Update on Ocular Dermatology Dawn Pewitt, OD, FAAO Triad Eye Institute | Grove, OK 02/12/17 COPE 51248-AS *No financial disclosures Benign Eyelid Lesions • Epithelial & adnexal tumors • Vascular tumors • Xanthomatous tumors • Infectious Epithelial & Adnexal Tumors • Squamous papilloma • Seborrheic keratosis (SK) • Cutaneous cysts • Sweat gland (eccrine & apocrine) • Fibrous tissue Squamous Papilloma • Aka skin 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 papule or plaque. • Classic waxy or “stuck-on” appearance. • Usually asymptomatic but may itch or become inflamed. Seborrheic Keratosis • Is the most common differential diagnosis of a malignant melanoma. • Patient reassurance. • Surgery vs. cryotherapy. Seborrheic Keratosis Cutaneous Cysts • A cyst is a closed cavity or sac containing fluid or semi-solid material within an epithelial, endothelial or membranous lining. • Epidermoid cyst: a cutaneous or subQ cystic swelling of the skin, often with a central punctum, derived from squamous epithelium • 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 acne. • 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. • Keloids: spread beyond the area of trauma - has a worse prognosis. Keloid vs Hypertrophic Scar Vascular Tumor • Pyogenic Granuloma: common benign vascular papule occurring in youth, possibly as a response to injury. • Sudden onset & tend to bleed. Xanthomatous Lesions • Accumulations of xanthoma 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 xanthomas • 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 • Pyodermas • Verruca (poxvirus) • Impetigo • Molluscum contagiosum • Folliculitis • Infections Exanthems • Furuncle • Rubella • Soft Tissue Classifications • Measles • Erysipelas & Cellulitis • 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 abscess of hair follicle by S. aureus • Erysipelas & Cellulitis • acute infection of dermis & subQ by S. Pyogenes Impetigo • Common in the young • Outbreaks occur in institutions (nurseries) • Predisposing factor • Insect bite • Trauma • Eczema Impetigo • Blisters remain for few days (yellow pus visible) • Blister ruptures & golden crust forms • Spreads rapidly • Ulceration if infection is deeper Impetigo • Topical antibiotics • 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 • Boils and carbuncles may occur anywhere • A hordeolum is a small boil • Management • Drainage (culture?) • Oral antibiotics Furunculosis Chancriform pyoderma Probably a reaction to a staph infection induced by trauma. An indolent well-defined ulcer 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 lesion 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, erythema infectiosum • Human herpes viruses • Simplex, zoster, CMV, etc. • Human Papilloma Virus (HPV) Verruca Verruca plana (flat) Verruca vulgaris Filiform Wart • 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 • Atopic dermatitis • Congenital immunodeficiency • Lymphoproliferative disorders • HIV infection • Flesh-colored dome-shaped papules 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 rash develops • Tender general lympadenopathy; may persist for some while Name This Condition A. Herpes Zoster B. Herpes Simplex C. Chickenpox 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 • Antibiotic ung • Warm/cool compresses • NSAID • Topical steroids /cycloplegics • Anti-glaucoma drops H. Zoster Ophthalmicus • Oral Antivirals • Ophthalmic • Acyclovir 800 mg