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Home , Epidermoid cyst, Folliculitis

Update on Ocular

Dawn Pewitt, OD, FAAO Triad Eye Institute | Grove, OK 02/12/17 COPE 51248-AS

*No financial disclosures

Benign Eyelid

• Epithelial & adnexal tumors • Vascular tumors • Xanthomatous tumors • Infectious Epithelial & Adnexal Tumors

• Squamous papilloma • (SK) • Cutaneous • Sweat gland (eccrine & apocrine) • Fibrous tissue Squamous Papilloma

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

• Abnormality of epidermal basal cell maturation that results in a well-defined, raised, rough-surfaced or plaque. • Classic waxy or “stuck-on” appearance. • Usually asymptomatic but may or become inflamed. Seborrheic Keratosis

• Is the most common differential diagnosis of a malignant . • Patient reassurance. • Surgery vs. cryotherapy. 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

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

Epidermoid Cyst

Dermoid Cyst

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

• Common in acnes. • Asymptomatic. • Usually occur on face but can develop anywhere when related to a blistering process. • Often disappear spontaneously after a number of months. • Formerly I&C • Laser ablation

Sweat Gland Tumors

• Eccrine hidrocystoma: rare disorder of the eccrine sweat duct that results in several small swellings, usu adjacent to the eyelids. It occurs particularly in hot climates. • Syringomata: a benign tumor of sweat ducts; usually occurs as multiple lesions Eccrine Hidrocystoma

• Multiple small swellings that increase in size with heat & become almost imperceptible in the winter. • Occur mainly around the eyes. • Most common in females. • Air-conditioning helpful. Syringomata

• Common in Asians & Afro-Caribbeans; can be familial; occur in Down syndrome. • Occur symmetrically, particularly around the eyes in females. • Reassurance vs gentle cautery. Apocrine Gland Tumors

• A benign cystic tumor of the apocrine secretory glands (gland of Moll). • Slow growing, appears in middle age. • Solitary dome-shaped. • No seasonal variation. Fibrous Tissue Tumors

• Hyperproliferative responses of connective tissue to trauma resulting from an imbalance between collagen synthesis and lysis. • Hypertrophic scars: confined to the area of trauma. • : spread beyond the area of trauma - has a worse prognosis. vs Hypertrophic Scar

Vascular Tumor

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

• Accumulations of cells – macrophages containing droplets of lipids • May be a symptom of a general metabolic disease or a local cell dysfunction • Classification: 1. Due to hyperlipidemia 2. Normolipidemia Xanthelasma

• Most common of all • Age of onset: over age 50 • Labs: fasting cholesterol and triglycerides • 50% of patients have no metabolic disease Xanthoma

Striatum Palmare Eruptive Xanthoma Infectious Lesions

• Bacterial Infections • Viral Infections • • Verruca (poxvirus) • • • • Infections • Furuncle • Rubella • Soft Tissue Classifications • Measles • & • Human Herpes Virus • HSV • Varicella-Zoster • Zoster

Bacterial Infections

• Impetigo • acute, contagious and superficial infections (S. aureus or by a B- hemolytic strep or both) • Furunculosis • acute deep of by S. aureus • Erysipelas & Cellulitis • acute infection of & subQ by S. Pyogenes Impetigo

• Common in the young • Outbreaks occur in institutions (nurseries) • Predisposing factor • Insect bite • Trauma • Eczema Impetigo

• remain for few days (yellow pus visible) • ruptures & golden crust forms • Spreads rapidly • Ulceration if infection is deeper Impetigo

• Topical • Systemic antibiotics for 5 days; they are effective within 24 hours Furunculosis

• Acute deep abscess of the hair follicle • S. aureus (usually) • Most common in adolescents and young adults • Acute painful swelling than may discharge pus Furunculosis

• and may occur anywhere • A hordeolum is a small

• Management • Drainage (culture?) • Oral antibiotics Furunculosis Chancriform

Probably a reaction to a staph infection induced by trauma. An indolent well-defined with a red margin. Occur around the eyes or mouth. Hordeolum/Chalazion

• Warm Compresses/lid scrubs, +/- EES ointment, +/- fish oil, +/- flax seed po • Treatment if not responsive to conservative measures (after 4 weeks) • If multiple lesions, doxycycline 100 BID for 2 weeks, then Qday • If one large without prior drainage, I&D • f/u in 6 weeks for possible steroid injection • If lesion is too small to drain, intralesional Kenalog injection Erysipelas & Cellulitis

