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 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 • • • • 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