AST - Skin Lesions

Eyelids Anatomy and Tumours

  • Eyelid Structure:

Benign tumours / growths

Cysts of the Eyelid

Cyst of Zeiss:

  • Description: Small, non-translucent cysts located on the anterior lid margin, resulting from modified sebaceous glands.

  • Characteristics: small, non-translucent cyst on anterior lid margin, often non-tender

  • Cyst of Moll:

    • Description: Modified apocrine sweat gland cyst.

      • Aprocrine hidrocystoma

      • small retention cyst

    • Characteristics: Small, round, translucent; fluid-filled and usually more common in the lower lid.

  • Eccrine Hidrocystoma:

    • Location: Found on the medial or lateral aspects of the eyelid, usually doesn’t involve lid margins.

    • fluid filled - will light up with slit lamp beam

    • similar to cyst of Moll

    • don’t usually self-resolve - cosmetic excision

    • bilateral, can be numerous

Sebaceous Cysts:

  • Arise from sebaceous glands

  • Central punctum with retained “cheesy secretion”

  • rarely found on eyelids, may occur at inner canthus.

  • can be massaged or squeezed.

Acne-Related Lesions

Comedones:

  • acne vulgaris

  • plug of keratin and sebum within dilated opening of hair follicle

  • if follicle open = blackhead: plug of melanin containing keratin

  • if follicle closed = whiteheads: cream coloured papules

  • common in older patients

  • don’t cause any significant problems

Milia:

  • occlusion of pilosebaceous units (hair follicles and associated sebaceous gland)

  • results in retention of keratin

  • tiny epidermoid cysts

  • white, round, superficial papules, usually in groups

  • typically seen in young children / infants

  • usually self resolving

Syringoma

  • proliferation of intraepidermal sweat gland epithelium

  • multiple small papules

  • randomly distributed

  • don’t require any intervention

Infective Lesions

  • Hordeolum (Stye):

    • Internal: Infection of Meibomian gland.

    • External: Infection of glands of Zeis or Moll.

  • Chalazion:

    • Sterile inflammation due to blocked Meibomian gland, may evolve from an internal hordeolum.

Xanthelasma:

  • common, often bilateral

  • middle aged to elderly patients

  • multiple yellowish subcutaneous plaques - lipid laden histiocytes in epidermis

  • most commonly at nasal aspect of lids

  • treatment for cosmetic reasons

  • may be associated with raised serum cholesterol and LDL cholesterol

    • high recurrence rate in patients with persistent elevated cholesterol.

  • increased risk of heart disease, heart attack within 10 years.

Squamous Papilloma

  • “skin tag”

  • very common

  • pedunculated: fresh coloured narrow based pedunculated lesion (skin tag)

  • Sessile: broad based flatter lesion

  • hyperkerotic filform lesion like a cutaneous horn

  • excision if necessary.

Pedunculated papillomas

Seborrhoeic Keratosis

  • Basal Cell papilloma

  • Common and slow growing lesion found on face, trunk and extremities of elderly patients.

  • greasy looking brownish plaque with a verruca looking surface

  • looks stuck on to skin

  • treatment by excision (usually for cosmetic reasons)

Actinic Keratosis

  • also called solar keratosis

  • common pre-malignant skin lesions

  • rare on eyelids

  • affects elderly faire skinned people with excessive amounts of sunlight exposure.

  • forehead & back of hands

  • flat, sclay hyperkeratotic lesions

  • may be nodular or wart-like

  • may be associated with cutaneous horn

  • Reasons for excision:

    • can develop into a skin cancer

    • often cosmetically problematic

    • cause changes to the architecture of the lids.

Pyogenic granuloma

  • fast growing vascularised proliferation of granulomatous tissue

  • follows surgery, trauma or infection

    • especially pterygium surgery

  • pink pedunculated or sessile mass

  • excised.

  • non-cancerous

  • normally arise from conjunctiva

Keratocanthoma

  • rapidly growing benign tumour

  • fair skinned individuals with chronic sun exposure

  • found frequently in immunosuppressed px following renal transplants

  • may resemble squamous cell carcinoma

  • pink papule which may rapidly increase in size in few days

  • usually stops growing and remains static for 2-3 months

  • end of growth phase is firm dome shaped nodule

  • may spontaneously involute

  • in regression central part becomes hyperkeratotic with possible keratin filled crater.

  • involution may take up to a year and leave a scar

Capillary Haemangioma

  • “Strawberry naevus”

  • demographic

    • common tumour of infancy

    • more common in females

    • may be familial tendency

  • signs / symptoms:

    • predilection for upper lid, possible orbital involvement

    • unilateral red raised lesion

      • blanches with pressure

    • mechanical ptosis possible

      • can cause amblyopia in young age group

  • usually grows quickly in first year life, and may resolve spontaneously around age 2

    • complete resolution by 4 in 40%, 70% by age 7

  • patients with large fast growing strawberry naevi:

    • Kasabch-Merritt syndrome – thrombocytopenia, anaemia and low coagulant factor levels

    • Maffuci syndrome – skin haemangiomas, enchrondromata of hands feet and long bones, bowing of long bones

  • treatment: treatment if vision threatened by amplyopia, ptosis or strabismus, steroid injection into tumour, beta blocking systemic medication (e.g., timolol gel)

Malignant Tumours

Basal Cell carcinoma

  • most common human malignancy

  • most frequently affects elderly patients

  • important risk factors:

    • fair skin

    • inability to tan

    • chronic exposure to sun

  • slow growing

  • frequent locations (most to least)

    • lower lid, medial canthus, upper lid, temporal canthus

    • 90% occur in head and neck

    • 10% involve eyelid

  • BCC in medial aspect more likely to invade orbit and sinuses, also more likely to reoccur

  • recurrent tumours following incomplete treatment more aggressive and harder to manage.

