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Home , Hypertrophic scar, Keloid, Papule, Skin cancer, Xanthoma

11/29/2016

Update on Ocular • No Financial Disclosures

Dawn Pewitt, OD, FAAO Triad Eye Institute, Grove, OK COPE 51248-AS

Benign Eyelid Lesions Epithelial & Adnexal Tumors

• Epithelial & adnexal tumors • Squamous • Vascular tumors • Seborrheic (SK) • Xanthomatous tumors • Cutaneous • Infectious • (eccrine & apocrine) • Fibrous tissue

Squamous Papilloma Periorbital

• Aka tags, achrochordons; fibroepithelial polyps • Common around eyelids, , or near flexures • Assoc with obesity and insulin resistance

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Seborrheic Keratosis

• Abnormality of epidermal • Is the most common basal maturation that differential diagnosis results in a well-defined, of a malignant raised, rough-surfaced or plaque. . • Classic waxy or “stuck-on” • Patient reassurance. appearance. • Surgery vs. • Usually asymptomatic but . may or become inflamed.

Seborrheic Keratosis Cutaneous Cysts

• A is a closed cavity or sac containing fluid or semi-solid material within an epithelial, endothelial or membranous lining. • : a cutaneous or subQ cystic swelling of the skin, often with a central punctum, derived from squamous • Dermoid cyst: a developmental cyst resulting from inclusion of embryonic epithelium at sites of embryonic fusion • Milia (whiteheads): small epidermoid cysts that presents as a white or cream-colored papule

Epidermoid Cyst Epidermoid Cyst

• Most occur spontaneously, can be assoc with . • Multiple cysts occur in Gardner’s syndrome. • Usually asymptomatic but can be inflamed.

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Epidermoid Cyst Dermoid Cyst

• Often present at birth. • Occur most commonly on the face, midline of the neck and the mastoid area.

Milia (Whiteheads) Sweat Gland Tumors

• Common in acnes. • Eccrine : rare disorder of the • Asymptomatic. eccrine sweat duct that results in several • Usually occur on face but can develop anywhere when small swellings, usu adjacent to the eyelids. It related to a blistering occurs particularly in hot climates. process. • Syringomata: a of sweat ducts; • Often disappear spontaneously in you after a usually occurs as multiple lesions number of months. •Formerly I&C • Laser ablation

Eccrine Hidrocystoma Syringomata

• Multiple small swellings • Common in Asians & that increase in size Afro-Caribbeans; can with heat & become be familial; occur in almost imperceptible in Down syndrome. the winter. • Occur symmetrically, • Occur mainly around particularly around the the eyes. eyes in females. • Most common in • Reassurance vs gentle females. cautery. • Air-conditioning helpful.

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Apocrine Gland Tumors Fibrous Tissue Tumors

• A benign cystic tumor • Hyperproliferative responses of connective of the apocrine tissue to trauma resulting from an imbalance secretory glands (gland between synthesis and lysis. of Moll). • Slow growing, appears in middle age. • Hypertrophic : confined to the area of • Solitary dome-shaped. trauma. • No seasonal variation. • : spread beyond the area of trauma - has a worse prognosis.

Keloid vs Hypertrophic Vascular Tumor

• Pyogenic : common benign vascular papule occurring in youth, possibly as a response to injury. • Sudden onset & tend to bleed.

Xanthomatous Lesions

• Accumulations of cells – macrophages • Most common of all containing droplets of lipids • May be a symptom of a general metabolic disease • Age of onset: over or a local cell dysfunction age 50 • Classification: • Labs: fasting 1. Due to and 2. Normolipidemia triglycerides • 50% of patients have no metabolic disease

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Xanthoma Infectious Lesions

Striatum Palmare Eruptive Xanthoma • • Verruca •

Impetigo Impetigo

• Common in the • remain for young few days (yellow • Outbreaks occur in pus visible) institutions • ruptures & (nurseries) golden forms • Predisposing factor • Insect bite • Spreads rapidly • Trauma • Ulceration if • Eczema infection is deeper

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Verruca Impetigo

Verruca plana (flat) Verruca vulgaris • Topical antibiotics • Systemic antibiotics for 5 days; they are effective within 24 hours

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Filiform Molluscum Contagiosum • Small base with elongated shape • May have associated conjunctivitis • Epidermal viral infection • Common in children and immuno- compromised • • Basophilic molluscum bodies

Molluscum Contagiosum Molluscum Contagiosum • May be associated with chronic follicular conjunctivitis • Management: excision, curettage, cryotherapy, trichloroacetic acid

