lumps & bumps

paraneoplastic syndrome

disease or symptom that is a consequence of cancer in the body but is not due to the local presence of cancer cells

what is squamous papilloma? what are its features?

benign hyperplasia of squamous epithelium

flesh colored with cerebriform surface (can be pigmented)

gradual onset & slow growth

what is seborrheic keratosis (basal cell papilloma)?

pigmented lesion caused by proliferation of keratinocytes

what age is seborrheic keratosis onset & common in?

onset 30s (more common in >50)

what skin is seborrheic keratosis present on? what are its features?

hair bearing areas (chest, face & back)

solitary lesion elevated with waxy surface & sharp demarcation

what are the predisposing factors of seborrheic keratosis?

sun exposure, age, genetics

no malignant potential

sudden appearance of multiple lesions of seborrheic keratosis can indicate what?

cancer elsewhere in the body (especially the GI tract)

what is verruca vulgaris?

squamous papilloma caused by human papilloma virus type 6 or 11

may have concomitant conjunctivitis

verruca vulgaris age of onset?

more common in children & young adults (5-20)

what is molluscum contagiosum? what age is it common in?

pox virus infection of the skin

common in children (2-4)

transmission of molluscum contagiosum in children vs adults

children: direct contact

adult: STD

features of molluscum contagiosum

multiple pearly flesh colored lesions with a small central dimple

associated with chronic follicular conjunctivitis

typically asymptomatic

self resolving

herpes simplex dermatitis is due to

usually due to primary infection (rarely reactivation)

herpes simplex dermatitis features

prodromal facial & lid tingling that lasts 24 hours

eyelid & periorbital vesicles with erythematous base

what is the treatment for herpes simplex dermatitis?

self limiting but faster with oral meds:

acyclovir 400 mg 5x/day x 7-10 days

herpes zoster dermatitis is caused by? who is more likely to get it?

unilateral infection caused by reactivation of varicella zoster virus

more common in elderly (& immunocompromised)

treatment for herpes zoster dermatitis

acyclovir 800 mg 5x/day x 10 days

erythromycin or bacitracin ung BID for 1-2 weeks

what is seen in the pre-eruptive phase of herpes zoster dermatitis

generalized malaise

fever, headache

pain, burning, itching along dermatome

what is seen in the acute eruptive phase of herpes zoster dermatitis?

vesiculopustular rash

what is seen in the chronic phase of herpes zoster dermatitis?

post herpetic neuralgia

age of onset of keratocanthoma?

27-78 (mostly >40)

keratocanthoma features

elevated margins with central crater on hair bearing skin

usually solitary

rapid onset & growth (<2 months)

spontaneous regression

if someone has multiple keratocanthoma lesions what cancer may they have?

colon cancer

what is the most common pre-cancerous cutaneous lesion?

actinic keratosis

what causes actinic keratosis?

gradual lifelong UV exposure

if untreated what can actinic keratosis progress to?

squamous cell carcinoma

what actinic keratosis looks like?

proliferation of atypical keratinocytes:

- multiple erythematous sessile plaques

- pink

when should you biopsy a actinic keratosis?

if its painful, ulcerated or bleeding

hyperkeratotic lesions that aren't responsive to therapy

what is the second most common eyelid malignancy?

squamous cell carcinoma

risk factors of developing squamous cell carcinoma

older age

light colored skin

long term sun exposure

history of many xrays

many severe sunburns early in life

males

lesions squamous cell carcinoma have a more favorable prognosis when they arise from what?

actinic keratosis

what is the most common malignant tumor of the skin & eyelid?

basal cell carcinoma

common locations of basal cell carcinoma

lower eyelid

medial canthus

upper eyelid

lateral canthus

what location of basal cell carcinoma is most difficult to manage & have greatest risk of recurrence?

medial canthus

what are hallmark signs of basal cell carcinoma?

pearly, waxy, rolled, telangiectatic borders with central ulceration

usually painless mainly in head & neck region

what is a melanocytic nevus?

darkly pigmented lesion containing modified melanocytes that begins at basal layer, migrates to dermis in young adulthood

when do acquired melanocytic nevus arise?

onset 5-15 years

how do oculodermal melanocytosis develop?

