Eyelid Lumps and Bumps

Acquired Tumors and Cysts with non-infectious

etiology

Benign Tumors
Actinic

Keratosis

What is it?
Slow growing keratinization of the epithelium
Results from excessive sun exposure
Pre-malignant: may transform into squamous cell carcinoma

Appearance

Rough, dry, and scaly plaque that is flat or slightly raised

Up to 2.5 cm diameter individually
Often multiple lesions in a single area that coalesce
Distinct boarders
May be skin colored to dark brown

Who gets it?

Elderly individuals with lightly pigmented skin

Rarely develops on the eyelid
Common on the scalp, ears, forehead, and backs of hands
The patient may notice itching or burning of the lesion

Benign Tumors
Actinic

Keratosis

Management
Biopsy for definitive diagnosis
Usually frozen (cryotherapy) or excised

Benign Tumors
Squamous

Cell Papilloma

What is it?
Outgrowth of fibrovascular connective tissue
Covered by irregular keratinized stratified squamous
epithelium

Appearance

Variable presentations
Skin tag type: narrow base, pedunculated, skin colored
Board base with raspberry like appearance
May be difficult to differentiate from viral wart (human
papillomavirus)

Who gets it?

No predilection to race or gender

Management
Removed by excision

Benign Tumors
Squamous

Cell Papilloma

Benign Tumors
Basal

Cell Papilloma

What is it?
Expansion of the squamous epithelium stemming from basal cell
proliferation
Slow growing lesion

Appearance

Round coin-like lesion with stuck-on appearance

Up to 2.5 cm diameter
Slightly raised and crusty: often keratinized similar to actinic keratosis
Tan to dark brown in color
Variety of textures: granular to velvety

Who gets it?

Common in the elderly
Most people develop at least one during their lives
Usually develop on the head, neck, or trunk

Management
No treatment required except for cosmetic reasons or if they become
irritated
Removed by excision

Benign Tumors
Basal

Cell Papilloma

Benign Tumors
Inverted

Follicular Keratosis

What is it?
Rare and often rapid growing lesion arising from a hair follicle
Histologically similar to basal cell papilloma, but with deeper
extension into the dermis

Appearance
Non pigmented papilloma at the lid margin
Up to 1 cm diameter

Who gets it?

Typically older males

Management
Deep excision
Recurrence is common if not completely removed

Benign Tumors
Inverted

Follicular Keratosis

Benign Tumors
Keratoacanthoma

What is it?
Rare and rapidly growing variant of actinic keratosis
Also pre-malignant, potentially transforming into squamous cell
carcinoma

Appearance
Initially appears as a pink hyperkeratotic lesion usually on the lower
lid
After a period of rapid growth, remains stable for several months
Then begins to involute and a keratin filled crater often forms
Complete involution can occur after a year leaving a residual scar

Who gets it?

Same demographic as actinic keratosis
Higher occurrence in patients on immunosuppressive therapy
following kidney transplants

Management
Usually excised
Occasionally treated with cryotherapy or radiotherapy

Benign Tumors
Keratoacanthoma

Benign Tumors
Melanocytic

Nevus

What is it?
Tumor composed of cells derived from either epidermal or dermal
melanocytes
Acquired and congenital forms
Generally low to no malignant potential

Appearance
Junctional: Uniform brown macule or plaque
Compound: Uniform, light to dark brown, raised papule
Intradermal: Papillomatous with little to no pigment. Associated with
dilated vessels and protruding lashes

Who gets it?

Junctional type occurs in the young
Compound type occurs in middle age
Intradermal type most common overall and occurs in the elderly

Management
Removal for cosmetic reasons or if malignancy is suspected
Excision may need to be followed by reconstruction depending on
location and size

Benign Tumors
Melanocytic

Nevus
Junctional Nevus

Compound Nevus

Intradermal Nevus

Benign Tumors
Xanthelasma

What is it?
Aggregation of lipid filled macrophages at the level of the dermis
Common and frequently bilateral

Appearance
Yellowish subcutaneous plaque
Usually on the medial portion of the eyelids
Often multiple

Who gets it?

Middle aged and the elderly
May be associated with elevated cholesterol especially when
occurring in younger individuals and with corneal arcus

Management

Removed for cosmetic reasons

Usually treated with carbon dioxide or argon laser
May be excised
Recurrence suggests persistently elevated cholesterol

Benign Tumors
Xanthelasma

Benign Tumors
Pilomatricoma

What is it?
Abnormal proliferation of the germinal matrix cells in a hair
follicle
Frequently becomes calcified

Appearance
Deep nodule
Becomes hard if calcified

Who gets it?

Common in young females

Management
Excision

Benign Tumors
Pilomatricoma

Benign Tumors
Neurofibroma

What is it?
Abnormal proliferation of Schwann cells, fibroblasts, and axons

Appearance
Characteristic S shaped lesion
Typically located on the upper lid

Who gets it?

