Hair follicle

The hair follicle is a dynamic organ found in mammalian skin.[1] It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction between hormones, neuropeptides and immune cells.[1] This complex interaction induces the hair follicle to produce different types of hair as seen on different parts of the body. For example, terminal hairs grow on the scalp and lanugo hairs are seen covering the bodies of fetuses in the uterus and in some new born babies.[1] The process of hair growth occurs in distinct sequential stages. The first stage is called anagen and is the active growth phase, catagen is the resting stage, telogen is the regression of the hair follicle phase, exogen is the active shedding of hair phase and lastly kenogen is the phase between the empty hair follicle and the growth of new hair.[1]

The function of hair in humans has long been a subject of interest and continues to be an important topic in society, developmental biology and medicine. Of all mammals, humans have the longest growth phase of scalp hair compared to hair growth on other parts of the body.[1] For centuries, humans have ascribed esthetics to scalp hair styling and dressing and it is often used to communicate social or cultural norms in societies. In addition to its role in defining human appearance, scalp hair also provides protection from UV sun rays and is an insulator against extremes of hot and cold temperatures.[1] Differences in the shape of the scalp hair follicle determine the observed ethnic differences in scalp hair appearance, length and texture.

There are many human diseases in which abnormalities in hair appearance, texture or growth are early signs of local disease of the hair follicle or systemic illness. Well known diseases of the hair follicle include alopecia or hair loss, hirsutism or excess hair growth and lupus erythematosus.[2]

Hair follicle
Hair follicle-en
Hair follicle
ArmHair
A photograph of hair on a human arm emerging from follicles
Details
SystemIntegumentary system
ArterySupratrochlear, supraorbital, superficial temporal, occipital
VeinSuperficial temporal, posterior auricular, occipital
NerveSupratrochlear, supraorbital, greater occipital, lesser occipital
LymphOccipital, mastoid
Identifiers
LatinFolliculus pili
MeSHD018859
TAA16.0.00.023
THH3.12.00.3.01034
FMA70660
Anatomical terminology

Structure

Blausen 0438 HairFollicleAnatomy 02
Structure of a hair follicle.

The position and distribution of hair follicles changes over the body. For example, the skin of the palms and soles do not have hair follicles whereas skin of the scalp, forearms, legs and genitalia have abundant hair follicles.[1] There are many structures that make up the hair follicle. Anatomically, the triad of hair follicle, sebaceous gland and arrector pili muscle make up the pilosebaceous unit.[1]

A hair follicle consists of :

  • The papilla is a large structure at the base of the hair follicle.[3] The papilla is made up mainly of connective tissue and a capillary loop. Cell division in the papilla is either rare or non-existent.
  • Around the papilla is the hair matrix.
  • A root sheath composed of an external and internal root sheath. The external root sheath appears empty with cuboid cells when stained with H&E stain. The internal root sheath is composed of three layers, Henle's layer, Huxley's layer, and an internal cuticle that is continuous with the outermost layer of the hair fiber.
  • The bulge is located in the outer root sheath at the insertion point of the arrector pili muscle. It houses several types of stem cells, which supply the entire hair follicle with new cells, and take part in healing the epidermis after a wound.[4][5] Stem cells express the marker LGR5+ in vivo.[6]

Other structures associated with the hair follicle include the cup in which the follicle grows known as the infundibulum,[7] the arrector pili muscles, the sebaceous glands, and the apocrine sweat glands. Hair follicle receptors sense the position of the hair.

Attached to the follicle is a tiny bundle of muscle fiber called the arrector pili. This muscle is responsible for causing the follicle lissis to become more perpendicular to the surface of the skin, and causing the follicle to protrude slightly above the surrounding skin (piloerection) and a pore encased with skin oil. This process results in goose bumps (or goose flesh).

Also attached to the follicle is a sebaceous gland, which produces the oily or waxy substance sebum. The higher the density of the hair, the more sebaceous glands that are found.

