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Human papillomavirus‐related verrucous cysts and hypergranulotic dyscornification within a cyst are likely distinct entities

We read with great interest the case series by Nanes et al. We hope to explore whether some of the “verrucous pilar cysts” that they report may alternatively have histopathologic features of hypergranulotic dyscornification, which we have recently described in an epidermoid cyst and in a series of 29 solitary keratoses. 2 All our cases were negative for human papillomavirus (HPV) infection as showed by an anti-HPV immunohistochemical stain (BPV-1/1H8 + CAMVIR, ab2417; Abcam, Cambridge, MA), although this antibody does not detect beta-HPV types. Hypergranulotic dyscornification (HD) is an epithelial reaction pattern that may be found in solitary benign keratoses; we postulate that it can be seen as an incidental finding like other reaction patterns including epidermolytic hyperkeratosis and acantholytic dyskeratosis. It was originally reported by Martin Reichel in a series of eight cases and also presented at two national dermatology and dermatopathology meetings. HD is best observed at the level of the granular layer that shows irregular geometric clumped keratohyaline granules, distinct from the fine and coarse speckled hypergranulosis of verrucous lesions confirmed to be secondary to HPV by immunohistochemical or molecular studies. Koilocytes/ koilocytic cells with perinuclear haloes are absent in HD. Additionally, dull eosinophilic anucleate shadows of cells, sometimes with a halo, can be seen within the stratum corneum forming broad eosinophilic columns, immediately above the areas of this peculiar hypergranulosis; also, discrete foci of bright pink cytoplasm can be seen in the stratum spinulosum. The histopathology depicted in select cases (Figures 1A,D, and especially F) described by Nanes et al is suggestive of hypergranulotic dyscornification within a cyst and may explain why six of eight of their cases were negative for HPV by polymerase chain reaction or immunohistochemistry. We agree that cysts may harbor HPV, such as some pilar cysts in the series from Nanes et al, and other epidermoid cysts in the literature. These typically display histopathologic features of verrucae including koilocytes/koilocytic change, and contain HPV by various detection methods. However, other so-called “HPV-related follicular cysts,” possibly including some in this series and those described by Aloi et al are negative for HPV and show a striking resemblance to HD with irregularly clumped keratohyaline granules and dull shadows of corneocytes above within the stratum corneum (in the luminal