Eyelid Neoplasms
KERATOACANTHOMA
Keratoacanthoma presents as an isolated lesion on the face with a unique appearance. The lesion is dome shaped with a central keratin-filled crater. It grows rapidly over weeks and may undergo spontaneous regression over months. Once considered benign, this is now considered a low-grade squamous carcinoma by most pathologists.
Epidemiology and Etiology
• Age: Most often older than 50 years; rarely younger than 20
• Gender: More common in males than in females by a ratio of 2 to 1
• Etiology: Unknown; ultraviolet radiation and chemical carcinogens may have a causative role. It is believed to originate from the pilosebaceous unit.
History
• Rapid onset of growth over a few weeks
• The lesion is often asymptomatic except for cosmetic changes.
• There may be occasional tenderness.
Examination
• Single, dome-shaped nodule with a central keratotic plug
• The lesion is firm and is slightly red to light brown in color (Fig. 3-1).
Special Considerations
• Once considered a benign lesion, there may still be some confusion in the literature about whether this is a squamous carcinoma.
• The lesion must be treated as a low-grade squamous carcinoma.
Differential Diagnosis
• Basal cell carcinoma
• Hyperkeratotic actinic keratosis
• Squamous carcinoma
Laboratory Tests
• Histopathology of the excised lesion
• Should be excised with frozen section guidance or with Mohs surgery
Treatment
• Excision with pathologic evaluation
• These lesions will sometimes spontaneously regress over a few months to a year.
• On the eyelid, these are always excised with margin evaluation.
 FIGURE 3-1. Keratoacanthoma. A. Lesion of the left upper eyelid that grew over 2 to 3 weeks. It was excised without recurrence. B. Large lesion of the left lower eyelid in a 40-year-old patient. The appearance could be that of a squamous cell carcinoma; however, the history of growth over 4 weeks and the patient’s younger age point to a keratoacanthoma. This lesion was excised without recurrence. |
Prognosis
• Good
• Depending on the size of the lesion, reconstruction of the defect may leave some eyelid changes.
ACTINIC KERATOSIS
These lesions may be single or multiple on chronically sun-exposed skin. They appear as dry, rough, scaly lesions that are stable but can rarely disappear spontaneously.
Synonym: solar keratosis
Epidemiology and Etiology
• Age: Older than age 40; rarely younger than age 30
• Gender: Higher incidence in males
• Etiology: Sun exposure over time in a fair-skinned white population results in actinic keratosis.
History
• Extensive sun exposure in youth
• Lesions present for months.
Examination
• Rough, slightly elevated, skin-colored or light brown lesions with hyperkeratotic scale (Fig. 3-2)
Special Considerations
• It is estimated that one squamous cell carcinoma will develop per 1000 actinic keratoses.
Differential Diagnosis
• Squamous cell carcinoma
• Discoid lupus
Laboratory Tests
• Pathologic evaluation if biopsied
Pathophysiology
• Repeated solar exposure results in damage to the keratinocytes by the cumulative effects of ultraviolet radiation.
Treatment
• Prevention through early and lifelong use of sunscreen
• Excise nodular lesions and submit for pathologic evaluation.
• Most flat lesions respond to liquid nitrogen or topical application of 5% 5-fluorouracil cream over a few days to weeks.
• Topical imiquimod cream has also been approved for treatment of actinic keratosis.
• These three treatments (liquid nitrogen, 5-fluorouracil, and imiquimod) must be used with caution around the eye and should be avoided in lesions at or near the lid margin.
Prognosis
• Some actinic keratoses may disappear spontaneously, but others remain for years unless treated.
• Incidence of squamous cell carcinoma developing in these lesions is unknown but has been estimated to be one squamous cell carcinoma in every 1000 actinic keratoses.
 FIGURE 3-2. Actinic keratosis. A. Multiple actinic keratoses on the cheek and brow with signs of chronic sun damage. B. Lesion involving the lower eyelid. |
LENTIGO MALIGNA
Lentigo maligna is a flat intraepidermal neoplasm and the precursor lesion of lentigo maligna melanoma. The lesion has striking variations of brown and black (Fig. 3-3), often described as a “stain.”
Epidemiology and Etiology
• Age: Median age is 65 years.
• Gender: Equal incidence in males and females
• Etiology: Sun exposure is a definite factor.
History
• History is usually not helpful, because the exact onset of lesion is unclear.
Examination
• Flat, dark brown or black color, sharply defined edges
• Often appears like a dark “stain” on the skin
Special Considerations
• This is a premalignant lesion and should be excised because of the chance of development into a lentigo maligna melanoma.
Differential Diagnosis
• Seborrheic keratosis
• Actinic keratosis
• Malignant melanoma
Laboratory Tests
• Histopathologic evaluation
Treatment
• Excision with margins sent for pathologic evaluation
Prognosis
• Excellent if excised before developing into a melanoma
 FIGURE 3-3. Lentigo maligna. A. A large macule with irregular borders and different shades of brown. (From Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D. Color Atlas & Synopsis of Clinical Dermatology. 4th ed. New York, NY: McGraw-Hill; 2001.) B. Recurrent lentigo maligna of the left brow. |
BASAL CELL CARCINOMA
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