Nodulo-ulcerative BCC

  • shiny firm pearly appearing nodule

  • dilated BVs on the surface

  • initially slow growing

  • if untreated, growth can become rapid and BCC develops central ulceration

  • raised rolled edges with dilated BVs over margins (rodent ulcer)

  • Over time may erode large portion of the lid.

Sclerosing BCC (morphoeic / morpheaform)

  • infiltrates laterally beneath skin as a plaque which may distort lid

  • may be difficult to define margins clinically

  • sclerosing BCC may resemble localised area of “chronic blepharitis”

  • can cause thickening of the eyelid and small areas of madarosis

Squamous cell carcinoma (SCC)

  • less common but more aggressive

    • accounts for 5-10% of eyelid malignancies

  • metastasises to regional lymph nodes and can spread to intracranial cavity via orbit

  • may arise de novo or from pre-existing actinic keratosis

  • predilection for lower lid and lid margin

  • more common in elderly patients

  • risk factors: fair complexion, history of chronic sun exposure and skin damage

  • diagnosis is often difficult

  • other benign lesions may resemble SCC

    • keratoacanthoma may show squamous cell changes at deeper levels.

  • SCC may look similar to BCC

    • but usually no surface vascularisation

    • SCC has more rapid growth

  • Plaque like SCC: roughened scaly reddened (erythematous) hyperkeratotic plaque - may arise from existing actinic keratosis

  • Nodular SCC: hyperkeratotic nodule - crusty erosions and fissures may develop

  • ulcerating SCC: red base and sharply defined indurated and everted boarders.

  • treatment: surgery and radiation therapy

Sebaceous gland carcinoma

  • arises from meibomian glands, occasionally glands of Zeiss or sebaceous glands

  • most commonly occur on the upper lid

  • sometimes simultaneous involvement of both lids - intraepithelial spread or multiple primaries

  • early tumours may mimic less aggressive lesions (chalazion)

  • needs prompt treatment as it can travel through the lymphatics and bloodstream and metastasize very quickly

    • treatment with chemotherapy

Nodular Meibomian Gland Carcinoma

  • discrete, hard nodule in upper tarsal plate

  • NB: recurrent or non-resolving chalazion

Spreading meibomian gland carcinoma

  • diffuse thickening of lid margin

  • similar to sclerosing BCC

  • may invade conjunctiva

  • pagetoid spread: extension to palpebral, fornix or bulbar conjunctiva

  • misdiagnosis as chronic conjunctivitis, SLK

Suspicion index for malignancy

  • ulceration

  • lack of tenderness

  • induration - volcano appearance

  • irregular borders

  • destruction of lid margin architecture

  • loss of lashes or fine skin hairs

  • loss of skin pores

Other Lid tumours

Karposi Sarcoma

  • vascular tumour affecting AIDS patients

  • small tumours are pink, red-violet or brown which may resemble maemartoma or naevus

  • larger tumours may ulcerate and bleed

Merkel Cell carcinoma

  • fast growing tumour arising from Merkel cells in dermis

  • elderly patients

  • highly malignant and potentially lethal

  • frequent metastatic spread at diagnosis

Pigmented lesions

Intradermal Naevi

  • usually elevated and often papillomatous in appearance

  • maybe non-pigmented or brown-black

  • lashes may grow through if on margin

  • “kissing” naevi: symmetrical lesions on upper and lower lids

  • naevus cells are in dermis and no malignant potential

Kissing naevi

Junctional Naevi:

  • flat, well circumscribed and uniform colour

  • cells located at junction of epidermis and dermis

  • low potential for malignant transformation

Compound Naevi:

  • intradermal and junctional components

  • usually brownish

  • low malignant potential due to junctional component

Management of Naevi:

  • document

  • size, location

  • photograph

  • educate patient

  • refer if “nervous”

Melanoma

  • rare on eyelids - but potentially lethal

  • skin melanomas pigmented but lid melanomas may be clinically non-pigemented.

  • superficial spreading melanoma: plaque with irregular outline and variable pigmentation

  • nodular melanoma: blue-black nodule surrounded by normal skin

  • lentigo maligna: slowly expanding pigmented macule which affects elderly patients most commonly.

    • Hutchinson freckle

    • sometimes associated with melanoma development.

  • ABCDE of Melanoma:

    • A: Asymmetry

    • B: Border irregularity

    • C: Colour variation

    • D: Diameter (>6mm)

    • E: Evolving nature