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Eyelid Lumps and Bumps
Eyelid Lumps and Bumps. Acquired Tumors and Cysts with non-infectious etiology. Benign Tumors. Actinic Keratosis What is it? Slow growing keratinization of the epithelium Results from excessive sun exposure Pre-malignant: may transform into squamous cell carcinoma Appearance
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Eyelid Lumps and Bumps
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Eyelid Lumps and Bumps
Acquired Tumors and Cysts with non-infectious etiology
Benign Tumors Actinic Keratosis What is it? Slow growing keratinization of the epithelium Results from excessive sun exposure Pre-malignant: may transform into squamous cell carcinoma Appearance Rough, dry, and scaly plaque that is flat or slightly raised Up to 2.5 cm diameter individually Often multiple lesions in a single area that coalesce Distinct boarders May be skin colored to dark brown Who gets it? Elderly individuals with lightly pigmented skin Rarely develops on the eyelid Common on the scalp, ears, forehead, and backs of hands The patient may notice itching or burning of the lesion Benign Tumors Actinic Keratosis Management Biopsy for definitive diagnosis Usually frozen (cryotherapy) or excised Benign Tumors Squamous Cell Papilloma What is it? Outgrowth of fibrovascular connective tissue Covered by irregular keratinized stratified squamous epithelium Appearance Variable presentations “Skin tag” type: narrow base, pedunculated, skin colored Board base with “raspberry like” appearance May be difficult to differentiate from viral wart (human papillomavirus) Who gets it? No predilection to race or gender Management Benign Tumors Basal Cell Papilloma What is it? Expansion of the squamous epithelium stemming from basal cell proliferation Slow growing lesion Appearance Round “coin-like” lesion with “stuck-on” appearance Up to 2.5 cm diameter Slightly raised and crusty: often keratinized similar to actinic keratosis Tan to dark brown in color Variety of textures: granular to velvety Who gets it? Common in the elderly Most people develop at least one during their lives Usually develop on the head, neck, or trunk Management No treatment required except for cosmetic reasons or if they become irritated Removed by excision Benign Tumors Inverted Follicular Keratosis What is it? Rare and often rapid growing lesion arising from a hair follicle Histologically similar to basal cell papilloma, but with deeper extension into the dermis Appearance Non pigmented papilloma at the lid margin Up to 1 cm diameter Who gets it? Management Deep excision Recurrence is common if not completely removed Benign Tumors Inverted Follicular Keratosis Benign Tumors Keratoacanthoma What is it? Rare and rapidly growing variant of actinic keratosis Also pre-malignant, potentially transforming into squamous cell carcinoma Appearance Initially appears as a pink hyperkeratotic lesion usually on the lower lid After a period of rapid growth, remains stable for several months Then begins to involute and a keratin filled crater often forms Complete involution can occur after a year leaving a residual scar Who gets it? Same demographic as actinic keratosis Higher occurrence in patients on immunosuppressive therapy following kidney transplants Management Usually excised Occasionally treated with cryotherapy or radiotherapy Benign Tumors Melanocytic Nevus What is it? Tumor composed of cells derived from either epidermal or dermal melanocytes Acquired and congenital forms Generally low to no malignant potential Appearance Junctional: Uniform brown macule or plaque Compound: Uniform, light to dark brown, raised papule Intradermal: Papillomatous with little to no pigment. Associated with dilated vessels and protruding lashes Who gets it? Junctional type occurs in the young Compound type occurs in middle age Intradermal type most common overall and occurs in the elderly Management Removal for cosmetic reasons or if malignancy is suspected Excision may need to be followed by reconstruction depending on location and size Benign Tumors