Variation

There are ethnic differences in several different hair characteristics. The differences in appearance and texture of hair are due to many factors: the position of the hair bulb relative to the hair follicle, size and shape of the dermal papilla, and the curvature of the hair follicle.[1] The scalp hair follicle in Caucasians is elliptical in shape and, therefore, produces straight or wavy hair, whereas the scalp hair follicle of people of African descent is more curvy, resulting in the growth of tightly curled hair.[1]

Terminal Scalp Hair Characteristics by Ethnicity[1]
ethnicity diameter

(micrometers)

cross-sectional shape appearance
Blonde-haired Caucasian 40–80 elliptical straight or wavy
Dark brown/black haired/red haired Caucasian 50–90 elliptical straight or wavy
African 60–100 elliptical and ribbon-like curly
Asian 80–100 circular straight
Terminal Scalp Hair Characteristics by Taxon [8][9]
Animal diameter

(micrometers)

cross-sectional shape appearance
Chimpanzee 101-113 circular straight
Orangutan 140-170 circular straight
Buffalo 110 circular straight

Development

In utero, the epithelium and underlying mesenchyme interact to form hair follicles.[10][11]

Aging

A key aspect of hair loss with age is the aging of the hair follicle. Ordinarily, hair follicle renewal is maintained by the stem cells associated with each follicle. Aging of the hair follicle appears to be primed by a sustained cellular response to the DNA damage that accumulates in renewing stem cells during aging.[12] This damage response involves the proteolysis of type XVII collagen by neutrophil elastase in response to the DNA damage in the hair follicle stem cells. Proteolysis of collagen leads to elimination of the damaged cells and then to terminal hair follicle miniaturization.

Hair growth

Hair-follicle cycling
Hair follicle

Hair grows in cycles of various phases:[13] anagen is the growth phase; catagen is the involuting or regressing phase; and telogen, the resting or quiescent phase (names derived using the Greek prefixes ana-, kata-, and telos- meaning up, down, and end respectively). Each phase has several morphologically and histologically distinguishable sub-phases. Prior to the start of cycling is a phase of follicular morphogenesis (formation of the follicle). There is also a shedding phase, or exogen, that is independent of anagen and telogen in which one or several hairs that might arise from a single follicle exits. Normally up to 90% of the hair follicles are in anagen phase, while 10–14% are in telogen and 1–2% in catagen. The cycle's length varies on different parts of the body. For eyebrows, the cycle is completed in around 4 months, while it takes the scalp 3–4 years to finish; this is the reason eyebrow hair have a much shorter length limit compared to hair on the head. Growth cycles are controlled by a chemical signal like epidermal growth factor. DLX3 is a crucial regulator of hair follicle differentiation and cycling. Specifically, colocalization of phosphorylated Smad1/5/8 complex and DLX3 regulate role for BMP signaling to Dlx3 during hair morphogenesis in animal models.[14][15]

Anagen phase

Anagen is the active growth phase of hair follicles[16] during which the root of the hair is dividing rapidly, adding to the hair shaft. During this phase the hair grows about 1 cm every 28 days. Scalp hair stays in this active phase of growth for 2–7 years; this period is genetically determined. At the end of the anagen phase an unknown signal causes the follicle to go into the catagen phase.

Catagen phase

The catagen phase is a short transition stage that occurs at the end of the anagen phase.[17] It signals the end of the active growth of a hair. This phase lasts for about 2–3 weeks while the hair converts to a club hair. A club hair is formed during the catagen phase when the part of the hair follicle in contact with the lower portion of the hair becomes attached to the hair shaft. This process cuts the hair off from its blood supply and from the cells that produce new hair. When a club hair is completely formed, about a 2-week process, the hair follicle enters the telogen phase.

Telogen phase

The telogen phase is the resting phase of the hair follicle.[18] When the body is subjected to extreme stress, as much as 70 percent of hair can prematurely enter the telogen phase and begin to fall, causing a noticeable loss of hair. This condition is called telogen effluvium.[19] The club hair is the final product of a hair follicle in the telogen stage, and is a dead, fully keratinized hair.[10] Fifty to one-hundred club hair are shed daily from a normal scalp.[10]

Timeline

  • Scalp: The time these phases last varies from person to person. Different hair color and follicle shape affects the timings of these phases.
    • Anagen phase, 2–8 years (occasionally much longer)
    • Catagen phase, 2–3 weeks
    • Telogen phase, around 3 months
  • Eyebrows:
    • Anagen phase, 4–7 months
    • Catagen phase, 3–4 weeks
    • Telogen phase, about 9 months

