Alarge variety of benign and malignant lesions can affect the eyelids.¹ Many are common elsewhere on the body, but some are seen predominantly on the eyelids. Although accurate diagnosis in many cases may require histopathologic examination, a clinical diagnosis can be made in about 80% of cases based on the gross appearance, texture, color, and behavior of lesions and on the unique characteristics of eyelid skin.²

Some cutaneous and systemic disorders may be associated with eyelid lesions. In many cases, the eyelid findings are specific for a particular disorder, but at other times they may be nonspecific. These ocular findings, in combination with other cutaneous and systemic abnormalities, can often allow the clinician to make the correct diagnosis, even before the biopsy. Localized unilateral eyelid lesions may represent benign or malignant neoplasms, infections, or inflammations. Bilateral lesions more frequently represent disseminated systemic conditions such as collagen vascular diseases, metabolic disorders, vesico-bullous disease, dermatoses, or hypersensitivity reactions.

Eyelid lesions can be classified according to the anatomic structures from which they arise. These include the epidermis, dermis, subcutaneous fat, as well as various cells and adnexal structures within these layers.³ Eyelid inflammations may present as a localized or diffuse erythematous area. They can be associated with loss of eyelashes, eyelid edema, induration, eczematous changes, tissue necrosis, and ulceration. If skin contraction occurs, the eyelid margins may become malpositioned manifesting as entropion, ectropion, or canthal angle dystopia. Inflammatory lesions may be painful and at times can be associated with lymphadenopathy. Infectious conditions of the eyelid result from viral, bacterial, fungal, or parasitic processes and may be primary or secondary. The latter can result from extensions of head and neck foci such as the sinuses or lacrimal sac, or from hematogenous spread from distant sites. The cause of the infection on the eyelid is often evident, such as in a site of trauma or recent surgery. However, when the infection is either atypical or recurrent, a biopsy, smear, or culture may help to exclude the presence of occult malignancy or uncover an unusual infectious organism. A systemic evaluation would be valuable for particularly aggressive infections and those caused by fungi and parasites.

From several recent large series looking at the frequency of eyelid lesions, benign processes account for approximately 40% to 85%, and malignant neoplasms for 15% to 60%. Among the benign lesions, the most frequent diagnoses are squamous papilloma, nevus, cysts, seborrheic keratosis, vascular lesions, and neural lesions. In the United States, South America, and Western Europe, the most common malignant tumor on the eyelid is the basal cell carcinoma (70%-90%) followed in rapidly descending order by squamous cell carcinoma (5%-15%), sebaceous carcinoma (2%-7%), and malignant melanoma (1%). Other rare tumors such as Kaposi sarcoma, adnexal carcinomas, and Merkel cell tumors are occasionally seen, as are metastatic cancers. Several series of malignant eyelid tumors from Asia and India reported sebaceous carcinoma to be the second most frequent periorbital cutaneous malignancy at between 20% and 40% and in some cases equal to or more frequent than basal cell carcinoma.⁴,⁵,⁶,⁷ Interestingly, studies from Taiwan, Hong Kong, and Singapore report a lower incidence of sebaceous carcinoma in the range of 10% to 20%.⁸,⁹,¹⁰,¹¹ But both basal cell and squamous cell tumors are significantly less common in non-Caucasian populations, which is likely responsible for this frequency disparity.