Lumps and Bumps: The Dermatology of Lid Lesions

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
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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
Eyelid Histology
• Adnexa
– Hair follicle
• 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 melanocytes
• 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
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
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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
JA Nerad, (2001) Oculoplastic Surgery
in up to 50%
• Variable light brown
pigmentation
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…
JJ Kanski (1995) Clinical Ophthalmology
• …or posteriorly
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
Summary
Classify lid lesions as:
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
Summary
Treatment Available
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
Thank You
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