Therapeutic Review: Benign lesions of the lids by Dr Anthony Maloof
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Patients with lesions involving the eyelid typically present complaining of aesthetic issues. The first step in the definitive management of eyelid lesions is the differentiation of benign vs malignant lesions. This may not always be easy to do clinically, necessitating incisional or excisional biopsy for definitive histological classification. In addition to and in spite of the diagnosis, lesions in the periocular area require both aesthetic management as well as definitive management.
This review focuses on the benign lesions of the eyelid. Although in most cases, aesthesis can be addressed, definitive management with restoration of aesthesis is not always straightforward despite the non malignant nature of these lesions.
The most common lesions which will present include
There are multiple other lesions which can mimic those above. They may be classified as follows:
Spidery blood vessels visible on the skin and composed of permanently enlarged blood vessels. These may be idiopathic, or occur in association with systemic diseases such as lupus or rosacea. They typically present as a focal red spot on the eyelid. Treatment may be via focal cautery, or if large, excision.
Chalazion: this has been covered in a previous review
Stye: this has also been covered in a previous review
Cyst of Moll:
A thin walled cyst with a bluish tinge. It may be small or large, and this can be confused with a basal cell carcinoma if large. (see Fig 1)
A cyst filled with semisolid sebum, arising from sebacous glands, and are often distinguished by the presence of a central plug clinically. The cysts appear skin coloured, although the contents are usually whitish when expressed. These lesions are typically non inflamed, and definitive treatment is via excision or curettage
This is an overgrowth or proliferation of sebaceous glands of the skin, appearing as single or multiple soft yellowish nodules on the skin typically of the face or head in the elderly (see Fig 2)
These are small epidermal inclusion cysts, and appear as tiny white spots on the skin. There are typically multiple lesions present, and these can occur in the newborn, and they arise from keratin filled cysts lying just beneath the epithelial layer. Unlike sebaceous cysts, no central plug is visible.
This is a benign tumour occurring from an overgrowth of epithelium. It is often elevated on a stalk, and is composed of the squamous layer of epithelium. It often has a central vascular core, and may bleed slightly if removed. It features slow growth (see Fig 3)
Seborrheic Keratoses are the most common skin lesion. Clinically, these lesions are characterized by elevated, irregular lesions which often have a crusted or even greasy appearance. Sometime, these lesions are pigmented. Typically, they have distinct edges, a tan-brown-black colour, and a “stuck on” appearance. When picked or irritated , they may ooze and bleed. They tend to be most common on sun-exposed areas in older patients, and the cause is not known. Some patients may have dozens of them, most commonly on the face, neck and trunk. They may be mistaken for melanomas but have no malignant potential. Removal is relatively routine with little scarring. Histologically, the epithelium may also show signs of increased pigmentation, especially in the basilar cell layer. There are no dysplastic changes noted in the epithelium (see Fig 4)
These are yellow plaques commonly occurring at the inner eyelids, more so in the upper than lower eyelid. Eyelid xanthelasma are called xanthelasma palpebrum, and are more common than cutaneous xanthoma. The lesions are soft and yellow, and form plaques. Histologically, these are foamy histiocytes located within the upper dermis, containing predominantly cholesterol. Up to 50% of patients have lipid disorders. Treatment involves management of lipid disorders. Topical treatment with tricholoroacetic acid may be helpful in large xanthelasmas, or surgical or laser excision as a definitive approach. Xanthelasmas may recur.
These are benign, usually asymptomatic, self-healing, red-to-yellowish papules and nodules. Papules or nodules occur in the skin, eyes, as well as elsewhere. These present usually in infancy and childhood, and histologically are composed of composed of histiocytic cells, both foamy laden and giant cells. These cells are thought to be immune cells of the skin. Lesions may be single or multiple, and may even involve the iris. Treatment is excision which is curative.
Hair / follicular
A benign usually solitary dome-shaped nodular lesion with a central pore that frequently contains a woolly hair-like tuft; it usually occurs on the head or neck, is derived from a hair follicle, and is characterized histologically by a central keratinous cystic cavity into which numerous abortive hair follicles radiate.
A small benign tumor derived from basal cells in the hair follicle. Trichoepithelioma may occur sporadically or as the cardinal feature of a relatively common genetic disorder called multiple familial trichoepithelioma characterized by the presence of many small tumors predominantly on the face, inherited in an autosomal dominant pattern. A trichoepithelioma can undergo malignant transformation into a basal cell carcinoma.(see Fig 5)
Pilomatrixoma (calcifying epithelioma of Malherbe)
A benign, often calcified tumor of the skin and the tissue just below the skin, often occurring as a single lesion on the face or upper extremities. Pilomatrixomas develop from an abnormal formation of cells that are similar to hair cells, which become hardened or calcified. The calcified cells form a mass beneath the skin. Most cases occur in children less than 10 years old. The lesion is typically a small, hard mass beneath the skin of the face, head, neck, or arms, usually less than 3 cm in diameter and the skin covering the mass appears normal, or may feel firm or hardened. Usually, the mass is painless, unless it becomes infected.
Treatment is by surgical excision.
This is a benign proliferation of melanocytes, which are the pigment forming cells of the skin. Proliferations of melanocytes are typically classified by their position within the skin, with a nevus being located within the epidermis. These do not require treatment. (see Fig 6)
Dermal nevi are melanocytic proliferations lying within the dermis. These usually present as a raised mass, often with hairs arising from the surface. They may become fleshy and coloured, and on the eyelid they are usually at the anterior margin, incorporating hairs. (see Fig 7)
Fungal infection of the skin may be a differential diagnosis of any unusual shaped lesion. Typically there is variability and slow growth, and the lesion may be bilateral. Unlike more common fungal skin infections, the lesion may be elevated as well as thickened, and may be misdiagnosed as an eyelid tumour. Diagnosis is via histology and microbiological confirmation, and treatment relies on systemic and topical antifungal agents.