstract]
  9. Klovekorn G, Klovekorn W, Plewig G, Pinkus H. [Giant pore and hair-shaft acanthoma. Clinical and histologic diagnosis]. Hautarzt. 1983 May. 34(5):209-16. [View Abstract]
  10. Gonzalez-Guerra E, Requena L, Kutzner H. [Immunohistochemical study of calretinin in normal hair follicles and tumors with follicular differentiation]. Actas Dermosifiliogr. 2008 Jul-Aug. 99(6):456-63. [View Abstract]
  11. Carlson-Sweet KL, Weigand DA, MacFarlane DF. Trichoid basal cell carcinoma found in a dilated pore on the nose. Dermatol Surg. 2000 Sep. 26(9):874-6. [View Abstract]
  12. Burns T, Breathnach S, Cox N. Root's Textbook of Dermatology. 7th ed. Malden, Mass: Blackwell Science Ltd; 2004. 37.3.
  13. Champion RH, Burton JL, Burns DA, Breathnach S. Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. Oxford, England: Blackwell Science; 1998. 1696.
  14. Elder D, Elenitsas R, Johnson Jr B. Lever's Histopathology of the Skin. 9th ed. Philadelphia, Pa: Lippincott Williams Wilkins; 2005. 871-872.
  15. Farmer ER, Hood AF. Pathology of the Skin. 2nd ed. New York, NY: McGraw-Hill; 2000. 1026-7.

Dilated pore of Winer on forehead.

Dilated pores of Winer on forehead and lateral upper labial region.

Dilated pore of Winer on lateral upper labial region.

Hematoxylin and eosin stain. Original magnification X40. Courtesy of Lawrence Machtinger, MD.

Image shows an epidermal lining that is atrophic near the ostium but progressively hypertrophic and proliferative, with numerous rete ridges, in the deeper part of the cavity (hematoxylin and eosin, original magnification X100).

The cavity is filled with laminated keratin (hematoxylin and eosin, original magnification X100).

Hematoxylin and eosin stain. Original magnification X40. Courtesy of Lawrence Machtinger, MD.

Image shows an epidermal lining that is atrophic near the ostium but progressively hypertrophic and proliferative, with numerous rete ridges, in the deeper part of the cavity (hematoxylin and eosin, original magnification X100).

The cavity is filled with laminated keratin (hematoxylin and eosin, original magnification X100).

Dilated pore of Winer on forehead.

Dilated pores of Winer on forehead and lateral upper labial region.

Dilated pore of Winer on lateral upper labial region.