• Acute infections of the dermis & subQ • Distinction sometimes difficult • Spread via lymphatics and via bloodstream (causing bacteremia) • Patients typically quite ill, high fever with rigors and confusion Viral Disorders of the Skin

• Pox viruses • Smallpox, molluscum contagiosum • “Childhood” ailments • Measles, rubella, infectiosum • Human herpes viruses • Simplex, zoster, CMV, etc. • Human Papilloma Virus (HPV) Verruca

Verruca plana (flat) Verruca vulgaris Filiform

• Small base with elongated shape • May have associated conjunctivitis Molluscum Contagiosum

• A self-limiting mucocutaneous infection caused by a large DNA pox virus. • Commonly associated with disorders of T cell function • • Congenital immunodeficiency • Lymphoproliferative disorders • HIV infection • Flesh-colored dome-shaped with a central depression on their surface. (‘umbilication’) Molluscum Contagiosum

• Epidermal viral infection (poxvirus) • Common in children and immuno- compromised • Histopathology • Basophilic molluscum bodies Molluscum Contagiosum

• May be associated with chronic follicular conjunctivitis • Individual lesion lasts ~2 months, rarely returns Molluscum Contagiosum

Since the lesions are harmless and involute spontaneously, can be left alone. • Cryotherapy • Drug therapy (cidofovir) • Curettage and cautery • In HIV-infection -> HAART Measles (Rubeola)

• 4 C’s • Conjunctivitis • Cough • Koplik’s spots • Coryza • Resolves within 14 days of height of eruption. • Dx made by antibody titre (4-fold increase) • Prevention best • Tx for symptoms only Rubella

• Caused by RNA togavirus • Spread by pharyngeal droplets • Very infectious • In school children may be asymptomatic • Symptomatic in adults and adolescents • Epidemics usually in spring Rubella

• Incubation period of 18 days (14-21d) • Prodrome occurs in older groups & lasts 1-5 days • ‘gritty’ conjunctivtis, fever, HA, malaise, sore throat (no coryza); these subside as the develops • Tender general lympadenopathy; may persist for some while Name This Condition

A. Herpes Zoster B. C. D. Kaposi’s Sarcoma

B! Primary Herpes Simplex Herpes Simplex

• Primary Infection • Sudden onset, fever, extensive grouped small blisters, regional lymph node swelling • Recurrent HSV • Begins with tingling or discomfort in the skin, followed by blisters. Acyclovir

• An acyclic analogue of deoxyguanosine and a specific inhibitor of thymidine kinase, which is only present in herpesvirus-infected cells. • Low clinical toxicity. It is not mutagenic, carcinogenic or teratogenic at therapeutic doses. Name This Condition

A. Chickenpox B. Kaposi’s Sarcoma C. Measles D. Molluscum Contagiosum

A! Chickenpox is a common disorder of youth caused by the varicella-zoster virus. The face has vesicles that become scabbed an usually result in 1-2 scars. Chickenpox (Varicella)

• Chickenpox and H. zoster are both caused by HHV-3. • Incubation of 9-23 days; followed by prodrome (fever & malaise) for 2 days. • Distribution is centripetal. Herpes Zoster

• Results from reactivation of HHV-3 (chickenpox) • Virus dormant in the dorsal root or cranial nerve ganglian; antibodies in serum • Vesicular eruption with vesicles surrounded by erythema Herpes Zoster

Herpes Zoster

• 62 yom, symptomatic x 6 days • Diagnosed by ED with chemical burn after using rubbing alcohol on head • Rx’d calamine lotion and hydroxyzine Do You Know?

What percentage of HZO patients will develop ocular complications without antiviral therapy?

