OPT 319 Bumps, Cysts, Non-Malignant

What is a hordeolum?

bacterial infection (Staph) of the sebaceous glands of the eyelid:

Gland of Zeis = lash follicle, more exterior

Meibomian gland = more interior

What are some S/S of a hordeolum?

redness

painful

pustular-like lesion

+/- conj. edema and purulent discharge

larger lesions may cause FB/ rubbing sensation = disrupt ocular surface, induce astigmatism

What are some associations with hordeolum?

poor hygiene

systemic infection

blepharitis

roseacea

trichiasis

ectropion

What is the underlying histology of a hordeolum?

abscess of polymorphonuclear leukocytes and necrotic tissue = pus head

What is the tx for a hordeolum?

hot, moist compresses

lid scrubs = mild soaps, shampoos, lid scrub products

lid massage

topical antibiotic gtts or ung = bacitracin, erythromycin, Neo-poly-dex = BUT these do not penetrate skin well

oral antibiotic = doxycycline 100 mg BID, Augmentin 500 mg BID

incision and drainage of the abscess if oral abx for 2 weeks does not resolve

What is preseptal cellulitis?

infection (staph and strep) of the eyelid soft tissue anterior to the eyelid septum, commonly spread from adjoining tissues: sinuses, hordeola, dacryo-adenitis/-cystitis

What are some S/S of preseptal cellulitis?

diffuse eyelid swelling and redness

+/- preauricular lymphadenopathy

+/- fever and malaise

What are some things that are seen in orbital cellulitis that helps differentiate it from preseptal cellulitis?

decreased vision

decreased color saturation

possible APD

possible proptosis

conj chemosis

altered / painful EOMs

What is the tx for preseptal cellulitis?

oral antibiotics = Augmentin, Levofloxacin, Azithromycin

IV abx if non-responsive, severe, or pediatric

CT, CBC, cultures if severe

What is a chalazion?

obstruction and inflammation of a sebaceous gland = lipogranuloma, either...

anterior = Zeis Gland (sebaceous cyst)

interior = Meibomian gland

What is the histopathology behind a chalazion?

lipid products escape gland to surrounding tissue = granulomatous inflam = mononuclear phagocyte response = increased macrophage, epithelioid cells, multinucleated giant cell response = empty spaces with surrounding epithelioid and foamy multinucleated cells

What are some S/S of chalazion?

slowly progressing, relatively painless bump, especially in UL

+/- recurrence

What are some risk factors/associations with chalazion?

adults (age 30+)

chronic blepharitis (lash debris, capped glands)

rosacea

hormonal factors

What are some tx options for chalazion?

warm compresses QID

intralesional steroid injection typically 0.2 cc Kenalog 40mg/mL

incision & curettage

What are 3 complications of steroid injection for chalazion tx?

skin depigmentation

microembolization = retinal/choroidal infarct

fat atrophy

When compared to intralesional injection and hot compresses, how effective is chalazion I&C?

I&C shows greater size reduction and resolution

I&C has less recurrence

BUT more pain and inconvienience with I&C

What is the rule of 6 in terms of success of chalazion intralesional steroid?

if the chalazion is <6mm size and present for <6 months, then there is a 60% chance it will respond to intralesional steroid injection

What is a new form of tx for chalazion?

IPL = normal dry eye area tx AND small applicator tip directly to the lesion with longer exposure (15min) and lower intensity

What are the 3 MOA's of IPL in treating chalazion?

antimicrobial effect

anti-inflammatory effect

kills demodex = targets melanin-like chromophore in backbone, also inhibits reproduction

What is a sebaceous cyst?

occluded gland of Zeis = sebum-filled opaque yellow lesion near lid margin

What is a hydrocystoma?

blockage of Glands of Moll (eccrine/apocrine sweat glands) = superficial, translucent, firm dome-shaped of clear fluid

What is an epidermal inclusion cyst?

firm, over-proliferation of epithelial cells entrapped in the dermis = stratified squamous epithelium shell and keratinized core

What is a syringoma?

comma-shaped gland = adenoma of intraepidermal eccrine duct = translcent yellow/flesh coloured waxy papule on LL

What are some risk factors for syringoma?

women >>> men, esp during menstruation and contraceptive

adolescence and continue through reproductive years

Down's syndrome

Japanese

Why are syringoma difficult to treat?

originates in deep dermis tissue

What is the tx for syringoma?

shave excision = high risk of scar

chemical peel = bichloracetic acid or tretinoin

electrocautery/RF

CO2 or Er:YAG laser = least scar potential

What are milia?

superficial white bumps = external layers of stratified squamous epithelium with keratin core

What are primary vs secondary milia?

primary = cysts of pilosebaceous unit of the vellus hair follicle

secondary = entraped material in eccrine grlands, etc.