Clinical significance

Disease

There are many human diseases in which abnormalities in hair appearance, texture or growth are early signs of local disease of the hair follicle or systemic illness. Well known diseases of the hair follicle include alopecia or hair loss, hirsutism or excess hair growth, and lupus erythematosus.[2] Therefore, understanding the function of the normal hair follicle is fundamental to diagnosing and treating many dermatologic and systemic diseases with hair abnormalities.[2]

Alopecia

male alopecia

Alopecia scales

Alopecia scale

An introduction to dermatology (1905) lupus erythematosus

lupus erythematosus

Hidradenitis

Hidradenitis suppurativa

Hair restoration

Hair follicles form the basis of the two primary methods of hair transplantation in hair restoration, Follicular Unit Transplantation (FUT) and follicular unit extraction (FUE). In each of these methods, naturally occurring groupings of one to four hairs, called follicular units, are extracted from the hair restoration patient and then surgically implanted in the balding area of the patient's scalp, known as the recipient area. These follicles are extracted from donor areas of the scalp, or other parts of the body, which are typically resistant to the miniaturization effects of the hormone DHT. It is this miniaturization of the hair shaft that is the primary predictive indicator of androgenetic alopecia,[20] commonly referred to as male pattern baldness or male hair loss. When these DHT-resistant follicles are transplanted to the recipient area, they continue to grow hair in the normal hair cycle, thus providing the hair restoration patient with permanent, naturally-growing hair. More than 60% of men and 10% of women suffer from hair loss.[21]

While hair transplantation dates back to the 1950s,[22] and plucked human hair follicle cell culture in vitro to the early 1980s,[23] it was not until 1995 when hair transplantation using individual follicular units was introduced into medical literature.[24]

