OPT 221 Eyelids: Benign - Study Material on Common Eyelid Lesions and Their Management

What is oculodermal melanocytosis?

hyperpigmentation, usually blue-black, of the eyelid, sclera, and uvea

What is the etiology of oculodermal melanocytosis?

-proliferation of melanocytes

-congenital

What demographics are most affected by oculodermal melanocytosis?

-most commonly affects Asian and African descent

-W>M

What are symptoms of oculodermal melanocytosis?

-asymptomatic

-gray, blue or black area on eyelid

What are signs of oculodermal melanocytosis?

-gray, blue, or black eyelid and/or facial hyperpigmentation (frequently follows the distribution of CNV1 and V2)

-patchy by extensive slate gray or blue scleral hyperpigmentation

-variable amounts of uveal hyperpigmentation

-may have diffuse iris nevus, iris mammillations

What complications are associated with oculodermal melanocytosis?

-secondary open angle glaucoma (pigment blocks the TM)

-malignant potential, may evolve to melanoma (most common melanoma is uveal)

How is oculodermal melanocytosis managed?

-monitor for glaucoma

-monitor for melanoma (SL exam, A seg photos)

-if symptomatic/cosmesis, refer out for laser therapy for skin discoloration (may cause scarring, hyperpigmentation may recur, does not reduce risk of melanoma or secondary glaucoma)

What are clinical pearls of oculodermal melanocytosis?

-Caucasians are least likely to have condition, but most likely to develop melanoma

-If only the sclera and uvea is involved, known as ocular melanocystosis

-If only the sclera is involved, known as scleral melanocystosis

What is melanocytic nevus?

benign epidermal/dermal tumor

What is the etiology of melanocytic nevus?

-proloferation of melanocytes

-associated with UV exposure

What is junctional melanocytic nevus?

melanocytes clump at the epidermal/dermal junction

What is compound melanocytic nevus?

melanocytes extend from the epidermis into the dermis

What is intradermal melanocytic nevus?

melanocytes clump within the dermis (this is the most common)

What are the demographics of patients most affected by melanocytic nevus?

-often appear during puberty

-more common in caucasians

-unilateral or bilateral

What are symptoms of melanocytic nevus?

-asymptomatic

-bump or mole, dark spot on eyelid

What are signs of melanocytic nevus?

-uniformly pigmented macule (flat lesion), papule, or nodule (dome shaped) bump

-most commonly tan, brown, or black

-may be amelanotic

-most common location in regards to the eyelid is on the margin

-flat or slightly elevated with distinct borders

What are complications associated with melanocytic nevus?

malignant potential; most important sign is documented change (but it may increase in size during puberty)

How is melanocytic nevus managed?

-monitor for malignant changes (SL exam, A seg photos)

-surgical excision for removal

-biopsy for suspicious lesions

What are clinical pearls for melanocytic nevus?

-can occur anywhere on the skin

-use pertinent malignant descriptors to catch change over time

-baseline A seg photo helps with assessment over time

What is a port wine stain?

benign, dilated capillaries in the dermis

What is the etiology of port wine stain?

-congenital

-may be associated with sturge weber syndrome

What are features of sturge weber syndrome?

-facial port wine stain

-choroidal hemangioma

-intracranial vascular abnormalities

-unilateral glaucoma (inc venous pressure)

What are the demographics of port wine stain?

present at birth

unilateral>bilateral

What are symptoms of port wine stain?

red birthmark (cosmesis mainly)

What are signs of port wine stain?

-flat, smooth, pink patch (can thicken and darken to more purple color over time)

-grows proportionately with the child

-tends to follow dermatomal distribution

-lesion is more prone to bleeding if scratched or injured

How is port wine stain managed?

-none if asymptomatic

-if symptomatic, refer out for laser surgery

(causes capillaries to burst, leads to gradual lightening, multiple laser treatments are necessary, cannot completely remove the lesion)

What are capillary hemangiomas?

benign vascular tumor

What is the etiology of capillary hemangiomas?

proliferation of vascular endothelial cells

What demographics are affected by capillary hemangiomas?

apparent during 1st few months of life (not necessarily born with it)

-unilateral

What are symptoms of capillary hemangiomas?

red or blue area on eyelid

What are signs of capillary hemangiomas?

-cutaneous lesions (bright red nodule, blanch with pressure

-subcutaneous lesion (bluish discoloration underneath normal skin)

-enlarge and/or change color with crying

-ptosis

-induced astigmatism

What is a possible complication of capillary hemangiomas?

amblyopia (refractive or deprivation)

How are capillary hemangiomas managed?

-monitor for regression (over 4 years 75% will resolve)

-correct refractive error

-if visual obstruction or astigmatism leading to amblyopia or severe cosmesis, refer for tx (propanolol, oral or injectable steroid, or laser photocoagulation)

What is conjunctival capillary hemangiomas?

bright red nodule on the conj; similar tx to eyelid hemangioma

What is a concern (DDx) for orbital capillary hemangiomas?

proptosis; MRI or CT scan to confirm diagnosis (similar tx to eyelid hemangioma)

What is an epidermoid cyst?

benign, superficial cyst filled with keratin

What is the etiology of epidermoid cyst?

