o t Treating eyelid lesions with chemical cauterisation

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t
Leonid Skorin Jr, OD, DO, FAAO, FAOCO
Treating eyelid lesions
with chemical cauterisation
Chemical cauterisation is a simple,
inexpensive and effective way to treat
eyelid lesions such as verrucae,
keratoses and xanthoma palpebrarum
(xanthelasma).
Verrucae (papilloma)
Verrucae are benign skin tumours produced by
the papillomavirus and are a form of viral wart1.
These lesions are more common in children and
can involve any part of the body, especially the
eyelids2,3. They can cause mechanical irritation of
the cornea and conjunctiva if they are located on
the eyelid margin. In addition, they can cause
conjunctivitis since they expose this tissue to the
viral exotoxins and desquamated epithelium,
which these lesions tend to shed4. Patients will
complain of a foreign body sensation,
photophobia, redness, burning and tearing2.
There are three types of verruca – verruca
vulgaris, verrucae plana and cutaneous horns.
Verrucae vulgaris is a raised, multi-lobulated,
grape-like mass of tissue attached to the eyelid
by a stalk (pedunculated) of varying thickness3
(Figure 1).
It is cauliflower-like and pitted in appearance
and may be darkly pigmented3. Both types have a
central fibrovascular core which branches out like
a tree. Newly formed verrucae have a soft, fleshy
texture, but over time, the surface thickens,
hardens and darkens as they become more
pigmented.
Cutaneous horns are the third type of
verrucae. These lesions are cornified verruca
vulgaris (Figure 3). Since they are keratinised
and firm to the touch, they lack the fleshy-soft
consistency of a verruca vulgaris3.
Figure 3
Cutaneous horn
The most common type of viral wart to occur
on the face and eyelid area is verruca plana5.
Chemical cauterisation usually works best for this
type of flatter verrucae (verruca plana).
Actinic keratoses
(solar keratoses)
The verruca plana is a round, slightly raised
flat (sessile) lesion varying in size from a few
millimetres to several centimetres in diameter
(Figure 2).
Actinic keratoses are intraepithelial squamous
dysplasias which can range from mild atypia to
squamous carcinomas in situ. They occur on sundamaged skin in middle-aged or older patients.
The sun-damaged skin is evidenced by dermal
elastosis – a degenerative change of the dermal
collagen which results in histologic altered
staining characteristics6.
These lesions are flat, scaly, light brown
pigmented, or erythematous and measure from a
few millimetres to up to 1cm (Figure 4). Actinic
keratosis only rarely become invasive and may
actually regress7.
Figure 2
Two pigmented verruca plana lesions
Figure 4
Actinic keratosis on the upper eyelid
Figure 1
Verruca vulgaris
36
May 3, 2002 OT
Xanthoma palpebrarum
(xanthelasma)
Xanthelasma is a lesion of the middle-aged or
elderly and usually occur bilaterally on the upper
and/or lower eyelids near the medial canthal
area6. They present as elevated, yellow, soft,
plaque-like lesions typically appearing just
beneath the skin surface8 (Figure 5).
Figure 5
Bilateral upper eyelid xanthelasmas, with a more
extensive lesion on the right upper eyelid
The xanthelasma lesion is filled with cholesterol
and other lipids which infiltrate xanthoma cells.
These lesions may be related to increased
blood lipid (cholesterol or triglyceride) levels.
Between 30% and 50% of younger patients
(aged 30 to 55 years) with these lesions have a
disturbance of lipid metabolism9. These patients
are at increased risk for atherosclerotic
cardiovascular diseases and possible systemic
disorders such as diabetes mellitus and
cirrhosis10. If a patient has xanthelasma and has
not had their blood cholesterol checked within
the last year or two, encourage them to see their
GP for a lipid profile.
Chemical cauterisation
Chemical cauterisation using dichloroacetic acid
(Bichloracetic Acid) is an inexpensive yet
efficient method to remove superficial eyelid
lesions such as verrucae, keratoses and
xanthelasmae. The dichloroacetic acid
Figure 6
Bichloracetic Acid treatment kit
www.optometry.co.uk
compound is a potent, clear, colourless liquid
cauterant-keratolytic agent which can be
purchased as a complete treatment kit (Figure
6). The treatment kit contains the acid itself,
petrolatum, wooden applicators, a brush, and
two glass vials.
