DISCOID LUPUS
Discoid lupus erythematosus involves the skin surfaces of the body. It rarely involves the eyelid and, therefore, can be difficult to diagnose. Characteristic features of the lesions
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Discoid Lupus 43
are redness, itching, scaling, scarring, and involvement of the hair follicles (118). This is sometimes considered a photosensitive dermatitis. Treatment includes sunscreens, topical steroids, and antimalarials. Less than 5% of people with discoid lupus develop systemic lupus erythematosus.10
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113, 114 Noninflamed chalazia as seen through the skin (113) and through the conjunctiva (114).
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115 Pyogenic granuloma on the conjunctival surface of the upper lid.
116 Molluscum contagiosum in a middle-aged male. After the mass was excised, the associated conjunctivitis cleared.
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118 |
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117 Verrucous lesion with extensive keratin (cutaneous horn).
118 Discoid lupus erythematosus in the left lower lid of a middle-aged female. She had no evidence of systemic lupus erythematosus.The lesion began in the lateral aspect of the eyelid margin and spread to the punctal area in a period of a few months.
44 Benign Tumors and Related Conditions
BENIGN CYSTIC LESIONS |
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Benign cystic lesions which occur on the eyelid may have a clear fluid within the wall, may appear solid white or yellowish, or may be completely underneath the skin, appearing as a subcutaneous tumor.
SUDORIFEROUS CYSTS
Sudoriferous cysts usually occur at the lid margin, but may occur on the skin. They are filled with a clear fluid and may become rather large. They arise from blocked excretory ducts of the glands of Moll.11
Surgical excision is the treatment of choice. In some cases, simply opening the cyst and allowing the fluid to egress will be sufficient. However, the cyst may recur if the wall is left in place. If the cyst is on the lid margin, an incision near the skin margin can be made. The cyst wall can then be removed through this incision and the incision closed with one or two 6-0 silk sutures. The sudoriferous cyst is often adjacent to the punctum, and, therefore, care must be used when removing these lesions.
SEBACEOUS CYSTS
These cysts may occur by obstruction of the gland of Zeis, the meibomian glands, or the sebaceous glands associated with the hair follicles of the lid surface or brow. The cysts are solid white or yellowish, and appear as small or large tumor-like elevations beneath the normal skin. Their consistency is soft to rubbery, depending on the nature of the contents(119).8
To completely excise the cyst, the surgeon must make an incision slightly longer than the diameter of the cyst. The incision should be made with attention to normal skin creases. Blunt dissection is then utilized to separate the cyst from the surrounding tissues. The cyst can then be completely removed through the skin incision. Bleeding is controlled with cautery, and the incision is then closed. If excess skin exists because the skin was stretched underneath the cyst, then the appropriate amount of excess skin should be removed prior to closing the skin with small sutures such as 6-0 silk, or 6-0 nylon, or rapidly dissolvable sutures.
EPIDERMAL INCLUSION CYSTS
Epidermal inclusion cysts may occur on the skin surface or the conjunctival surface of the eyelid. They are usually caused by implantation of epidermis in the dermis following trauma (120–127).
Milia are histologically similar to epidermal inclusion cysts. However, they are usually pinhead-sized elevations in the skin of the lids. Numerous milia may be present, and they appear as white, round, slightly elevated lesions. Often, the milia are congenital, but they may be derived from dilated scarred hair follicles, or from sebaceous glands.11
119 Sebaceous cyst just below the brow of the right eye.
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121
120, 121 Epidermal inclusion cysts. 120: A large epidermal inclusion cyst of the right upper lid causing mechanical ptosis. 121: Epidermal inclusion cyst of the left medial canthal area.
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Benign Cystic Lesions |
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124
125
122–124 Follicular cyst. 122: Large follicular cyst in an elderly male.The cyst had been growing for years. 123, 124: Cyst being removed at surgery. 125: Inclusion cyst in the medial canthal area in a male patient.This lesion had vessels on the skin and was thought to be a basal cell carcinoma by clinical inspection.
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126, 127 Epidermal inclusion cyst. 126: Swelling in the medial aspect of the left upper lid. 127:The lid is everted showing a pigmented mass.
46 Benign Tumors and Related Conditions
EPIDERMOID CYSTS
Epidermoid cysts occur in the superficial or deep tissues of the lid. They are lined by a squamous surface epithelium and are filled by desquamated keratinized cells. Sebaceous cysts are similar to epidermoid cysts; however, the former are filled with sebaceous material.2
DERMOID CYSTS
Dermoid cysts are classified as choristomas, growths that arise during embryologic development from tissue elements which are not normally present in the location of the lesion. Dermoid cysts are believed to be caused by surface epidermis which is sequestered during development. Sequestration usually occurs adjacent to bony suture lines around the orbit.12 These cysts, which generally occur as subcutaneous nodules beneath the lateral brow or in the area of the medial canthus below the medial aspect of the brow, are usually discovered in early childhood. Most dermoid cysts are attached to the periosteum near the orbital rim (128, 129). On occasion, these cysts progress into the orbit.
Orbital X-rays are usually normal in patients with subcutaneous dermoids. However, if an orbital component is present, there may be evidence of defects in the orbital bones adjacent to the lesion. Ultrasonography and computerized tomography are helpful in the diagnosis.
TREATMENT
Most dermoid cysts can be removed through a skin incision. The incision should be parallel to the brow and in a lid crease if possible. The incision is made slightly larger than the long axis of the cyst. Subcutaneous dissection is then performed to free the cyst from the surrounding tissues. The cyst is usually attached to the periosteum by a stalk that must be excised. Every effort should be made to remove the cyst in its entirety since spillage of its contents may result in an inflammatory reaction. If the cyst is opened and its contents spill into the surrounding tissues, the area should be liberally irrigated with saline or a similar solution. However, in patients in whom the cysts are broken, inflammatory reactions are rare.
Some patients in early adulthood have a dermoid cyst which was never surgically treated. In such cases the thin walled cyst is filled with a liquid material, and can be removed without recurrence even though the cyst is sometimes broken. Some of these cysts are attached to bone and cannot be removed without being broken.
COMEDO (BLACKHEAD)
Comedones appear as black areas at the site of pilosebaceous follicles. They are caused by an occlusion of the follicular orifice and contain keratotic debris and inspissated secretion. A collection of comedones in the area of the outer canthus or brow may cause the patient to wonder if this mass is a tumor (130). Careful examination of the lesion with subsequent expression of the comedones will usually make a diagnosis.
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128 Dermoid cyst near the superior temporal orbital rim in a 4-year-old male.
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129 Dermoid cyst in a 17-year-old female.The cyst was never treated when the woman was a child.The cyst liquefied but never ruptured.The cyst was carefully removed at surgery. She was seen 23 years later and reported that she never had any problems with scars or recurrences.
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130 Cluster of comedones, inclusion cysts with keratin, and sebaceous cysts located in the lateral canthal area.