Solitary lesions occur in adults
25% associated with neurofibromatosis-1
Children with neurofibromatosis-1 are affected by diffuse
lesions

Management
Solitary lesions removed by excision
Diffuse lesions are more difficult to remove

Benign Tumors
Neurofibroma

Malignant Tumors
Basal

Cell Carcinoma

What is it?
Locally invasive proliferation of pluripotent epidermal basal cells
Most common human malignancy and most common eyelid
malignancy
Slow growing with no metastatic potential

Appearance
Usually on the lower eyelid
Non-tender ulceration
Irregular boarders
Possible keratinization
Destruction of eyelid architecture
Nodular type: pearl like appearance with dilated blood vessels on
surface
Noduloulcerative type: central ulcer with raised pearly edges
Sclerosing type: lateral, hardened, infiltration beneath the
epidermis. May be confused with chronic blepharitis

Malignant Tumors
Basal

Cell Carcinoma

Who gets it?

Common in the elderly
Risk factors include fair skin and high cumulative sun exposure

Management
Diagnosis confirmed with biopsy
Excision is the common removal technique
Mohs micrographic surgery removes the tumor along with a
thin layer of surrounding tissue. The surround is immediately
examined for tumor cells and the procedure repeated if any
are found. Highest cure rate at 98%.
Recurring tumors tend to be more invasive and difficult to
treat

Malignant Tumors
Basal

Cell Carcinoma

Nodular

Ulcerative

Sclerosing

Malignant Tumors
Squamous

Cell Carcinoma

What is it?
Proliferation of invasive cells arising from the squamous cell layer of
the epidermis
Can arise de novo or from existing actinic keratosis or
keratoacanthoma
Less common, but more aggressive than basal cell carcinoma
Lymph node metastasis in 20% of cases

Appearance

Variety of appearances and may be difficult to distinguish from BCC

Scaly with irregular boarders
Absence of surface vasculature
Extensive keratinization usually present
Lesions may bleed
Nodular type: keratinized nodule that develops erosions and fissures
Ulcerating type: everted boarders with a red, well defined base
Cutaneous horn: invasive growth underlies keratin horn

Malignant Tumors
Squamous

Cell Carcinoma

Who gets it?

Most common occurrence is in the elderly
Risk factors include fair skin, sun exposure, and immune
suppression

Management

Can be fatal if left untreated (2,500 annual deaths in USA)

Confirmed with biopsy
Mohs micrographic surgery: highest cure rate 94-99%
Other options include standard scalpel excision, cryotherapy,
and radiotherapy

Malignant Tumors
Squamous

Cell Carcinoma

Nodular

Cutaneous horn

Ulcerative

Large ulcerative

Malignant Tumors
Sebaceous

Gland Carcinoma

What is it?
Slow growing tumor
Arises from the meibomian glands, glands of Zeis, or
sebaceous glands in the caruncle
More likely to occur on the upper lid where glands are more
numerous

Appearance
No pathognomonic presentation
Initially can appear similar to chalazion or chronic blepharitis
Yellowish material may be seen within the tumor
Nodular type: hard, painless, immobile nodule similar to
chalazion
Spreading type: thickened lid margin, loss of lashes, similar to
chronic blepharitis

Malignant Tumors
Sebaceous

Gland Carcinoma

Who gets it?

Females in their 60's and 70's most commonly affected
Youngest reported case was in a 3 year old

Management

Because of appearance, diagnosis is often delayed

Mortality rate is 5-10%
Large (1cm) and non-resolving chalazion should be suspected
Cryotherapy and surgical excision are the standard treatments
Recurrence is as high as 33%
Little documentation for Mohs, but possibly lower recurrence
rate

Malignant Tumors
Sebaceous

Nodular

Gland Carcinoma

Spreading

Conjunctival involvement

Malignant Tumors
Melanoma

What is it?
Epidermal and dermal proliferation of transformed and invasive
melanocytes
Arises from existing nevus, lentigo maligna (pre-malignancy), or de
novo
High potential for metastasis
Potentially fatal (represents greater than 2/3 of all skin cancer
deaths)

Appearance

Rarely develops on the eyelid (1% of all eyelid lesions)

Half of those that do are non-pigmented
Asymmetric plaque or nodule
Irregular and indistinct boarders
Variable colors in the lesion (blue and black)
Diameter larger than ~6mm
Associated with destruction of local anatomy and loss of lashes

Malignant Tumors
Melanoma

Who gets it?