References

  1. ^ a b c d e f g h i j k Hair growth and disorders. Blume-Peytavi, Ulrike. Berlin: Springer. 2008. ISBN 9783540469117. OCLC 272298782.CS1 maint: others (link)
  2. ^ a b c Gilhar, Amos; Etzioni, Amos; Paus, Ralf (2012-04-19). "Alopecia areata". The New England Journal of Medicine. 366 (16): 1515–1525. doi:10.1056/NEJMra1103442. ISSN 1533-4406. PMID 22512484.
  3. ^ Pawlina, Wojciech; Ross, Michael W.; Kaye, Gordon I. (2003). Histology: a text and atlas: with cell and molecular biology. Hagerstown, Maryland: Lippincott Williams & Wilkins. ISBN 978-0-683-30242-4.
  4. ^ Ma DR; Yang EN; Lee ST (2004). "A review: the location, molecular characterisation and multipotency of hair follicle epidermal stem cells". Ann. Acad. Med. Singap. 33 (6): 784–8. PMID 15608839.
  5. ^ Cotsarelis G (2006). "Epithelial stem cells: a folliculocentric view". J. Invest. Dermatol. 126 (7): 1459–68. doi:10.1038/sj.jid.5700376. PMID 16778814.
  6. ^ Lin, K. K.; Andersen, B. (2008). "Have Hair Follicle Stem Cells Shed Their Tranquil Image?". Cell Stem Cell. 3 (6): 581–582. doi:10.1016/j.stem.2008.11.005. PMID 19041772.
  7. ^ "Histologic Diagnosis of Inflammatory Skin Diseases, Chapter 1. Embryologic, Histologic, and Anatomic Aspects". Derm101.com. Archived from the original on 2012-10-21.
  8. ^ Chernova, Olga (May 2014). "Scanning electron microscopy of the hair medulla of orangutan, chimpanzee, and man". Journal of Biological Sciences. 456 (1): 199–202. doi:10.1134/S0012496614030065. PMID 24985515.
  9. ^ S.V, Kshirsagar (July 2009). "Comparative Study of Human and Animal Hair in Relation with Diameter and Medullary Index" (PDF). Indian Journal of Forensic Medicine and Pathology. 2 (3).
  10. ^ a b c Paus R; Cotsarelis G (August 1999). "The biology of hair follicles". N. Engl. J. Med. 341 (7): 491–7. doi:10.1056/NEJM199908123410706. PMID 10441606.
  11. ^ "Hair Follicle". 2017-11-27. Wednesday, 19 December 2018
  12. ^ Matsumura H, Mohri Y, Binh NT, Morinaga H, Fukuda M, Ito M, Kurata S, Hoeijmakers J, Nishimura EK (2016). "Hair follicle aging is driven by transepidermal elimination of stem cells via COL17A1 proteolysis". Science. 351 (6273): aad4395. doi:10.1126/science.aad4395. PMID 26912707.
  13. ^ K. S. Stenn & R. Paus (1 January 2001). "Controls of Hair Follicle Cycling". Physiological Reviews. 81 (1): 449–494. doi:10.1152/physrev.2001.81.1.449. PMID 11152763. (comprehensive topic review, successor to landmark review of 1954 by HB Chase)
  14. ^ Hwang, J.; Mehrani, T.; Millar, S. E.; Morasso, M. I. (2008). "Dlx3 is a crucial regulator of hair follicle differentiation and cycling". Development. 135 (18): 3149–3159. doi:10.1242/dev.022202. PMC 2707782. PMID 18684741.
  15. ^ Park, G. T.; Morasso, M. I. (2002). "Bone morphogenetic protein-2 (BMP-2) transactivates Dlx3 through Smad1 and Smad4: Alternative mode for Dlx3 induction in mouse keratinocytes". Nucleic Acids Research. 30 (2): 515–522. doi:10.1093/nar/30.2.515. PMC 99823. PMID 11788714.
  16. ^ Brannon, Maryland, Heather. "Anagen Phase". The New York Times. Retrieved 2007-11-14.
  17. ^ Brannon, Maryland, Heather. "Categen Phase". The New York Times. Retrieved 2007-11-14.
  18. ^ Brannon, Maryland, Heather. "Telogen Phase". The New York Times. Retrieved 2007-11-14.
  19. ^ S Malkud (1 September 2015). "Telogen Effluvium: A Review". J Clin Diagn Res. 9 (9): WE01–3. doi:10.7860/JCDR/2015/15219.6492. PMC 4606321. PMID 26500992.
  20. ^ Bernstein RM; Rassman WR (September 1997). "Follicular transplantation. Patient evaluation and surgical planning". Dermatol Surg. 23 (9): 771–84, discussion 801–5. doi:10.1111/j.1524-4725.1997.tb00417.x. PMID 9311372.
  21. ^ https://www.mapleholistics.com/blog/clarifying-shampoo-explained/
  22. ^ Orentreich N (November 1959). "Autografts in alopecias and other selected dermatological conditions". Ann. N. Y. Acad. Sci. 83 (3): 463–79. doi:10.1111/j.1749-6632.1960.tb40920.x. PMID 14429008.
  23. ^ Wells J; Sieber VK (December 1985). "Morphological characteristics of cells derived from plucked human hair in vitro". Br. J. Dermatol. 113 (6): 669–75. doi:10.1111/j.1365-2133.1985.tb02402.x. PMID 2420350.
  24. ^ Bernstein RM; Rassman WR; Szaniawski W; Halperin A: (1995). "Follicular Transplantation". Intl J Aesthetic Restorative Surgery. 3: 119–32. ISSN 1069-5249. OCLC 28084113.

External links

Media related to Hair follicle at Wikimedia Commons

Apocrine sweat gland

An apocrine sweat gland (; from Greek apo– "away" and krinein "to separate") is composed of a coiled secretory portion located at the junction of the dermis and subcutaneous fat, from which a straight portion inserts and secretes into the infundibular portion of the hair follicle. In humans, apocrine sweat glands are found only in certain locations of the body: the axillae (armpits), areola and nipples of the breast, ear canal, eyelids, wings of the nostril, perianal region, and some parts of the external genitalia. Modified apocrine glands include the ciliary glands in the eyelids; the ceruminous glands, which produce ear wax; and the mammary glands, which produce milk. The rest of the body is covered by eccrine sweat glands.Most non-primate mammals, however, have apocrine sweat glands over the greater part of their body. Domestic animals such as dogs and cats have apocrine glands at each hair follicle but eccrine glands only in foot pads and snout. Their apocrine glands, like those in humans, produce an odorless, oily, opaque secretion that gains its characteristic odor upon bacterial decomposition. Eccrine glands on their paws increase friction and prevent them from slipping when fleeing from danger.

Boil

A boil, also called a furuncle, is a deep folliculitis, infection of the hair follicle. It is most commonly caused by infection by the bacterium Staphylococcus aureus, resulting in a painful swollen area on the skin caused by an accumulation of pus and dead tissue. Boils which are expanded are basically pus-filled nodules. Individual boils clustered together are called carbuncles.