-surface skin cells (epidermal tissue) move deeper into the skin and multiple forming a wall (so cysts are filled with keratin)

-congenital or acquired

-unilateral or bilateral

What are symptoms of epidermoid cyst?

-asymptomatic , cosmesis

-bump or cyst on eyelid

What are signs of epidermoid cyst?

-flesh colored or yellow white elevated, mobile, smooth papule or nodule (becomes darker as keratin incorporates dead skin cells)

-NOT translucent

-surrounding inflammation if cystic wall ruptures within the skin

-multiple, tiny, superficial epidermoid cysts are called milia

How is epidermoid cyst managed?

-surgical excision for removal

-unmanaged can progress slowly until ruptures

-cystic wall needs to be removed to prevent recurrence

What is a sebaceous cyst?

benign, superficial cyst filled with sebum

What is the etiology of sebaceous cysts?

-blockage of sebaceous gland with retention of sebum

-if located on the eyelid margin, called a cyst of zeis

-likely a result of trauma to the skin

-unilateral or bilateral

What are symptoms of sebaceous cysts?

-asymptomatic, cosmesis

-bump on eyelid

What are signs of sebaceous cyst?

-flesh colored to yellow papule or nodule (dome shaped bump)

-surrounding inflammation if cystic wall ruptures within the skin

How are sebaceous cysts managed?

-non if asymptomatic

-surgical excision for removal (wall needs to be removed to prevent recurrence)

What are sudoriferous cysts (hidrocystomas)?

benign, superficial cyst filled with sweat

What is the etiology of sudoriferous cysts (hidrocystomas)?

-blockage of a sweat gland with retention of sweat

-eccrine=adnexal

-apocrine=canthi/hair follicle

-likely a result of friction, mechanical trauma to the skin

-unilateral or bilateral

What are symptoms of sudoriferous cysts (hidrocystomas)?

-asymptomatic, cosmesis

-bump on eyelid

-itching, discomfort

-Hx of increase in size over weeks to months

-Hx of previous drainage, either spontaneously or by practitioner

What are signs of sudoriferous cysts (hidrocystomas)?

-flesh colored, round, mobile papule or nodule

-translucent

-surrounding inflammation if cystic wall ruptures within the skin

-if located non eyelid margin, it is apocrine (cyst of moll)

How are sudoriferous cysts (hidrocystomas) managed?

-none if asymptomatic (pt education of regression and recurrence cycle)

-can attempt incision and drainage of eccrine hidrocystomas

-surgical excision for removal

What is squamous papilloma?

benign epidermal tumor

What is the etiology of squamous papilloma?

-proliferation of squamous epithelial cells overlying a fibrovascular core (varying degrees of hyperkeratosis)

-may be response to viral infection (HPV)

What demographics are most often affected by squamous papilloma?

-if associated with HPV, young adults are more commonly affected

-if non viral, typically develops after the age of 40

unilateral or bilateral

What are symptoms of squamous papilloma?

-asymptomatic, cosmesis

-bump or stalk on eyelid

-irritation of the bump with manipulation

What are signs of squamous papilloma?

-flesh colored or hyperpigmented papule or nodule (pedunculated or sessile)

-surrounding inflammation if rubbed constantly

How is squamous papilloma managed?

-non is asymptomatic

-surgical excision for removal (entire lesion needs to be removed to prevent recurrence; especially if viral)

What is seborrheic keratosis?

benign epidermal tumor

What is the etiology of seborrheic keratosis?

proliferation of basal epithelial cells with keratin filled invaginations

What demographics are affected by seborrheic keratosis?

after age 40 (more common in elderly patients)

What are symptoms of seborrheic keratosis?

-asymptomatic, cosmesis

-bump or scab on eyelid/adnexa

-irritation of bump

What are signs of seborrheic keratosis?

-hyperpigmented papule or nodule

-slightly elevated from the skin with a stuck on appearance

-rough or smooth surface

-waxy and granular to velvety texture

-surrounding inflammation if rubbed constantly

How is seborrheic keratosis managed?

-none if asymptomatic

-surgical excision for removal (currettage/scraping, cryotherapy, chemical cautery, cautery, laser)

What is seborrheic keratosis called when there are multiple papules on the face?

dermatosis papulosa nigra

more common in african americans and asians

What is xanthelasma?

benign, lipid laden papules at the level of the dermis on the eyelids

What is the etiology of xanthelasma?

may be associated with hyperlipidemia/hypercholesterolemia

What demographics are more often affected by xanthelasma?

occurs over age of 40 (bilateral>>unilateral)

What are symptoms of xanthelasma?

-asymptomatic, cosmesis

-yellow plaques around the eyes

What are signs of xanthelasma?

-multiple>>singular, soft yellow plaques

-typically involves the medial canthus upper eyelids>lower eyelids

How is xanthelasma managed?

-Monitor if asymptomatic

-If symptomatic, consider scope of practice for removal vs referral for removal (Size plays a role in mgmt, >8mm must refer in state of TN e.g. surgical excision, cryotherapy, laser treatment, chemical cauterization Potential for recurrence, suggests uncontrolled hypercholesterolemia)

-If no previous diagnosis of hypercholesterolemia and patient is ≤40 years of age, consider ordering lipid panel or refer to PCP