If the patient is not of Caucasian descent,
be aware that he may develop a keloid from
this treatment. A keloid is a scar compound of
collagenous and cellular fibrous material that
sometimes follows an injury or surgery. If a
patient develops keloids following an injury or
surgery in the past, treatment should be
withheld.
To quell any reflex lacrimation and prevent
any unnecessary irritation from the acid’s
fumes, apply a topical anaesthetic to the eye.
Then, apply the petrolatum around the lesion
to be treated (Figure 7).
Figure 7
Petrolatum being brushed around a
xanthelasma
Brush a ring, about 2-3mm wide, around the
area to be treated. This protects the normal
uninvolved skin. Any normal tissue not
protected may be damaged by the acid. Avoid
getting petrolatum on the area to be treated
because any tissue it covers will not be affected
by the acid.
Next, transfer a few drops of acid into the
vial provided with the kit. Never work with the
bottle itself. Because it is a powerful keratin
solvent, work with small amounts of the
dichloroacetic acid. Dip the pointed tip of the
wooden applicator about 2-3mm into the vial,
emersing the end within the acid. Before
removing the wooden applicator, tap it against
the inside of the vial neck, allowing any excess
acid to run down the inside of the vial.
Remember to keep the vial away from the
patient’s face and do not pass the acid soaked
wooden applicator over the patient’s face or
eyes.
Using good illumination and a magnifying
loupe if needed, apply the acid directly to the
lesion using the pointed end of the applicator
(Figure 8). Cover the entire lesion, but take care
not to let the acid spill over to normal tissue.
Warn the patient that they will experience a
www.optometry.co.uk
(Figure 9). The treated lesion darkens after
several hours and forms an eschar (scar) after
a couple of days (Figure 10).
The eschar sloughs off after one or two
weeks, exposing healthy pink skin beneath it
that soon returns to normal colour. The
patient should be warned not to remove the
eschar prematurely to minimise the risk of
infection. Female patients may apply make-up
onto the eschar. If any portion of the lesion
remains after two weeks, the area can be
retreated.
Conclusion
Figure 8
Dichloracetic acid being applied to the
xanthelasma with a wooden applicator
burning sensation when the acid is applied to
their skin surface and for a short time
afterwards.
If the lesion is on the eyelid margin, the lid
should be pulled away from the globe while the
acid is applied. The lid is not released before
the acid has dried. The patient should look in a
direction opposite from the lesion during acid
application. A Jaeger plate (a short, flattened
piece of clear Lucite or metal with a concave
outer surface and convex inner surface) can be
used as a protective barrier between the eyelid
and globe during acid application3.
Immediately after the acid is applied, the
surface of the lesion turns a milky greyish
white, becomes sticky and appears to melt
Chemical cauterisation is a safe, relatively
painless, effective and economical way of
treating selected eyelid lesions. Besides the
functional improvement, the patient also
gains cosmetic benefits from the eyelid lesion
removal.
About the author
Dr Leonid Skorin is a licensed optometrist and
a board-certified ophthalmologist. Trained in
neuro-ophthalmology, he has numerous
publications and has lectured internationally.
References
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Roberts CM. Quick Consult to Diagnosing and
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Marren SE, Bartlett JD, Melore GG. Diseases of
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Clinical Ocular Pharmacology, 4th ed. Boston:
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Stenson S, Newman R, Fedukowicz H.
Laboratory studies in acute conjunctivitis.
Arch. Ophthalmol. 1982; 100: 1275-1277.
Schmidt LM. Warts: their diagnosis and
treatment. Pediatr. Ann. 1976; 5: 782-790.
Figure 9
The xanthelasma has turned white and
appears to melt after the acid application
Bertucci GM. Periocular skin lesions and
common eyelid tumors. In: Chen WP (ed).
Oculoplastic Surgery The Essentials. New York:
Thieme, 2001: 233-234.
Burgdorf W, Nasermann T, Janner M, et al:
Dermatopathology. New York: Springer-Verlag,
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Douste-Blazy P, Marcel YL, Cohen L, et al.
Increased frequency of Apo E-ND phenotype
and hyperapobeta lipoproteinemia in
normolipidemic subjects with xanthelasmas of
the eyelid. Ann. Intern. Med. 1982; 96: 164169.
Figure 10
Eschar (different patient than seen in
Figures 7-9)
Parkes ML, Waller TS. Xanthelasma
palpebrarum. Laryngoscope 1984; 94: 12381240.
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