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Paisley tie differential diagnoses
By Sujitha Yadlapati, MD, and Thomas Davis, MD, FAAD
Diagnosis Histopathologic Clinical features and Histology image
features associations
Desmoplastic • Central dell • Also known as a scle-
trichoepithelioma • Tadpole-shaped rosing epithelial ham-
cords and strands artoma, sometimes
• Pink collagenous associated with a
stroma melanocytic nevus
• Respects the der- • Solitary, firm, flesh-
mal subcutaneous colored papule with
junction; often has central dell. The clas-
a horizontal growth sic presentation is on
pattern. the cheek of a young
• Horn cysts with cal- woman.
cification common
• Clefts between
collagen fibers
within stroma ver-
sus epithelium and
stroma as seen in
morpheaform BCC

Microcystic adnexal • Deeply infiltrative • Indurated plaque on

carcinoma (MAC) tumor the upper lip, cheek,
• Bland basaloid or chin
strands in the der- • More common in mid-
mis dle-aged and older
• Bi lineage differen- adults
Sujitha tiation (horn cysts – • High recurrence rate
Yadlapati, follicular differentia-
tion; tadpole ducts
MD, is a PGY-2 – sweat duct differ-
dermatology resident entiation)
at HCA Healthcare • Frequently exhibits
Corpus Christi perineural invasion
Medical Center-Bay • Lymphoid aggre-
Area Program. gates

Morpheaform Basal • Thin cords of basa- • Indurated firm plaque

cell carcinoma loid cells invading resembling a scar in
the dermis an older individual.
• Sclerotic stroma
• Clefting between
epithelium and
stroma (if present)
• Mitoses and apop-
totic cells often
present
• May demonstrate
perineural invasion

Thomas Davis, Syringoma • Islands or clusters • Cheek, under the eyes

of tadpole-shaped in young women
MD, FAAD, is a sweat ducts in • Clear cell variant can
dermatopathologist
dense sclerotic be noted in diabetes
with Sagis Diagnostics background stroma. • Common in Asian
in Dallas and serves • Lacks follicular women, and children
as vice-president of differentiation with Down syndrome
education for the • Eruptive syringomas
organization. can be noted on the
chest, back, or penis.

p. 1 • Winter 2021 www.aad.org/DIR

boards fodder
Paisley tie differential diagnoses
By Sujitha Yadlapati, MD, and Thomas Davis, MD, FAAD

Characteristics of Paisley tie pattern tumors

Characteristic MAC Desmoplastic Syringoma Morpheaform BCC
trichoepithelioma
Paisley tie pattern Yes, throughout Yes Yes Sometimes super-
the tumor ficially
Stroma Red, sclerotic Red, sclerotic Red, sclerotic Red, sclerotic; may
have mucin
Horn cysts Common Common Occasional (lacks fol- Occasional
licular differentiation)
Calcification Rare Common Rare Rare
Deeply invasive Yes (a hallmark of No No Can be
MAC)
Perineural invasion Yes No No Yes
Central dell No Yes No No
Clinical presentation Firm plaque on the Firm papule on the Small papules on lower Indurated scar-like
upper lip, medial cheek of a young lids, common with plaque in an older
cheek, or chin female Down syndrome, and in individual
Asian females
References:
1. Elston, D. “Sweat gland neoplasms.” Dermatopathology, by Dirk M. Elston et al., 3rd ed., Elsevier, 2019, pp. 88-9.
2. Elston, D. “Pilar and sebaceous neoplasms.” Dermatopathology, by Dirk M. Elston et al., 3rd ed., Elsevier, 2019, pp. 72.
3. Rapini, R. “Sweat Gland neoplasms.” Practical Dermatopathology, by Ronald P. Rapini, 3rd ed., Elsevier Health Sciences,
2012, pp. 286-8.

p. 2 • Winter 2021 www.aad.org/DIR