Transcript Eyelid Lumps and Bumps

Eyelid Lumps and Bumps
Acquired Tumors and Cysts with non-infectious etiology
Benign Tumors
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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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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?
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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
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Actinic Keratosis
◦ Management
 Biopsy for definitive diagnosis
 Usually frozen (cryotherapy) or excised
Benign Tumors
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Squamous Cell Papilloma
◦ What is it?
 Outgrowth of fibrovascular connective tissue
 Covered by irregular keratinized stratified squamous epithelium
◦ Appearance
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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
 Removed by excision
Benign Tumors
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Squamous Cell Papilloma
Benign Tumors
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Basal Cell Papilloma
◦ What is it?
 Expansion of the squamous epithelium stemming from basal cell proliferation
 Slow growing lesion
◦ Appearance
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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
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Basal Cell Papilloma
Benign Tumors
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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?
 Typically older males
◦ Management
 Deep excision
 Recurrence is common if not completely removed
Benign Tumors
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Inverted Follicular Keratosis
Benign Tumors
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Keratoacanthoma
◦ What is it?
 Rare and rapidly growing variant of actinic keratosis
 Also pre-malignant, potentially transforming into squamous cell carcinoma
◦ Appearance
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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
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Keratoacanthoma
Benign Tumors
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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
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Melanocytic Nevus
Junctional Nevus
Compound Nevus
Intradermal Nevus
Benign Tumors
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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
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Removed for cosmetic reasons
Usually treated with carbon dioxide or argon laser
May be excised
Recurrence suggests persistently elevated cholesterol
Benign Tumors
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Xanthelasma
Benign Tumors
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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?
 Common in young females
◦ Management
 Excision
Benign Tumors
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Pilomatricoma
Benign Tumors
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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
Benign Tumors
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Neurofibroma
Malignant Tumors
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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
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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
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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
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Basal Cell Carcinoma
Nodular
Ulcerative
Sclerosing
Malignant Tumors
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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
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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
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Squamous Cell Carcinoma
◦ Who gets it?
 Most common occurrence is in the elderly
 Risk factors include fair skin, sun exposure, and immune suppression
◦ Management
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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
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Squamous Cell Carcinoma
Nodular
Cutaneous horn
Ulcerative
Large ulcerative
Malignant Tumors
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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
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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
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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
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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
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Sebaceous Gland Carcinoma
Nodular
Spreading
Conjunctival involvement
Malignant Tumors
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Melanoma
◦ What is it?
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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
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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
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Melanoma
◦ Who gets it?
 Most common in elderly individuals with light skin
 History of sun damaged skin
◦ Management
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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
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Melanoma
Malignant Tumors
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Merkel Cell Carcinoma
◦ What is it?
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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
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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
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Merkel Cell Carcinoma
◦ Who gets it?
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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
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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%
Malignant Tumors
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Merkel Cell Carcinoma
Cysts
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Chalazion
◦ What is it?
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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
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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
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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
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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
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Cyst of Moll
◦ What is it?
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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
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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
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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
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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
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Milia
◦ What is it?
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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
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Kanski, Jack J. Clinical Ophthalmology a Systemic Approach. 6th ed. Edinburgh, UK: Elsevier, 2007.
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http://www.mayoclinic.com/health/actinic-keratosis/DS00568
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http://www.consultantlive.com/photoclinic/article/10162/1265743
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http://www.skincancer.org/Basal-Cell-Carcinoma/
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http://www.skincancer.org/squamous-cell-carcinoma.html
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http://emedicine.medscape.com/article/1101433-overview
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http://emedicine.medscape.com/article/1213671-overview
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http://emedicine.medscape.com/article/1100917-overview
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781304/
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http://emedicine.medscape.com/article/1058063-overview
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http://emedicine.medscape.com/article/1059871-overview