Benign Tumors Xanthelasma What is it? Aggregation of lipid filled macrophages at the level of the dermis Common and frequently bilateral Appearance Yellowish subcutaneous plaque Usually on the medial portion of the eyelids Often multiple Who gets it? Middle aged and the elderly May be associated with elevated cholesterol especially when occurring in younger individuals and with corneal arcus Management Removed for cosmetic reasons Usually treated with carbon dioxide or argon laser May be excised Recurrence suggests persistently elevated cholesterol Benign Tumors Pilomatricoma What is it? Abnormal proliferation of the germinal matrix cells in a hair follicle Frequently becomes calcified Appearance Deep nodule Becomes hard if calcified Who gets it? Management Benign Tumors Neurofibroma What is it? Abnormal proliferation of Schwann cells, fibroblasts, and axons Appearance Characteristic S shaped lesion Typically located on the upper lid Who gets it? Solitary lesions occur in adults 25% associated with neurofibromatosis-1 Children with neurofibromatosis-1 are affected by diffuse lesions Management Solitary lesions removed by excision Diffuse lesions are more difficult to remove Malignant Tumors Basal Cell Carcinoma What is it? Locally invasive proliferation of pluripotent epidermal basal cells Most common human malignancy and most common eyelid malignancy Slow growing with no metastatic potential Appearance Usually on the lower eyelid Non-tender ulceration Irregular boarders Possible keratinization Destruction of eyelid architecture Nodular type: pearl like appearance with dilated blood vessels on surface Noduloulcerative type: central ulcer with raised pearly edges Sclerosing type: lateral, hardened, infiltration beneath the epidermis. May be confused with chronic blepharitis Malignant Tumors Basal Cell Carcinoma Who gets it? Common in the elderly Risk factors include fair skin and high cumulative sun exposure Management Diagnosis confirmed with biopsy Excision is the common removal technique Mohs micrographic surgery removes the tumor along with a thin layer of surrounding tissue. The surround is immediately examined for tumor cells and the procedure repeated if any are found. Highest cure rate at 98%. Recurring tumors tend to be more invasive and difficult to treat Malignant Tumors
Malignant Tumors Squamous Cell Carcinoma What is it? Proliferation of invasive cells arising from the squamous cell layer of the epidermis Can arise de novo or from existing actinic keratosis or keratoacanthoma Less common, but more aggressive than basal cell carcinoma Lymph node metastasis in 20% of cases Appearance Variety of appearances and may be difficult to distinguish from BCC Scaly with irregular boarders Absence of surface vasculature Extensive keratinization usually present Lesions may bleed Nodular type: keratinized nodule that develops erosions and fissures Ulcerating type: everted boarders with a red, well defined base Cutaneous horn: invasive growth underlies keratin horn Malignant Tumors Squamous Cell Carcinoma Who gets it? Most common occurrence is in the elderly Risk factors include fair skin, sun exposure, and immune suppression Management Can be fatal if left untreated (2,500 annual deaths in USA) Confirmed with biopsy Mohs micrographic surgery: highest cure rate 94-99% Other options include standard scalpel excision, cryotherapy, and radiotherapy Malignant Tumors
Malignant Tumors Sebaceous Gland Carcinoma What is it? Slow growing tumor Arises from the meibomian glands, glands of Zeis, or sebaceous glands in the caruncle More likely to occur on the upper lid where glands are more numerous Appearance No pathognomonic presentation Initially can appear similar to chalazion or chronic blepharitis Yellowish material may be seen within the tumor Nodular type: hard, painless, immobile nodule similar to chalazion Spreading type: thickened lid margin, loss of lashes, similar to chronic blepharitis Malignant Tumors Sebaceous Gland Carcinoma Who gets it? Females in their 60's and 70's most commonly affected Youngest reported case was in a 3 year old Management Because of appearance, diagnosis is often delayed Mortality rate is 5-10% Large (1cm) and non-resolving chalazion should be suspected Cryotherapy and surgical excision are the standard treatments Recurrence is as high as 33% Little documentation for Mohs, but possibly lower recurrence rate Malignant Tumors Sebaceous Gland Carcinoma
Malignant Tumors Melanoma What is it? Epidermal and dermal proliferation of transformed and invasive melanocytes Arises from existing nevus, lentigo maligna (pre-malignancy), or de novo High potential for metastasis Potentially fatal (represents greater than 2/3 of all skin cancer deaths) Appearance Rarely develops on the eyelid (1% of all eyelid lesions) Half of those that do are non-pigmented Asymmetric plaque or nodule Irregular and indistinct boarders Variable colors in the lesion (blue and black) Diameter larger than ~6mm Associated with destruction of local anatomy and loss of lashes Malignant Tumors Melanoma Who gets it? Most common in elderly individuals with light skin History of sun damaged skin Management Question any new, changing, or irregular appearing lesions Melanoma confirmed with biopsy Wide surgical excision with up to a 1 cm margin for confirmed malignancy Local lymph