C! 50-70% H. Zoster Ophthalmicus

• Common Findings • Conjunctivitis • Episcleritis • Scleritis • Keratitis • Iridocyclitis • Glaucoma • Less common (cataract, CN palsies, ARN/PORN, CRVO, CRAO, optic neuritis) H. Zoster Ophthalmicus

Treatments • Antiviral • ung • Warm/cool compresses • NSAID • Topical steroids /cycloplegics • Anti-glaucoma drops H. Zoster Ophthalmicus

• Oral Antivirals • Ophthalmic • Acyclovir 800 mg po 5x/d • Viroptic • Valacyclovir 1000 mg po tid • Zirgan 0.15% • Famciclovir 500 mg po tid x 7 days

Solar Damage and Skin Cancer

The propensity for solar damage depends upon: • Skin type Fitzpatrick Skin Types • The cumulative exposure to UV •Always burns, never tans ** light •Always burns, sometimes tans ** • The intensity of exposure • The exposure in childhood •Sometimes burns, always tans • Residence nearer to the equator •Never burns, always tans •Black skin Non-Melanoma Skin Cancer

• Cutaneous Horn • Actinic (Solar) Keratosis • Keratoacanthoma • • Basal Cell Carcinoma Cutaneous Horn

• Marked cohesion that gives rise to a horny outgrowth. • May be caused by a wart, solar keratosis, keratoacanthoma or squamous cell carcinoma. • Surgical excision with histologic eval. Cutaneous Horn

• A red indurated base suggests SCC. • A flat or sl raised base suggests AK. • A well-defined warty base suggests seborrheic keratosis. Keratoacanthoma

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

Keratoacanthoma

Atlas of Clinical Dermatology, du Vivier. Figures 10.49, 10.50

• A premalignant disorder of the vs variant of squamous cell carcinoma. • Often multiple lesions on chronically solar-exposed skin (face, ears, back of hands) Actinic Keratosis

• Management • Cryotherapy • Surgery • Topical therapy (5-fluorouracil) • Photodynamic therapy • Solar protection & sunscreens Actinic Keratosis

Squamous Cell Carcinoma

• A malignant tumor arising from keratinocytes that may metastasize. • Twice as common in males. • UV irradiation most common cause. Squamous Cell Carcinoma

• SCC starts as a thickening of the skin & becomes an indurated plaque • Grows laterally & vertically, becomes fixed & nodular • Surface may be crusted, eroded or ulcerated Squamous Cell Carcinoma

• Most occur on sun-exposed areas. The surrounding skin usu has signs of actinic damage. • Ear & lip lesions often metastasize Squamous Cell Carcinoma

• Perineural infiltration of SCC of the eyelids facilitates spread into the orbit, intracranial cavity and periorbital structures via: • Trigeminal nerve branches • Extraocular motor nerves • Facial nerve Conjunctival SCC

Lymph Nodes of Eyelids

MOHS MOHS

Basal Cell Carcinoma

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

• Occurs most commonly on face.

• Tend to bleed, scab, painless.

• Rarely metastasize but is locally invasive. • *Danger Zones (eye, ear & nose) • 33-43% recurrence of periorbital lesions Nodular BCC

Basal Cell Carcinoma / Traction

Rodent Ulcer BCC Pigmented BCC

• Features similar to a rodent ulcer but the margins are heavily pigmented. • May be mistaken for a Malignant Melanoma. Superficial BCC

• Solitary patch on the trunk or limbs; often mistaken for or eczema. • Well-defined slightly raised, red plaque with adherent scale. • Pearly borders. Cicatricial BCC

• Most often misdiagnosed as a scar. • Telangiectasia and pearly color. • Spreads insidiously and is larger than appears. H-ABCDS

• H = Hair / History • C = Color / Changes • A = Asymmetry / Avascular • D = Diameter / Distribution • B = Borders / Bleeding • S = Surface / Symptoms Malignant Melanoma

• May arise spontaneously or from pre-existing lesions. • Metastasis likely.

SMM from a dysplastic Maligna

• Flat, pigmented lesion on the face that gradually enlarges. • Aka Hutchinson’s . • Variable colors & irregular margin. Lentigo Maligna Melanoma

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

• In one study, more than half of LM showed clinically unsuspected LMM upon biopsy Superficial Spreading Malignant Melanoma

• Flat patch of pigmentation that becomes palpable. Spreads laterally & horizontally and has an irregular border. • Most frequently found on upper back • Age of onset: 30-50 years of age • SSM = 70 of all in whites Superficial Spreading Malignant Melanoma

• Tumors > 3mm thick have a poor prognosis. • Nonlinear relationship between depth of invasion and survival rate. Nodular Malignant Melanoma

• Has no horizontal growth phase. • Grows vertically ab initio. • Arises rapidly. • NM = 15-30% of all melanomas in US MM - depth of lesion

• Lesions <0.75mm in thickness have ~90% survival rate at 10 yrs • Lesions <0.75mm in thickness have ~100% survival rate at 5 yrs • Lesions >1.5mm in thickness have ~50% to 60% survival rate at 5 yrs