CN V & melanocytes originate from the neural crest & occur when there is incomplete migration of melanocytes from neural crest to epidermis during embryonic develop

what ethnic group is more likely to get oculodermal melanocytosis?

asians & african Americans

what do oculodermal melanocytosis look like?

cutaneous lesion is flat, tan to gray, follows first & second division of CN V

rarely bilateral

what is the demographic of lentigo maligna?

middle aged & elderly

Caucasians

how can you tell the difference between lentigo maligna and melanocytic nevus?

melanocytic nevus is normally seen since birth or early childhood

lentigo maligna is acquired later in life

what does lentigo maligna look like?

flat, well circumscribed, irregular, tan brown lesion

enlarges over years

what is primary malignant melanoma caused by?

proliferation of atypical melanocytes invading the dermis from excess UV exposure

which melanoma has the worst prognosis?

eyelid margin melanoma

origins of sebaceous gland carcinoma

mebomian glands of upper tarsus

glands of zeis

caruncle

What can a sebaceous gland carcinoma masquerade as?

chronic blepharoconjunctivitis

recurrent chalazia

cardinal signs of sebaceous gland carcinoma?

madarosis

poliosis

thickening of lid margin (mostly upper lid)

what is eyelid xanthelasma?

aggregation of lipid filled macrophages within the dermis that is usually bilateral & seen in elderly patients that have hyperlipidemia

what does eyelid xanthelasma look like?

single or multiple flat yellow placoid lesions that affect loose aspect of eyelids (usually medial aspect)

what a sebaceous cyst?

due to a painless occlusion of a sebaceous gland duct that can occur in meibomian glands of upper tarsus, glands of zeis and scalp & eyebrows

what is a sudiferous cyst due to?

retention of sweat - heat, humidity & perspiration can cause enlargement in size & number

what do sudiferous cyst look like

clear cyst translucent lesion near eyelid margin

what is an eyelid syringoma?

bengin proliferation of eccrine sweat glands that is bilateral & multiple

what is neurofibroma?

bengin peripheral nerve sheath tumor composed of a bundle of enlarged peripheral nerves caused by a proliferation of axons, fibroblasts & Schwann cells

what is a plexiform neurofibroma?

benign tumor of peripheral nerves in eyelid that causes an S shaped curve of upper eyelid & feels like a bag of worms & could cause proptosis

what gene mutation is neurofibromatosis type I associated with?

NF1 gene

what is the diagnostic criteria for neurofibroma?

2+ neurofibromas or 1 plexiform neurofibroma

2+ lisch nodules

what is a capillary hemangioma?

one of the most common tumors of infancy that looks like a strawberry birthmark that is cause by disorganized overgrowth of mature capillary tissue due to endothelial cell proliferation

when will most capillary hemangiomas regress?

by 7 years

what is the main complication in capillary hemangioma?

amblyopia & strabismus

what is the treatment of capillary hemangioma?

topical beta blocker (timolol): first line for superficial lesion

oral propranolol: for deeper lesions

what is a nevus flammeus (port wine stain)?

congenital vascular malformation within the superficial dermis that is present at birth & enlarges with time

when the upper eyelid is involved in nevus flammeus what is it a strong indication for?

glaucoma development

what is the presentation of nevus flammeus?

follows cutaneous distribution of CN V

sharply demarcated pink-purplish patch

does not blanch with pressure

most frequently on face

associated soft tissue hypertrophy

eyelid lesions in kaposi sarcoma is pathognomonic for what disease?