What are some risk factors for developing milia?

sun damage

LT topical steroid cream

skin creams/makeup

babies (primary)

What is molluscum contagiosum?

infectious pox virus = intracytoplasmic molluscum bodies form in epithelial cells where virus replicates = multiple small flesh-coloured, waxy papules with umbilicated center that continues to release virus

+/- follicular conjunctivitis

What 2 populations is molluscum contagiosum more common in?

young kids

immunocompromised

What are some tx for molluscum contagiosum?

may resolve on it's own

excision

curettage

electrodessication

cryotherapy

What is pilomatricoma?

calcium deposition = granulomatous response = slow growing, hard, benign tumor of lash hair bulb = typically reddish surround with whiteish calcium nodules

What is a conj inclusion cyst?

displaced conj epithelial cells form a cystic cavity = thin-walled cyst is filled with seroud fluid

What are some potential causes of conj inclusion cysts?

trauma

inflammation

lymphangiectasia = poor lymphatic drainage, dilated lymphatic vessel

What are some tx options for conj inclusion cysts?

self-resolving as blinking helps fluid move along

excision

alcohol

cryo

CO2 laser

What is a neoplasm/tumor?

non-specific, enlarged, abnormal mass of cells BUT not necessarily cancer!

What is a malignancy?

cancerous lesion w/ potential to spread

What is an adenoma?

benign neoplasm pertaining to gland tissue

What is a papilloma?

benign neoplasm pertaining to epithelial tissue

What is a carcinoma?

malignant neoplasm pertaining to epithelial tissue

What is a hamartoma?

tumor made up of cells that are normal for that area

What is a choristoma?

tumor made up of cells that are NOT normal for that area

What is an ulceration?

loss of epithelial tissue

What is hyperkeratosis?

excess keratin = scaly, waxy appearance

What is an induration?

swelling, redness

What is a macule/plaque?

flat lesion, with plaque being larger than macule

What is a papule/nodule?

circular, well-circumscribed bumps, with a nodule being larger than a papule

What are the ABCDE's of describing skin lesions?

A = asymmetry = benign lesions tend to be more symmetric

B = borders of the lesion = benign lesion tend to have regular borders

C = colour = changes in color, inconsistent color can be concern for malignancy

D = diameter = larger lesions (> 5mm) give concern for malignancy

E = evolution or elevation = how has it changed in color, bleeding, crusting, change in tissue composition, etc.

What is the most common epithelial tumor of the eyelid?

squamous papilloma

What is a squamous papilloma?

over-growth of squamous epithelium = often pedunculated (on a stalk, skin tag) or may be sessile (flat)

What typically causes a squamous papilloma?

low-risk types of HPV

What are some associated risk factors for squamous papilloma?

middle aged-older adults

areas of skin rubbing

increased weight of pt

What is verruca vulgaris?

epidermal tissue wart, either plane (flat) or finger-like projections (filiform/digitate) = can increase in pigment and keratinization over time

What typically causes a verruca vulgaris?

types VI or XI of HPV

What is a cutaneous horn?

somewhat non-specific descriptor of hyperkeratinized, elongated growth seen in verruca, seborrheic keratosis, basal cell and squamous cell carcinoma

Aside from the usual excision like we use for other non-malignant lesions, what is an additional tx we should do for cutaneous horn?

send off for lab histophathology to determine underlying etiology (possible carcinoma)

What is serborrheic keratosis?

basal epithelial cell tumor consisting of hyper-keratinized epithelium = well-demaracted, greasy, stuck-on appearance w/ slight elevation

What is dermatosis papulosa nigra?

acanthosis, papillomatosis, hyperkeratosis of epidermis = hyperpigmented, smooth papules 1-5mm size with 1-3mm elevation on cheeks, temples, forehead

Who is dermatosis papulosa nigra most common in?

African or Asian descent

What causes xanthelasma?

macrophages take on excess lipid = foamy histiocytes in reticular dermis filled w/ intracellular fat deposits = dense yellow papules or plaques filled with cholesterol, UL > LL

What is the tx for xanthelasma?

> age 50 = no tx needed

< age 50 = refer for hyperlipidemia testing

What is a capillary hemangioma?

elevated bight red (vascular) lesion that will blanch with pressure

In what populations is capillary hemangioma more common?

infants

females >>> males

What are some tx options for capillary hemangioma?

self-resolving in 70% of pediatric cases

intralesional steroid

surgical excision w/ cautery

propranolol (oral)

What is the most common vascular lesion of the conj/lids?

pyogenic granuloma

What is a pyogenic granuloma?

angiogenic dysregulation = overgrowth of capillary vascular tissue = bright red, lobulated, elevated vascular lesion of conjunctiva or skin (often pedunculated)

What are some typical causes of pyogenic granuloma?

trauma

post-surgery

chronic irritation

Pyogenic granuloma is a ________________, since the lesions is not pus-producing nore granulomatous.

misnomer

What are some tx options for a pyogenic granuloma?

topical steroid = prednisolone acetate QID x 10-14 days

beta blocker 0.5% topical BID x 3 weeks

excision

steroid injection