Shave biopsy is contraindicated! MM Testing

• Blood work: liver panel (LDH, GGT, SGOT, SGPT, alkaline phosphatase) • Chest x-ray • Immunizations

• After diagnosis: • Annual dilated eye exam with report to PCP/dermatologist Eczema/Dermatitis

• 3 stages • Acute • Subacute • Chronic

• Types • Atopic eczema • Seborrheic eczema • Acute Eczema

Subacute & Chronic Eczema Atopic Dermatitis (atopic eczema)

• Common chronic pruritic inflammatory disorder (self limiting) • Mainly of childhood • Occurs in all races • Relapses & remissions • Genetically determined; assoc with other atopic disorders Atopic Dermatitis

Ocular findings 1. Eyelid dermatitis 2. Chronic blepharitis 3. Recurrent conjunctivitis 4. Dennie-Morgan infraorbital fold 5. Keratoconus 6. Anterior subcapsular cataract 7. Retinal detachment Atopic Dermatitis

Dennie-Morgan Lines

Atopic Shiner Management of Atopic Dermatitis

• General • Ocular • Lubricants • Lubricants • Soap substitutes • Mast cell stabilizers • Bath additives • Steroids (ointment – not cream) • Topical glucocorticoids • Oral antihistamines • Tar • Antibiotic ointment • Tacrolimus • Antihistamines / diet Adult Seborrheic Dermatitis

• Eczematous process • Unknown cause ( P. ovale vs other?) • Oral ketoconazole/topical steroids • “Seborrheic” term is a misnomer (scales are exfoliated stratum corneum) • Blepharitis • Meibomitis (meibomian gland occlusion & abscess formation) • Conjunctival hyperemia • Dry eye symptoms Adult Seborrheic Dermatitis

Differential Dx of Seborrheic Dermatitis 1. Atopic dermatitis 2. 3. Dermatophytosis 4. Langerhans cell histiocytosis 5. Psoriasis 6. 7. Systemic erythematosus 8. Tinea infection Management of Seborrheic Dermatitis

• General • Ocular • Topical steroids • Lid scrubs • Warm compresses • Antifungals • Digital Massage • Selsun; Nizoral • Lubricants • Keratolytics • Salicyclic acid shampoo • Topical calcineurin inhibitors • Alternatives • tea tree oil shampoo Contact Dermatitis

• An eczematous reaction resulting from the interaction of an external substance with the skin. • 2 types: • Primary irritant dermatitis • Allergic contact dermatitis Primary Irritant Dermatitis

• Common disorder • May occur anywhere on the skin • Napkin dermatitis • House wife’s dermatitis • Asteatotic eczema Primary Irritant Dermatitis

• Symptoms: itching and sometimes soreness • Starts under an ring & spreads (spares palms) • Management • Avoid irritant • Skin must be kept out of water • Patch test to r/o allergy • Topical steroids • Emollients (liberal) Allergic Contact Dermatitis

• A delayed hypersensitivity reaction • Common causes: metal, rubber, perfumes, polish, dyes, cosmetics, some plants Allergic Contact Dermatitis Management of Allergic Contact Dermatitis Name This Condition

A. Psoriasis B. Allergic contact dermatitis C. Chronic eczema D. Solar keratosis

B! Psoriasis Abnormality of keratinocytes Psoriasis

• A common chronic benign hyperproliferative & immunologic condition • Often inherited • Characterized by symmetrical, well-defined, red plaques with a thick silvery scale • Pimecrolimus (Elidel) • Etanercept (Enbrel) Psoriasis

• Genetics • 1/3 of its have fmhx • Injury • Koebner phenomenon • Drugs • Nicotine, alcohol, antimalarials, lithium • Rapid steroid withdrawal Psoriasis

Ocular findings (~10% of patients have ocular findings) • Blepharitis • Iritis/uveitis • Lid position (ectropion, entropion, trichiasis) • Lid scrubs (Ocusoft) • Monitor IOPs Patient Case

• 68 yom consult from PCP for DM eye exam • c/o broken glasses Patient Case

• Pt report h/o working with cement (construction worker) • Uses Selson shampoo on head/face/body • Uses vasoline on back • Tar never worked Subacute vs Chronic Psoriasis

Psoriasis and PUVA

Thank you!

Dawn Pewitt, OD, FAAO [email protected]