Introduction

Trichilemmal (pilar/pilosebaceous) cysts are lined by stratified squamous epithelium and consist of a well keratinized epidermal wall surrounding semisolid hair keratin.^[1,2] They are most common in women, 90% are found in the scalp. They are solitary in 30% and 70% are multiple.^[3] As the cysts are attached to skin clinically, they pose a difficulty in differentiating from sebaceous cysts. Accurate diagnosis is made on histopathology by pathologists. Unlike sebaceous cyst, pilar cyst have no central punctum, an absent granular layer on histology.^[4] In Ayurveda, it can be correlated with Kaphaja Granthi^[5] by its Lakshanas and Chedana Karma told for its management by Sushruta. In view of this, we have classically embraced Chedana Karma as taught by Sushruta and we have got promising results in this single case study.

Case Report

A 53-year-old female patient visited Shalya Tantra OPD of SDM Ayurveda Hospital, Udupi with compl-aints of painless swelling over scalp in last 1 year. Onset of swelling was gradual and no associated symptoms were preset like pain, discharge or itching. Swelling gradually increased in size in about a year to cause cosmetic disfigurement. Her past history is significant for a similar lesion on scalp and was operated 4 years back. Family history revealed surgery for similar lesion in her mother. Her general and systemic examination was unremarkable with pulse rate 74/min, Blood pressure 130/80mmhg. Routine laboratory investigations were within normal limits. The systemic examination revealed no evident abnormalities.

Local examination

On examination, the swelling was located in the parietal region of the scalp. It was solitary, well defined, smooth and tense, measuring 3*2 cm.

On palpation swelling was fixed to the skin and free from deep fascia. Swelling proved positive for transillumination test (fig. 1).

No tenderness or rise in temperature noted and cough impulse was negative. Based on these finding a clinical diagnosis of Pilar cyst was made after considering differential swellings on the scalp like: Pilar cyst, Lipoma, Sabaceous cyst, Dermoid cyst, Meningeocele and Vascular malformations.

Figure 3: Incision of site

Figure 4: Excision of cyst

After the treatment, the patient achieved complete recovery with no relapse during the 3 months of clinical follow-up.

Discussion

Pilar cyst is derived from external root sheath of the follicular isthmus, which is also referred to as isthmus-catagen cyst. Pilar cyst accounts for 20% of epithelial cysts and the rest are epidermal.^[6] Histologically, pilar cysts are characterized by the absence of intercellular bridges between the epithelial cells lining the cyst wall. The peripheral epithelial layers display a palisading arrangement, while the cells closer to the cyst cavity are larger and contain abundant pale cytoplasm.^[7] In Ayurveda, Granthi^[8] is characterized by Vrutta, Unnata, Gratitha Shopha. Pilar cyst can be considered under Kaphaja Granthi having Lakshanas like Alpa Vedana, Chirabhivruddhi, Pashanavat Samhanana and Shukla Ghana Srava. The classical treatment explained for Kaphaja Granthi is Shodhana, Vimlapana, Lepa and Chedana. Chedana Karma,^[9] one among Ashtavidha Shastra Karma is indicated for its complete resolution. Kaishora Guggulu is a formulation indicated in Vrana and found to have anti-inflammatory property and promote wound healing.^[10] Gandhaka Rasayana has proved antimicrobial properties promotes fibroblast activation and by modulation of proteins helps in tissue remodelling.^[11] Panchatiktaka Kashaya accelerates tissue repair, encourages hea-lthy granulation tissue and reduce inflammation.^[12]