Lumps and Bumps: The Dermatology of Lid Lesions Thomas J. Joly, MD, PhD Assistant Professor of Ophthalmology Eastern Virginia Medical School Ophthalmic Plastic Surgery Service Virginia Eye Consultants
Don t Miss the Forest for the Trees Goals: Raise your comfort level with benign lesions Lower your suspicion level for malignant lesions Increase your diagnostic recognition
Eyelid Histology Skin layers Epidermis Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum Stratum basalis Basal cells Melanocytes Dermis Collagen, elastin Adnexal structures AAO (1998) Basic & Clinical Science Course
Eyelid Histology Terminology Acanthosis: thickened stratum spinosum Hyperkeratosis: thickened stratum corneum Parakeratosis: nuclei retained in stratum corneum Dyskeratosis: keratin deep to stratum corneum Dysplasia: Disorderly maturation of the epidermal layers or cellular atypia Hyperplasia: Rapid growth through increased cell mitosis Elastosis: degeneration of collagen due to UV exposure
Adnexa Hair follicle Eyelid Histology Sebaceous glands (of Zeis) Apocrine sweat glands (of Moll) Eccrine sweat glands Meibomian sebaceous glands Caruncle Conjunctiva Non-keritanized epithelium Mucus cells
Eyelid Histology Terminology Sudoriferous: sweat, can be apocrine or eccrine Apocrine: secretion by cellular decapitation, specialized scent glands include the glands of Moll associated with each lash Eccrine: water secretion by osmotic cellular pumps Sebaceous: oil secretion, glands include the Meibomian glands of the tarsus, glands of Zeis associated with each lash follicle, and glands in the caruncle and brow
Benign Neoplasia of Epithelial Origin
Squamous Papilloma Benign hyperplasia of epidermis in folds over fibrovascular core, possible with hyperkeratosis but with no dysplasia AAO (1998) Basic & Clinical Science Course
Verruca Vulgaris Squamous papilloma caused by human papillomavirus infection Intracellular viral inclusions seen on histology Concomitant conjunctivitis resolves w/ removal AAO (1998) Basic & Clinical Science Course
Molluscum Contagiosum Epithelial papule due to pox virus infection Typical mulluscum bodies seen on histology Concomitant follicular conjunctivitis resolves with removal FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery
Seborrheic Keratosis Papilloma with irregular acanthosis, variable pigmentation, and variable hyperkeratosis Appears greasy and stuck-on with sebaceous hyperplasia and accumulated desquamated keratin. AAO (1998) Basic & Clinical Science Course
Inverted Follicular Keratosis Papilloma with marked hyperkeratosis and acanthosis May be an inflammatory reaction of a seborrheic keratosis AAO (1998) Basic & Clinical Science Course
Acrochordon (fibroephithelioma, skin tag) Solitary pedunculated hyperplastic epithelium surrounding fibrovascular core Multiple skin tags associated w/ pregnancy, intestinal polyposis JA Nerad, (2001) Oculoplastic Surgery
Cutaneous Horn Multiple layers of hyperkeratosis, may arise from a benign papilloma, inverted follicular keratosis, actinic keratosis, or malignant squamous cell carcinoma. JJ Kanski (1995) Clinical Ophthalmology
Pyogenic granuloma Misnamed Not pyogenic (no pus) Not granulomatous inflammation Vascular proliferation, often associated with conjunctival wound healing May be arrested early stage of wound healing
Melanocytic Nevus (mole) Benign proliferation of Congenital or acquired Life cycle: Junctional within stratum basale, young, dark, flat Compound descending partially into dermis, middleaged, still pigmented, domed Intradermal completely below the epidermis, old, domed, often depigmented melanocytes AAO (1998) Basic & Clinical Science Course
Congenital Nevus AAO (1998) Basic & Clinical Science Course
Giant Hairy Nevus Courtesy Thomas J. Joly, MD, PhD
Junctional Nevus JJ Kanski (1995) Clinical Ophthalmology
Compound Nevus
Intradermal Nevus (mole) Courtesy Thomas J. Joly, MD, PhD
Xanthelasma Lipid and cholesterol deposits within dermal histiocytes Sometimes associated with hypercholesterolemia or lipoprotein abnormalities
Xanthoma Lipid and cholesterol deposits within histiocytes deep to dermis Associated with xanthogranulomatous disease
Malignant Neoplasia of Epithelial Origin Hallmarks of malignancy: Ulceration Destruction of normal architecture Non-tender Induration Irregular, asymmetric Telangiectasia Pearly borders
Actinic Keratosis Pre-malignant condition (squamous cell CA) Dysplasia, dyskeratosis, hyperkeratosis, elastosis, chronic inflammation AAO (1998) Basic & Clinical Science Course
Keratoacanthoma (pseudoepitheliomatous hyperplasia) Rapidly growing epithelial hyperplasia, with hyperkeratosis and reactive inflammation May be incited by trauma, inflammation or infection Generally considered a low-grade form of squamous cell carcinoma, or pre-malignancy JB Crawford (1981) Duane s Clinical Ophthalmology
