Epithelial hyperplasias

The terminology used to describe benign epithelial proliferations, the most common type of benign eyelid lesions, continues to evolve. It is helpful to group these various benign epithelial proliferations under the clinical heading of papillomas. (This designation does not necessarily imply any association with the papillomavirus.) Clinical and histologic characterizations of these lesions overlap considerably. Included within this group are seborrheic keratosis, pseudoepitheliomatous hyperplasia, verruca vulgaris (wart), acrochordon (also called skin tag, fibroepithelial polyp, or squamous papilloma) (Fig 10-21), basosquamous acanthoma, squamous acanthoma, and many others. All of these benign proliferations can be managed with shave excision at the dermal–epidermal junction.

Seborrheic keratosis (Fig 10-22) is an example of an acquired benign eyelid papilloma that tends to affect middle-aged and elderly persons. Its clinical appearance varies; it may be sessile or pedunculated and have varying degrees of pigmentation and hyperkeratosis. On facial skin, seborrheic keratosis typically appears as a smooth, greasy, stuck-on lesion. On the thinner eyelid skin, however, it can be more lobulated, papillary, or pedunculated, with visible excrescences on its surface. These lesions can be managed by shave excision. A seborrheic keratosis involving a hair follicle, called an irritated follicular keratosis, may be more elevated and nodular (Fig 10-23) and can be confused with a keratoacanthoma or squamous cell carcinoma.

Figure 10-21 Acrochordon (also known as skin tag, fibroepithelial polyp, or squamous papilloma) of the right lower eyelid.

(Courtesy of Bobby S. Korn, MD, PhD.)

Figure 10-22 Seborrheic keratosis of the left upper eyelid.

(Courtesy of Bobby S. Korn, MD, PhD.)

Pseudoepitheliomatous hyperplasia is not a discrete lesion but rather a pattern of reactive changes in the epidermis that may develop over areas of inflammation or neoplasia.

Verruca vulgaris (wart), caused by epidermal infection with the human papillomavirus (type 6 or 11), rarely occurs in thin eyelid skin (Fig 10-24). Cryotherapy or excision may eradicate the lesion and minimize the risk of viral spread.

Cutaneous horn is a descriptive, nondiagnostic term referring to exuberant hyperkeratosis. This lesion may be associated with various benign or malignant histologic processes, including seborrheic keratosis, verruca vulgaris, and squamous or basal cell carcinoma. Biopsy of the base of the cutaneous horn is recommended.

Figure 10-23 Follicular keratosis of the left upper eyelid.

(Courtesy of Cat N. Burkat, MD.)

Figure 10-24 Verruca vulgaris (wart) of the left lower eyelid.

(Courtesy of Cat N. Burkat, MD.)

Benign epithelial lesions

After papillomas, cysts of the epidermis are the second most common type of benign periocular cutaneous lesions, accounting for approximately 18% of excised benign lesions. Most of these are epidermal inclusion cysts, which arise from the infundibulum of the hair follicle, either spontaneously or following traumatic implantation of epidermal tissue into the dermis (Fig 10-25). The lesions are slow growing, elevated, round, and smooth. They often have a central pore, indicating the remaining pilar duct. Although these cysts are often called sebaceous cysts, they are actually filled with keratin. Rupture of the cyst wall may cause an inflammatory foreign-body reaction. The cysts may also become secondarily infected.

Recommended treatment for small cysts is excision or marsupialization, which involves excising around the periphery of the cyst but leaving the base of the cyst wall to serve as the new surface epithelium. Larger or deeper cysts may require complete excision, in which case the cyst wall should be removed intact to reduce the possibility of recurrence.

Multiple tiny epidermal inclusion cysts are called milia (Fig 10-26). They are particularly common in newborn infants. Generally, milia resolve spontaneously, but they may be marsupialized with a sharp blade or needle. Multiple confluent milia may be treated with topical retinoic acid cream.

A less common epidermal cyst is the pilar, or trichilemmal, cyst. Such cysts are clinically indistinguishable from epidermal inclusion cysts, but they tend to occur in areas containing large and numerous hair follicles. Approximately 90% of pilar cysts occur on the scalp; in the periocular region, they are generally found in the eyebrows. The cysts are filled with desquamated epithelium, and calcification occurs in approximately 25% of cases.

Figure 10-25 Epidermal inclusion cyst of the left lower eyelid.

(Courtesy of Cat N. Burkat, MD.)

Figure 10-26 Milia of the left upper and lower eyelid.

(Courtesy of Bobby S. Korn, MD, PhD.)

Molluscum contagiosum is a viral infection of the epidermis that often involves the eyelid in children with an associated follicular conjunctivitis (Fig 10-27). Occasionally, multiple exuberant lesions appear in adult patients with AIDS. The lesions are characteristically waxy and nodular, with a central umbilication. They may produce an associated follicular conjunctivitis. Treatment is observation, oral cimetadine, excision, controlled cryotherapy, or curettage.

Xanthelasmas are yellowish plaques that occur commonly in the medial canthal areas of the upper and lower eyelids (Fig 10-28). They represent lipid-laden macrophages in the superficial dermis and subdermal tissues. Deep extension into the orbicularis oculi muscle can occur. In rare instances, xanthelasmas are associated with hyperlipidemia or congenital disorders of lipid metabolism, so patients whose lipid levels are unknown may benefit from having them checked by their primary care physician. When excising these lesions, the surgeon must be careful to avoid causing cicatricial ectropion or eyelid retraction. Other treatment options include serial excision, laser ablation, and topical trichloroacetic acid. Xanthelasmas may commonly recur after excision.

Figure 10-27 Molluscum contagiosum. A, Umbilicated eyelid lesion. B, Molluscum lesions can cause conjunctivitis, which typically resolves after removal of the lesion.

(Courtesy of Vikram Durairaj, MD.)

Figure 10-28 Xanthelasmas of the lower eyelids.

(Courtesy of Cat N. Burkat, MD.)

Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.