Most human infections are caused by coagulase-positive S. aureus strains, notable for the bacteria's ability to produce coagulase, an enzyme that can clot blood. Almost any organ system can be infected by S. aureus.

Comedo

A comedo is a clogged hair follicle (pore) in the skin. Keratin (skin debris) combines with oil to block the follicle. A comedo can be open (blackhead) or closed by skin (whitehead) and occur with or without acne. The word comedo comes from the Latin comedere, meaning 'to eat up', and was historically used to describe parasitic worms; in modern medical terminology, it is used to suggest the worm-like appearance of the expressed material.The chronic inflammatory condition that usually includes both comedones and inflamed papules and pustules (pimples) is called acne. Infection causes inflammation and the development of pus. Whether a skin condition classifies as acne depends on the amount of comedones and infection. Comedones should not be confused with sebaceous filaments.

Comedo-type ductal carcinoma in situ (DCIS) is not related to the skin conditions discussed here. DCIS is a non-invasive form of breast cancer, but comedo-type DCIS may be more aggressive and so may be more likely to become invasive.

Demodex folliculorum

Demodex folliculorum is a microscopic mite that can only survive on the skin of humans. Most people have D. folliculorum on their skin. Usually, the mites do not cause any harm, and are therefore considered an example of commensalism rather than parasitism. If D. folliculorum does cause disease, this is known as demodicosis.

Electrology

Electrology is the practice of electrical hair removal to permanently remove human hair from the body. Electrolysis is the actual process of removing hair using electricity.

In electrolysis, a qualified professional called an electrologist slides a hair-thin, solid metal probe into each hair follicle without puncturing the skin (when inserted properly). Electricity is delivered to the follicle through the probe, which causes localized damage to the areas that generate hairs, either through the formation of caustic sodium hydroxide (the galvanic method), overheating (thermolysis), or both (the blend method).

Follicle

Follicle may refer to:

Follicle (anatomy), a small spherical group of cells containing a cavity:

Dental follicle

Hair follicle

Lymph follicle

Ovarian follicle

Thyroid follicle

Follicle (fruit)

Folliculitis decalvans

Folliculitis decalvans is an inflammation of the hair follicle that leads to bogginess or induration of involved parts of the scalp along with pustules, erosions, crusts, ulcers, and scale. It begins at a central point and spreads outward, leaving scarring, sores, and, due to the inflammation, hair loss in its wake. No permanent cure has been found for this condition, but there is promise in a regimen of dual therapy with rifampin 300 mg twice daily and clindamycin 300 mg twice daily. This new treatment can be used to control the condition, and tests have indicated that after 3 to 5 months long uninterrupted courses of treatment, many patients have seen limited to no recurrence.

GPR177

G protein-coupled receptor 177 (GPR177), commonly known as Wntless, is a human gene that encodes a receptor for Wnt proteins in Wnt-secreting cells.Wntless was shown to be a cargo for the retromer complex. It has been found essential for hair follicle induction.

Hair follicle nevus

Hair follicle nevus is a cutaneous condition that presents as a small papule from which fine hairs protrude evenly from the surface.

Hair plexus

A hair plexus or root hair plexus is a special group of nerve fiber endings and serves as a very sensitive mechanoreceptor for touch sensation. Each hair plexus forms a network around a hair follicle and is a receptor, which means it sends and receives nerve impulses to and from the brain when the hair moves.Endings of sensory nerve fibers which form a plexus around a hair follicle in hairy skin. They are mechanoreceptors conveying touch sensation. Specifically, crude touch and pressure sensation conveyed through the spinocervical tract, which is located in the posterior part of the lateral funiculus and terminates in the lateral cervical nucleus. The plexus acts as a receptor.

Henle's layer

Henle's layer is the third and the outermost layer of the inner root sheath of the hair follicle, consisting of a single layer of cubical cells with clear flattened nuclei. It is named after German physician, pathologist and anatomist Friedrich Gustav Jakob Henle.

Intermittent hair–follicle dystrophy

Intermittent hair–follicle dystrophy is a disorder of the hair follicle leading to increased fragility of the shaft, with no identifiable biochemical disturbance, also with an unknown prevalence.

