benign and malignant tumors of the eyelids

where are the fine hair follicles, sweat glands, and sebaceous glands

dermis

layers of the epidermis

1. basal

   1. mitotic

   2. melanocytes

2. spinosum

   1. squamous cells

   2. keratinocytes

3. granular

4. keratinized squamous

where do malignant eyelid lesions originate

deep to epidermis and infiltrates indward (towards blood and lymphatics)

what are the precancerous conditions

1. actinic keratosis

2. keratacanthoma

where do the benign eyelid lesions originate

1. epidermis and grows outwards

melanocytic nevus aka

moles

acquired

patho phys of melanocytic nevus

Clusters of Melanocytes derived from neural crest migrate to the skin during embryonic development and proliferates

clinical presentation of melanocytic nevus aqcuired

1. • Onset during childhood (5-15yo)

2. • Varies depending on age of patient and stage of nevus 3 stages:

   1. Junctional (Childhood)

   2. Compound (Young adult)

   3. Intradermal (Later in life)

junctional melanocutic nevus

1. Flat and even colored

2. Limited to basal epidermis

3. Found in childhood

compound melanocytic nevus

Elevated and even colored

Level of Basal epidermis and dermis

Found in young adults

intradermal melanocytic nevus

Elevated and lightly colored or depigmented

Located in dermis

Found in older adults

melanocytic nevus management

1. monitor for change

2. send for ecision adn biopsy if sus

3. TAKE A PIC FOR COMPARISON

what are the congenital melanocytic nevus

1. congenital divided kissing nevus

2. Large Congenital periocular type

Congenital divided “Kissing” nevus

Develops before embryologic separation of eyelids, divides when eyelids separate

Large Congenital periocular type

• Deeply pigmented and larger than acquired nevus

• Elevated and has excess hairs

• Greater chance of malignant transformation to malignant melanoma up to 5%

• Greater risk with larger size

oculodermal melanocytosis aka

nevus of ota

oculodermal melanocytosis cause

1. Congenital pigmentation of periocular skin, uveal tract, sometimes orbits, meninges, and palate.

epi of oculodermal melanocytosis

1 Present at birth or during 1st year of life

• More common in Asians, particularly Japanese population and African descent

• HOWEVER, Higher risk of malignant uveal melanomas in whites 1:400

• Females > Male

pathophys of oculodermal melanocytosis

Excess melanocytes from neural crest origin become entrapped in the dermis during embryologic development

clinical presentation of nevus of ota

1. Flat, blue-grayish pigmentation of face, periocular skin, conjunctiva and sclera •

2. Tends to follow CN 5 V1 & V2 distribution

3. • Can have iris mammillations —> bumps on iris

4. • Often Unilateral, bilateral in only10% cases

5. • Risk of congenital glaucoma

   1. • Infiltration of Melanocytes in drainage angle can lead to reduced outflow and increased intraocular pressure

6. • Risk of Uveal melanoma

management of oculodermal melanocytosis

1. Routinely evaluate to detect early uveal melanoma with dilated fundus examination

2. • Routinely evaluate with comprehensive eye exam to detect glaucoma

3. • May be removed with laser therapy for cosmesis

   1. • Refer to dermatologist or oculoplastics

squamous papilloma aka

skin tag

squamous papilloma cauase

1. idiopathic

2. benign squamous cell/keratinocyte proliferation

whats the most common benign eyelid lesion

Squamous Papilloma

patho phys of Squamous Papilloma

Benign hyperplasia of the squamous epithelium

clinical presentation of Squamous Papilloma

1. Can be sessile/Immobile and broad with smooth surface

2. • Can be pedunculated/stalked, elevated, with rough surface

3. • Can be solitary or multiple

4. • Flesh colored or pigmented

5. • Gradual onset and progress slowly

management of Squamous Papilloma

Observation or excision for cosmesis

seborrheic keratosis cause

Benign proliferation of immature keratinocytes

seborrheic keratosis epi

• Common, middle to older age, no gender predilection•

seborrheic keratosis patho phys

hyperkeratosis and proliferation of keratinocytes with keratin-filled cysts, pigmented due to transfer of melanin from melanocytes

clinical presentation of seborrheic keratosis

1. Solitary, elevated, hyperpigmented (Brown, black, tan), waxy and scaly plaque

2. • Characteristic “Stuck-on” appearance

3. • Gradual growth

4. • Variant: Dermatosis Papulosa Nigra (DPN) in Asians and blacks

xanthelasma cause

Accumulation of cholesterol rich material in skin

epi of xanthelasma

Common

• Middle to older age

• Females>males

• ~50% correlation to lipid disorder

patho phys of Xanthelasma

Form of lipoma that consist of infiltration of the dermis by foam cells (macrophages transformed by lipid)