Basal Cell Carcinoma Invasive, non-metastasizing nests of basal cells Pearly borders, telangiectasia, ulceration, lash loss Commonly on lower lid, medial canthus Types Nodular Ulcerative (rodent ulcer) Cystic Morpheaform (sclerosing) Pigmented JJ Kanski (1995) Clinical Ophthalmology
Nodular Basal Cell Carcinoma AAO (1998) Basic & Clinical Science Course
Pigmented Basal Cell Carcinoma JB Crawford (1981) Duane s Clinical Ophthalmology
Cystic Basal Cell Carcinoma JB Crawford (1981) Duane s Clinical Ophthalmology
Morpheaform Basal Cell Carcinoma AAO (1998) Basic & Clinical Science Course
Squamous Cell Carcinoma Invasive & metastasizing nests of spinosum or granulosum cells with keratin pearls Ulceration develops under keratin crust Much less common than basal cell cancer JJ Kanski (1995) Clinical Ophthalmology AAO (1998) Basic & Clinical Science Course
Squamous Cell Carcinoma conjunctival Courtesy Thomas J. Joly, MD, PhD
Lentigo Maligna (Hutchinson s melanotic freckle) Premalignant proliferation of melanocytes Melanoma may form in up to 50% Variable light brown pigmentation JA Nerad, (2001) Oculoplastic Surgery
Melanoma Invasive, metastazing melanocyte proliferation Hallmarks: Heterochromia, >10mm, change Types Superficial spreading: 80% of cutaneous melanomas Nodular: most common eyelid Lentigo maligna melanoma SL Robbins et al. (1984) Pathologic Basis of Disease
Neoplasia of Adnexal Origin
Apocrine hidrocystoma (cyst of Moll, sudoriferous cyst) Blockage of an apocrine sudoriferous gland of Moll resulting in sub-epidermal cyst Usually solitary Cystadenoma is a benign proliferation of multiple cysts
Apocrine cystadenoma
Eccrine hidrocystoma Cystic benign hyperplasia of eccrine glands JA Nerad, (2001) Oculoplastic Surgery
Syringoma Benign adenoma of eccrine sweat glands Arise in dermis Grow premenstrually, in pregnancy, with estrogen therapy FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery
Trichoepithelioma Benign hamartoma of hair follicle Appear as small white papule within lashes Hereditary (multiple) or nonhereditary (solitary)
Pilomatrixoma (calcifying epithelioma of Malherbe) Benign hamartoma of hair follicle producing hair shaft protein, with calcifications Deep, hard nodule, commonly in children Associated w/ Gardner s Syndrome (colon polyps) Courtesy Thomas J. Joly, MD, PhD
Epidermal inclusion cyst Cyst of sequestered, degenerated keratin from a follicular infundibulum Surface pore Often misnamed sebaceous cyst not sebaceous AAO (1998) Basic & Clinical Science Course
Milia Cyst of sequestered, degenerated keratin from a follicular infundibulum, smaller than epithelial inclusion cyst Primary, newborn, or secondary to processes stimulating epithelial proliferation dermabrasion, injury FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery
Sebaceous Hyperplasia Benign sebaceous gland proliferation Shiny, indurated papules w/ umbilication Skin thickened on cheek, nose, forehead
Comedone (blackhead) Sequestered sebaceous secretions Gland orifice blocked with dried, blackened secretions FA Nesi et al. (1997) Smith s Ophthalmic and Resconstructive Surgery
Hordeolum (stye) Acute staphylococcal infection of a gland of Moll or Zeiss (external hordeolum) or Meibomian gland (internal hordeolum) JJ Kanski (1995) Clinical Ophthalmology
Chalazion Chronic, non-infected inflammatory nodule due to Meibomian blockage and secretion backup into surrounding tissue Can drain anteriorly or posteriorly JJ Kanski (1995) Clinical Ophthalmology Redatlas.com
Sebaceous Carcinoma Adenocarcinoma of Meibomian or Zeis glands Can mimic chronic chalazion or blepharitis Pagetoid spread Metastasis JB Crawford (1981) Duane s Clinical Ophthalmology
Classify lid lesions as: Summary Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma
Summary Most common Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma
Summary Most dangerous Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma
Summary Strongly recommend treatment Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma
Treatment Available Summary Epithelial Benign Squamous papilloma Verruca vulgaris Molluscum contagiosum Seborrheic keratosis Inverted follicular keratosis Melanocytic nevus Xanthalasma Cutaneous horn Epithelial Malignant /Premalignant Actinic keratosis Keratoacanthoma Basal cell carcinoma Squamous cell CA Melanoma Adnexal Apocrine hidrocystoma Eccrine hidrocystoma Trichoepithelioma Pilomatrixoma Epidermal inclusion cyst Milia Syringoma Sebaceous hyperplasia Comedone Hordeolum Chalazion Sebaceous carcinoma
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