Ophiasis

Ophiasis is a form of alopecia areata characterized by the loss of hair in the shape of a wave at the circumference of the head.It gets its name from "ophis", which is the Greek word for snake, because of the apparent similarity to a snake-shape and the pattern of hair loss.The term "sisaipho" is used to characterize the inverse pattern. Sisaipho is, almost, the reverse spelling of ophiasis. It is also called "ophiasis inversus".This form of hair loss "...targets the body's own hair follicles, resulting in hair loss..." and although the immune system could be attacking hair follicle melanocytes, dermal papilla cells, and keratinocytes,” but the foundational cause of this disease is yet to be confirmed.

Outer root sheath

The outer root sheath of the hair follicle encloses the inner root sheath and hair shaft.

It is continuous with the basal layer of the interfollicular epidermis (skin).

Perioral dermatitis

Perioral dermatitis is a type of skin rash. Symptoms include multiple small (1–2 mm) bumps and blisters sometimes with background redness and scale, localized to the skin around the mouth and nostrils. Less commonly the eyes and genitalia may be involved. It can be persistent or recurring and resembles particularly rosacea and to some extent acne and allergic dermatitis. The term "dermatitis" is a misnomer because this is not an eczematous process.The cause is unclear. Topical steroids are associated with the condition and moisturizers and cosmetics may contribute. The underlying mechanism may involve blockage of the skin surface followed by subsequent excessive growth of skin flora. Fluoridated toothpaste and some micro-organisms including Candida may also worsen the condition, but their roles in this condition is unclear. It is considered a disease of the hair follicle with biopsy samples showing microscopic changes around the hair follicle. Diagnosis is based on symptoms.Treatment is typically by stopping topical steroids, changing cosmetics, and in more severe cases, taking tetracyclines by mouth. Stopping steroids may initially worse the rash. The condition is estimated to affect 0.5-1% of people a year in the developed world. Up to 90% of those affected are women between the ages of 16 and 45 years, though it also affects children and the elderly, and has an increasing incidence in men.

Root sheath

The inner or epidermic coat of the hair follicle is closely adherent to the root of the hair, and consists of two strata named respectively the outer and inner root sheaths.

Scarring hair loss

Scarring hair loss, also known as cicatricial alopecia, is the loss of hair which is accompanied with scarring. This is in contrast to non scarring hair loss.

It can be caused by a diverse group of rare disorders that destroy the hair follicle, replace it with scar tissue, and cause permanent hair loss. A variety of distributions are possible. In some cases, hair loss is gradual, without symptoms, and is unnoticed for long periods. In other cases, hair loss is associated with severe itching, burning and pain and is rapidly progressive. The inflammation that destroys the follicle is below the skin surface and there is usually no "scar" seen on the scalp. Affected areas of the scalp may show little signs of inflammation, or have redness, scaling, increased or decreased pigmentation, pustules, or draining sinuses. Scarring hair loss occurs in otherwise healthy men and women of all ages and is seen worldwide.

Skin appendage

Skin appendages (or adnexa) are skin-associated structures that serve a particular function including sensation, contractility, lubrication and heat loss. In humans, some of the more common skin appendages are hairs (sensation, heat loss, filter for breathing, protection), arrector pilli (smooth muscles that pull hairs straight), sebaceous glands (secrete sebum onto hair follicle, which oils the hair), sweat glands (can secrete sweat with strong odour (apocrine) or with a faint odour (merocrine or eccrine)), and nails (protection).

Skin appendages are derived from the skin, and are usually adjacent to it.Types of appendages include hair, glands, and nails.

Trichilemmal cyst

A trichilemmal cyst, is a common cyst that forms from a hair follicle. They are most often found on the scalp. The cysts are smooth, mobile and filled with keratin, a protein component found in hair, nails, skin, and horns. They are, however, clinically and histologically distinct from trichilemmal horns, which are much more rare and not limited to the scalp. Trichilemmal cysts may run in families and they may or may not be inflamed and tender, often depending on whether they have ruptured. Rarely, these cysts may grow more extensively and form rapidly multiplying trichilemmal tumors, also called proliferating trichilemmal cysts, which are benign but may grow aggressively at the cyst site. Very rarely, trichilemmal cysts can become cancerous.

Skin
Subcutaneous tissue
Adnexa

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