clinical presentation of xanthelasma

1. One or more flat, minimally elevated, creamyyellow, plaque-like lesions

2. • Often found medial aspect of eyelids

3. • Often bilateral and symmetric

management of xanthelasma

1. lipid disorder eval w PCP

2. observation or excision for comesis

milia aka

milk spots

milia cause

1. Congenital

2. • Acquired

   1. • Primary spontaneous eruption

   2. • Secondary to trauma, radiation, UV exposure, herpes zoster ophthalmicus

epi of milia

1. • Congenital form seen in newborns due to maturing of glands

2. • Any age, and persons

pathophys of milia

Sub-epidermally trapped keratin cysts/blockages of the pilosebaceous unit

clinical presentation of milia

Multiple, umbilicated, well-circumscribed, pinhead sized white nodules

epidermal inclusion cysts aka

epidermoid cysts

epidermal inclusion cyyst epi

1. • Male>Female

2. • Multiple lesions seen in patients with Gardner syndrome or Muir -Torre syndrome which has increased risk of colorectal cancer

pathophys of epidermal inclusion cyst

Cyst lined by keratinized epithelium of epidermis and filled with liberated keratin often associated with a hair follicle

clinica presentatino of epidermal inclusion cysts

• Smooth, soft, white -yellow, round and movable lesion

• Smaller version is called milia

sebaceous cyst epi

1. elderly

sebaceous cyst pathophys

1. Secondary to occlusion of the duct of a sebaceous gland, filled with sebaceous material.

2. • Can occur in eyelid and adjacent tissue, most commonly affecting meibomian gland, less often Zeis glands

sebaceous cyst clinical presentation

1. Meibomian gland cysts are small, focal, subcutaneous nodule with minimal to no inflammation

2. • Extrameibomian gland cyst (Zeis) grow larger, smooth, yellow, opaque, “cheesy”, freely movable, and can rupture causing inflammation.

hidrocystoma types

1. eccrine

2. apocrine

eccrine hidrocystoma - retention cyst cause

Retention of sweat worsened by heat, humidity, and perspiration

eccrine hidrocystoma - retention cyst epi

1. • More common around eyelids but can occur anyway on the body

2. • Increases in number and size during summer and decrease in winter

3. • More common in adult women

eccrine hidrocystoma - retention cyst pathophys

Blocked sweat duct leading to retention of sweat within eccrine sweat gland and subsequent dilation forming a cyst.

apocrine hidrocystoma - sudiferous cyst cause

Benign tumor formation within Gland of Moll along eyelid margin

apocrine hidrocystoma - sudiferous cyst epi

1. • More common around medial canthus of eyes

2. • Typically found around hair follicles

3. • Not temperature dependent

4. • No gender predilection

5. • Adults >55 yo

apocrine hidrocystoma - sudiferous cyst pathophys

Abnormal proliferation (adenoma) of coil structure of apocrine secretory gland (Gland of Moll)

eccrine hydrocystoma clinical presentation

1. Clear, cystic, translucent lesion

   1. • Sometimes appear bluish

2. • Can occur near but not at eyelid margin and around cheeks

3. • More likely to be multiple lesions

apocrine hydrocystoma clinical presentation

1. • Smooth, dome-shaped, translucent, larger and slow growing

2. • Often has a bluish-black color

3. • Occur near inner canthus, at eyelid margin and eyebrows •

4. More solitary

eyelid dermoid cysts cause

1. Congenital cystic lesion that can affect eyelid, orbit or both

whats the most common orbital tumor in kids

eyelid dermoid cyst

pathophys of eyelid dermoid cyst

1. • Entrapped ectoderm at a site of embryologic bony fusion therefore, occurs around bony orbital rim

2. • Composed of hair follicles, sebaceous glands, and sweat glands

clinical presentatino of eyelid dermoid cysts

1. Smooth, subcutaneous mass, firm and not movable due to attachment to underlying periosteum

2. • Located superior-temporally at the site of the zygomaticofrontal suture

congenital capillary hemangioma aka

strawberry hemangioma

Congenital Capillary Hemangioma cause

Congenital, ”birth mark”

Congenital Capillary Hemangioma epi

1. • More common in preterm infants with low birth weight

2. • Most common infantile vascular tumor

3. • Females>males

Congenital Capillary Hemangioma pahtophys

Benign vascular tumor apparent at birth due to overgrowth of blood vessels that do not form properly during pregnancy

Congenital Capillary Hemangioma clinical presentation

1. Superficial Form: red, flat, lesion that enlarges then completely regresses by age 5

2. • Deep Form: Subcutaneous and under epidermis, blue-gray color, soft and palpable, IF deep in orbits, can cause proptosis

Congenital Capillary Hemangioma management

Most regress spontaneously, observation recommended unless sight threatening if affecting orbits