AIDS

what does kaposi sarcoma present as?

red, purple, brown or blue subcutaneous lesion

who does eyelid lymphoma typically affect?

elderly patients

or immunocompromised younger patients

what is a conjunctival dermoid?

type of choristoma (bengin malformation composed of normal tissue at abnormal location)

features of conjunctival dermoid?

variably sized yellow white limbal mass

lined with squamous epithelium & filled with sweat glands, fat & cilia

what systemic syndrome can goldenhar syndrome be a part of?

hypoplasia of malar, maxillary & mandibular regions

macrostomia (wide mouth)

microtioa (underdeveloped pinna)

pre-auricular & facial skin tags

mental handicap

hemivertebrae

what is a pyogenic granuloma?

fibrovascular proliferation response to a physical insult that consists of granulation tissue, proliferation of small blood vessels & inflammatory cells that are a rapidly growing dark pink fleshy conjunctival mass

why is pyogenic granuloma a misnomer?

because it doesn't produce pus (pyogenic) & it isn't granulomatous

features of conjunctival nevus?

solitary lesion

flat or slightly elevated

mobile over underlying sclera

stable size & pigmentation over time

contains cystic components

racial melanosis (complexion related pigmentation) features

bilateral diffuse flat pigmentation of conjunctiva caused by presence of excess melanin within basal layer

what is intraepithelial neoplasia?

pre-cancerous squamous cell neoplasia of the conjunctiva epithelium that can progress to invasive SCC

what are predisposing factors of intraepithelial neoplasia?

sunlight

HPV

what does intraepithelial neoplasia look like?

flesh sessile lesion near limbus or interpalpebral fissure

what does primary acquired melanosis look like?

unilateral, non cystic patches on the conjunctiva & peripheral cornea

solitary or diffuse or multifocal

what is the cause of primary acquired melanosis?

due to increase in melanocyte numbers in the basal layers of the epithelium typically seen in middle aged caucasians

what do malignant conjunctival melanomas arise from?

mostly primary acquired melanosis

some from pre-existing nevi

what is the demographic for malignant conjunctival melanoma?

lighter skinned elderly

where is malignant conjunctival melanoma likely to metastasis to?

pre auricular & submandibular nodes

what is squamous cell carcinoma on the conjunctiva difficult to differentiate from?

conjunctival intraepithelial neoplasia

what is the management for squamous cell carcinoma in the conjunctiva?

excision

topical mitomycin c

5 fluorouracil

cidofovir

what does conjunctiva lymphoma look like?

diffuse, slightly elevated, fleshy pink mass

usually occurs in fornices or bulbar conjunctiva

is unilateral or bilateral conjunctival lymphoma more likely to be systemic lymphoma?

bilateral

what are brushfield spots?

small whitish peripheral iris speckles arranged a concentric ring that consists of aggregation of CT often seen in Down syndrome

what are lisch nodules?

pigmented aggregation of melanocytes & spindles cells in the superficial iris stroma often seen in NF1

what is a iris nevus?

benign proliferation of melanocytes in superficial iris stroma that is a flat or elevated pigmented lesion

what factors could make an iris nevus at risk of malignant transformation?

younger age (<40)

inferior location

diffuse iris involvement

bleeding from lesion

what is an iris cyst

benign cyst originating from the iris epithelium that is asymptomatic & non-progressive & can cause elevated IOP due to angle obstruction

how you rule out iris melanoma in iris cysts?

hollow center on B scan & ultrasound biomicroscopy

what is an orbital fat prolapse?

protrusion of orbital fat through defect in tenon's capsule into the conjunctival fornix

soft yellow mass in supratemporal conjunctival fornix

who is likely to get orbital fat prolapse?

older obese males

what is a dermoid cyst?

congenital cystic lesion due to entrapped ectoderm at site of embryologic bony suture (most common at supratemporal bony rim)

characteristics of dermoid cyst

firm, non-movable subcutaneous mass

filled with hair follicles, sebaceous glands & sweat glands