Solar Damage and Non-Melanoma Skin Skin Cancer • The propensity for solar Fitzpatrick Skin Types • damage depends upon: 1) Always , never • Skin type tans ** • Actinic (Solar) Keratosis • The cumulative exposure 2) Always burns, • to UV light sometimes tans ** • The intensity of exposure 3) Sometimes burns, • Squamous Cell • The exposure in always tans childhood 4) Never burns, always • Basal Cell Carcinoma • Residence nearer to the tans equator 5) Black skin

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Cutaneous Horn Cutaneous Horn

• Marked cohesion that gives rise • A red indurated to a horny outgrowth. base suggests SCC. • May be caused by a wart, solar • A flat or sl raised base suggests AK. keratosis, keratoacanthoma or . • A well-defined warty base suggests • Surgical excision with histologic eval. seborrheic keratosis.

Keratoacanthoma Keratoacanthoma

• Well-defined uniform , either red or flesh colored. • Central keratin-filled crater. • Usually 1.5-2.0cm in diameter (or more) • Involutes & leaves scar (~4 months)

Keratoacanthoma

• A premalignant disorder of the vs variant of squamous cell carcinoma. • Often multiple lesions on chronically solar- exposed skin (face, , back of hands) Atlas of Clinical Dermatology, du Vivier. Figures 10.49, 10.50

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Actinic Keratosis Actinic Keratosis

• Management • Cryotherapy • Surgery • Topical therapy (5- ) • • Solar protection &

Squamous Cell Carcinoma Squamous Cell Carcinoma

• SCC starts as a thickening of the skin & becomes an indurated plaque. • Grows laterally & vertically, becomes • A malignant tumor arising from keratinocytes fixed & nodular that may metastasize. • Surface may be • Twice as common in males. crusted, eroded or ulcerated. • UV irradiation most common cause.

Squamous Cell Carcinoma Squamous Cell Carcinoma

• Most occur on - • Perineural infiltration of exposed areas. The SCC of the eyelids surrounding skin facilitates spread into usu has signs of the orbit, intracranial actinic damage. cavity and periorbital • & lip lesions structures via: • Trigeminal nerve often metastasize branches • Extraocular motor nerves • Facial nerve

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Conjunctival SCC Lymph Nodes of Eyelids

MOHS Basal Cell Carcinoma

• A common, locally destructive, malignant cutaneous tumor derived from the basal cells of the lower epidermis. • Subtypes include: rodent, pigmented, cystic, superficial spreading

Basal Cell Carcinoma Nodular BCC

• Occurs most commonly on face. • Tend to bleed, scab, painless. • Rarely metastasize but is locally invasive. • *Danger Zones (eye, ear & nose)

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Basal Cell Carcinoma / Rodent BCC Traction

Pigmented BCC Superficial BCC

• Features similar to a • Solitary patch on the rodent ulcer but the trunk or limbs; often margins are heavily mistaken for pigmented. or eczema. • May be mistaken for • Well-defined slightly a Malignant raised, red plaque Melanoma. with adherent scale. • Pearly borders.

Cicatricial BCC H-ABCDS

• Most often • H = / History • C = Color / Changes misdiagnosed as a • A = Asymmetry / • D = Diameter / scar. Avascular Distribution • and • B = Borders / • S = Surface / pearly color. Bleeding Symptoms • Spreads insidiously and is larger than appears.

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Malignant Melanoma Maligna

• May arise spontaneously or from pre-existing • Flat, pigmented lesions. lesion on the face • likely. that gradually enlarges. • Aka Hutchinson’s . • Variable colors & irreglar margin.

Lentigo Maligna Melanoma Melanoma

• LM is a precursor of LMM • 30% to 50% of LM progress to LMM • Focal papular & nodular areas signal into the .

Superficial Spreading Superficial Spreading Malignant Melanoma Malignant Melanoma • Flat patch of pigmentation that becomes • Tumors > 3mm thick have a poor prognosis. palpable. Spreads laterally & horizontally and • Nonlinear relationship between depth of has an irregular border. invasion and survival rate.

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Nodular Malignant Melanoma MM - depth of lesion

• Has no horizontal • Lesions <0.75mm in growth phase. thickness have ~90% survival rate at 10 yrs • Grows vertically ab • Lesions <0.75mm in initio. thickness have ~100% survival rate at 5 yrs • Lesions >1.5mm in thickness have ~50% to 60% survival rate at 5 yrs

MM Testing Recommend

• Blood work: liver • Color Atlas of Clinical Dermatology, 4th panel (LDH, GGT, edition. Fitzpatrick et al. SGOT, SGPT, alkaline phosphatase) • Chest x-ray

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