Acquired Capillary Hemangioma aka

cherry hemangioma

acquired capillary hemangioma cause

Related to aging,

some genetic predisposition,

hormonal changes such as pregnancy

Acquired Capillary Hemangioma epi

1. Middle aged and older adults

2. • Very common, can occur anywhere on the body

3. • Affects anyone, no gender, race predilection

pathophys of Acquired Capillary Hemangioma

Overgrowth of capillary vessels that become dilated

Clinical Presentation Acquired Capillary Hemangioma

• Solitary, distinct, elevated and movable

• Small lesions are red

• Larger lesions are red-blue

nevus flammeus aka

port wine stain

nevus flammeus cause

1. Congenital vascular malformation

2. • Can be isolated finding but can be associated with Sturge-Weber syndrome

epi of envus flammeus

• Present at birth, ~0.5% of newborns

• No gender predilection

pathophys of nevus flammeus

Congenital low flow vascular malformations of dermal capillaries that grows larger over time and does not regress

clinical presentation of nevus flammeus

1. Red to purple lesions around eyelids and periorbital region

2. • Often Unilateral but sometimes crosses midline

3. • Flat at birth but can become nodular with age

4. • Growth parallels growth of individual

5. • Follows the CN 5 (Trigeminal nerve) distribution

6. • Sturge-Weber Syndrome (SWS)

   1. • Neurocutaneous disorder with abnormal blood vessel growth in brain, skin and eye

   2. • Ocular complications:

      1. • Episcleral telangiectasia, Congenital glaucoma, Choroidal hemangioma and retinal detachment

      2. • Upper eyelid involvement highly associated with glaucoma

what indicates congenital glaucoma

bulphthalmos

management of nevus flammeus

1. • Laser photocoagulation or other forms of lasers to permanently close dilated vessels to improve cosmetic appearance.

2. • Treat ocular complications associated with SWS.

   1. • Glaucoma, RD

actinic keratosis aka

solar keratosis

cause of actinic keratosis

Aging change in skin, and secondary to gradual damage from lifelong exposure to ultraviolet light

epi of actinic keratosis

1. • Fair skinned individuals

2. • Individuals exposed to prolonged and excessive sunlight

3. • Older aged individuals

4. • Males > Females

pathophys of actnic keratosis

Excessive and cumulative UV exposure induces DNA damage in keratinocytes leading to abnormal cell proliferation and growth within epidermis

actinic keratosis clinical presentatino

1. • Multiple, red to pink, rough and scaly patches of skin

2. • Dry, Flat, Immobile, plaques, that can become nodular

3. • Affected skin may have ”sandpaper” texture

4. • Maybe itchy

5. • Precursor to Squamous Cell Carcinoma

management for actinic keratosis

1. • Larger lesions should be excised and biopsied by Oculoplastic or dermatologist

2. • Topical Chemotherapeutics

3. • Topical Immunomodulator

keratoacanthoma cause

Exact unknown, possibly related to UV radiation and chemical carcinogen

Keratoacanthoma epi

1. Older age >50

2. • Males>Females,

3. • Sun-exposure

Keratoacanthoma pathophys

Hyperkeratosis within a pilosebaceous unit with three phases:

1. Proliferation 2. Maturation 3. Involution.

keratoacanthoma clinical presentation

• Dome-shaped with keratin filled central crater

• Rapid onset and grows over weeks and may spontaneously regress over months leaving a scar

• Considered as a low-grade form of Squamous Cell Carcinoma (SCC) or precursor to SCC

basal cell carcinoma cause

Gradual damage from prolonged exposure to ultraviolet light, prior irradiation, immunosuppression and indoor tanning

whats the most common malignant tumor of the eyelid

basal cell carcinoma

epi of basal cell carcinoma

1. Most common malignant tumor of eyelid

2. • Fair skinned individuals

3. • Older age >50 yo

4. • Males>Females

5. • Often found in sun exposed areas of body

6. • Lower eyelid most common

pathophys of basal cell carcinoma

DNA mutations of basal cells within epidermis cause uncontrolled cell growth, proliferation, tumor formation, tissue infiltration and invasion

clinical presentation of basal cell carcinoma

1. . Nodular and Noduloulcerative (Rodent Ulcer) 80% of Eyelid BCC

   1. • Pearly, waxy, translucent tumor with rolled borders with telangiectasia (feeder vessels)

   2. • Loss of hair or lashes, become bleeding ulcer

2. 2. Sclerosing/ Morpheaform <2% of Eyelid BCC

   1. • Pale, flat, ill-defined margins, hardened plaque

   2. • No distinct tumor, difficult to diagnose, invasive

managemetn of basal cell carcinoma

1. Refer to oculoplastic, dermatology, ocular oncology Excisional biopsy, Mohs microsurgery, Eyelid reconstruction as needed

squamous cell carcinoma cause

1. • Gradual damage from prolonged exposure to ultraviolet light, prior irradiation and immunosuppression

2. • May arise from premalignant lesions such as Actinic Keratosis or Keratoacanthoma.

squamous cell carcinoma epi

1. • Fair skinned individuals >50 yo

2. • Males>Females

3. • <10% of eyelid malignancies, less common than BCC

pathophys of squamous cell carcinoma

DNA mutations of Squamous cell/ keratinocytes within epidermis cause uncontrolled cell growth, proliferation, tumor formation, tissue infiltration and invasion

bowens disease SCC aka

Superficial SCC in situ)

• in situ - in its place

Bowen’s Disease SCC clinical prseentation

1. • Pre-cancerous, Non-invasive but can convert to Invasive SCC

2. • Well defined, red, crusted, keratotic, scaly lesion, similar to actinic keratosis

3. • May resemble psoriasis or eczema