o 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 Amer M, Tosson Z, Soliman A, et al. Verrucae treated by levamisole. Int. J. Dermatol. 1991; 30: 738-740. Roberts CM. Quick Consult to Diagnosing and Treating Ocular Disease. Boston: Butterworth Heinemann, 2002: 23-25. Marren SE, Bartlett JD, Melore GG. Diseases of the eyelids. In: Bartlett JD, Jaanus SD (eds). Clinical Ocular Pharmacology, 4th ed. Boston: Butterworth Heinemann, 2001: 511-515. 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, 1984: 115-197. Skorin L. Eyelid swelling: What’s the underlying cause? Consultant 2001; 41: 1624a-1624j. 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. 37