node dissection if malignancy is more than 1.5 mm deep Prognosis and recurrence is tied to size and any metastasis of original lesion Patients should be followed closely following surgery Malignant Tumors Merkel Cell Carcinoma What is it? Very rare and fast growing form of skin cancer Highly malignant and potentially fatal Arises from Merkel cells located in the basal layer of the epidermis Normal cells thought to play a regulatory role in epidermal growth Appearance Frequently involves the upper eyelid Red, purple, or violet colored, well defined nodule Wide variation in size, from less that 2cm to larger than 15cm Overlying skin is intact Malignant Tumors Merkel Cell Carcinoma Who gets it? Average age of diagnosis is 75 20x more likely to occur in whites than blacks No gender predilection Risk factors include sun exposure and immune suppression Management Many have metastasized by the time they are diagnosed CT and/or MRI imaging used to evaluate systemic spread Primary tumor removed with a wide excision (margins up to 3cm if possible) Chemotherapy and/or radiotherapy depending on spread 2 year mortality rate of 30-50% Cysts Chalazion What is it? AKA meibomian cyst Fatty secretions of a meibomian gland are retained Causes a chronic, painless inflammation Patients with rosacea or meibomian gland dysfunction are more prone to developing multiple and recurrent chalazion Appearance Nodule that has enlarged gradually May enlarge up to nearly 1 cm If large enough, may induce astigmatism by pressing on the cornea Cysts Chalazion Treatment About one third drain and resolve spontaneously Standard therapy aimed at stimulating and speeding draining by using warm compress and massage Steroid injection through the palpebral conjunctiva 0.1-0.2 ml Kenalog (triamcinolone) 80% success rate May cause local depigmentation of the skin Oral tetracycline/doxycycline useful in patients with chronic lid inflammation Do not use in children or pregnant/nursing women! 250mg PO qid tetracycline 100mg PO bid doxycycline 1-2 week course Incision and drainage through the palpebral conjunctiva and tarsal plate Biopsy a recurrent chalazion - it may be sebaceous cell carcinoma Cysts Cyst of Zeis What is it? Variation of chalazion Non-translucent retention cyst involving the anterior lid margin Gland of Zeis produces oil for eye lashes Cysts Cyst of Moll What is it? Variation of chalazion AKA Sudoriferous cyst Translucent retention cyst involving the anterior lid margin Variation of chalazion Gland of Moll is a modified sweat gland also emptying to the lashes Cysts Epidermoid Cyst What is it? AKA sebaceous cyst Cyst lined by stratified squamous epithelium and containing keratin and sebaceous material Result from ingrowth of surface epidermis after trauma or surgery Appearance Round, well defined, non-tender mass Ruptured cysts cause an acute inflammatory response and possible secondary infection Treatment Complete surgical excision Cysts Eccrine Hidrocystoma What is it? Rare cyst that forms from retained sweat in a blocked and dilated sweat duct More common in females Appearance Similar to Cyst of Moll with the exception that it does not involve the lid margin Painless and usually asymptomatic May grow up to 6mm Treatment Monitor or needle puncture if desired Cysts Syringoma What is it? Benign and asymptomatic proliferation of sweat gland duct epithelium Relatively common Most common in adult females Appearance Multiple small (3mm or less) papules May be skin color or yellowish Treatment Removed for cosmetic reasons only No set recommended removal technique Options include excision, cryotherapy, dermabrasion, electrocautery and more Cysts Milia What is it? Tiny epidermoid cysts that tend to occur in clusters Result from a blocked vellus hair follicles that retain the keratin Very common – occurs in half of all infants May also occur following dermabrasion or damage to the follicle Appearance Small pearly white to yellowish papules Treatment No treatment necessary Needle puncture and expression may be performed if desired Resources Kanski, Jack J. Clinical Ophthalmology a Systemic Approach. 6th ed. Edinburgh, UK: Elsevier, 2007. http://www.mayoclinic.com/health/actinic-keratosis/DS00568 http://www.consultantlive.com/photoclinic/article/10162/1265743 http://www.skincancer.org/Basal-Cell-Carcinoma/ http://www.skincancer.org/squamous-cell-carcinoma.html http://emedicine.medscape.com/article/1101433-overview http://emedicine.medscape.com/article/1213671-overview http://emedicine.medscape.com/article/1100917-overview http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781304/ http://emedicine.medscape.com/article/1058063-overview http://emedicine.medscape.com/article/1059871-overview