Most common in elderly individuals with light skin
History of sun damaged skin

Management
Question any new, changing, or irregular appearing lesions
Melanoma confirmed with biopsy
Wide surgical excision with up to a 1 cm margin for confirmed
malignancy
Local lymph node dissection if malignancy is more than 1.5
mm deep
Prognosis and recurrence is tied to size and any metastasis of
original lesion
Patients should be followed closely following surgery

Malignant Tumors
Melanoma

Malignant Tumors
Merkel

Cell Carcinoma

What is it?
Very rare and fast growing form of skin cancer
Highly malignant and potentially fatal
Arises from Merkel cells located in the basal layer of the
epidermis
Normal cells thought to play a regulatory role in epidermal
growth

Appearance

Frequently involves the upper eyelid

Red, purple, or violet colored, well defined nodule
Wide variation in size, from less that 2cm to larger than 15cm
Overlying skin is intact

Malignant Tumors
Merkel

Cell Carcinoma

Who gets it?

Average age of diagnosis is 75

20x more likely to occur in whites than blacks
No gender predilection
Risk factors include sun exposure and immune suppression

Management
Many have metastasized by the time they are diagnosed
CT and/or MRI imaging used to evaluate systemic spread
Primary tumor removed with a wide excision (margins up to
3cm if possible)
Chemotherapy and/or radiotherapy depending on spread
2 year mortality rate of 30-50%

Malignant Tumors
Merkel

Cell Carcinoma

Cysts
Chalazion

What is it?

AKA meibomian cyst

Fatty secretions of a meibomian gland are retained
Causes a chronic, painless inflammation
Patients with rosacea or meibomian gland dysfunction are
more prone to developing multiple and recurrent chalazion

Appearance
Nodule that has enlarged gradually
May enlarge up to nearly 1 cm
If large enough, may induce astigmatism by pressing on the
cornea

Cysts
Chalazion

Treatment
About one third drain and resolve spontaneously
Standard therapy aimed at stimulating and speeding draining by
using warm compress and massage
Steroid injection through the palpebral conjunctiva
0.1-0.2 ml Kenalog (triamcinolone)
80% success rate
May cause local depigmentation of the skin

Oral tetracycline/doxycycline useful in patients with chronic lid

inflammation

Do not use in children or pregnant/nursing women!

250mg PO qid tetracycline
100mg PO bid doxycycline
1-2 week course

Incision and drainage through the palpebral conjunctiva and tarsal

plate
Biopsy a recurrent chalazion - it may be sebaceous cell carcinoma

Cysts
Cyst

of Zeis

What is it?
Variation of chalazion
Non-translucent retention cyst involving the anterior lid margin
Gland of Zeis produces oil for eye lashes

Cysts
Cyst

of Moll

What is it?

Variation of chalazion
AKA Sudoriferous cyst
Translucent retention cyst involving the anterior lid margin
Variation of chalazion
Gland of Moll is a modified sweat gland also emptying to the
lashes

Cysts
Epidermoid

Cyst

What is it?
AKA sebaceous cyst
Cyst lined by stratified squamous epithelium and containing
keratin and sebaceous material
Result from ingrowth of surface epidermis after trauma or
surgery

Appearance
Round, well defined, non-tender mass
Ruptured cysts cause an acute inflammatory response and
possible secondary infection

Treatment
Complete surgical excision

Cysts
Eccrine

Hidrocystoma

What is it?
Rare cyst that forms from retained sweat in a blocked and
dilated sweat duct
More common in females

Appearance
Similar to Cyst of Moll with the exception that it does not
involve the lid margin
Painless and usually asymptomatic
May grow up to 6mm

Treatment
Monitor or needle puncture if desired

Cysts
Syringoma

What is it?
Benign and asymptomatic proliferation of sweat gland duct
epithelium
Relatively common
Most common in adult females

Appearance
Multiple small (3mm or less) papules
May be skin color or yellowish

Treatment
Removed for cosmetic reasons only
No set recommended removal technique
Options include excision, cryotherapy, dermabrasion,
electrocautery and more

Cysts
Milia

What is it?
Tiny epidermoid cysts that tend to occur in clusters
Result from a blocked vellus hair follicles that retain the
keratin
Very common occurs in half of all infants
May also occur following dermabrasion or damage to the
follicle

Appearance
Small pearly white to yellowish papules

Treatment
No treatment necessary
Needle puncture and expression may be performed if desired

Resources

Kanski, Jack J. Clinical Ophthalmology a Systemic Approach. 6th ed. Edinburgh, UK:
Elsevier, 2007.

http://www.mayoclinic.com/health/actinic-keratosis/DS00568

http://www.consultantlive.com/photoclinic/article/10162/1265743

http://www.skincancer.org/Basal-Cell-Carcinoma/

http://www.skincancer.org/squamous-cell-carcinoma.html

http://emedicine.medscape.com/article/1101433-overview

http://emedicine.medscape.com/article/1213671-overview

http://emedicine.medscape.com/article/1100917-overview

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781304/

http://emedicine.medscape.com/article/1058063-overview

http://emedicine.medscape.com/article/1059871-overview