Eyelid Lesions
Lora R. Dagi Glass
Juliana Wilson
THE CLINICAL CHALLENGE
Eyelid lesions commonly present in the emergency department (ED) or urgent care settings. There are an estimated two million visits a year to the ED for eye complaints, almost 50% of which are nontraumatic complaints. Eyelid lesions are the sixth most common cause of nontraumatic eye complaints. Most nontraumatic complaints can be discharged home.1 Although eyelid lesions are typically not threatening to the vision, patients are often symptomatic and may be concerned about the cosmetic appearance.
Eyelid lesions should be approached by taking a detailed history of timing, pain or discomfort, discharge, attempted treatment, and any visual symptoms. Examination should include a detailed external review of the face and eyelid region, looking at the nature of the lesion from a dermatologic perspective. Where is it located? Is it macular or papular, inflamed or cool, draining or bleeding, ulcerated or otherwise causing local destruction (such as eyelash loss, or madarosis), tender, or itchy? Are there associated lesions elsewhere on the face?
Lesions of eyelids can be categorized by their anatomic location: epithelial layer, glandular, and mucosal layer. Here, we describe common lesions that plague each anatomic region and explore their differential diagnosis. As with any other epithelialized area, molluscum contagiosum lesions commonly present on the eyelid. Specialized sebaceous glands of the eyelid, or meibomian glands, cause chalazia or hordeola when inflamed. Pyogenic granuloma occurs when the nonkeratinized, or mucosal, inner epithelial lining suffers from inflammation just as the mouth or other mucosal regions of the body can.
MOLLUSCUM CONTAGIOSUM
Pathophysiology
Molluscum contagiosum is a pox virus infection of the skin that is commonly seen in children and immunocompromised persons but that may occur at any age and in any immune state. It spreads easily via contact with persons or infected surfaces. It can occur in any location but commonly occurs on the face and eyelids. It is painless, skin colored, and can be pruritic.
Approach/The Focused Exam
There may be single or multiple lesions (sometimes even conglomerated), and these lesions may be limited to the eyelid or periocular region or present in multiple regions. Molluscum lesions classically present as small umbilicated nodules that are skin colored or slightly lighter/pearly (Figure 33.1). They can also present as a giant lesion or as an erythematous lesion. They can be itchy and irritated and may cause surrounding dermatitis and/or conjunctivitis.
 Figure 33.1: Molluscum contagiosum lesions on the upper eyelid. |
Differential Diagnosis
Small growths that can be mistaken for molluscum include benign periocular lesions such as epidermal inclusion cysts (Figure 33.2), hidrocystomas (Figure 33.3), papillomas (Figure 33.4), syringomas (Figure 33.5), and chalazia (Figure 33.6). Also, although able to present across the age
spectrum, most occur more commonly in adults. Hidrocystomas transilluminate, whereas molluscum does not. Cancerous periocular lesions such as basal cell carcinoma (Figure 33.7) and squamous cell carcinoma are more common in adults (Figure 33.8) and tend to present with a chronic, singular lesion. They may also have overlying telangiectasia, madarosis (eyelash loss), or other destruction of the surrounding architecture. Other causes of conjunctivitis, including infectious or allergic conjunctivitis, will not be associated with the typical molluscum lesion. Other causes of
dermatitis, including infectious, allergic, or atopic dermatitis (Figure 33.9), will also not present with the typical molluscum lesion.
spectrum, most occur more commonly in adults. Hidrocystomas transilluminate, whereas molluscum does not. Cancerous periocular lesions such as basal cell carcinoma (Figure 33.7) and squamous cell carcinoma are more common in adults (Figure 33.8) and tend to present with a chronic, singular lesion. They may also have overlying telangiectasia, madarosis (eyelash loss), or other destruction of the surrounding architecture. Other causes of conjunctivitis, including infectious or allergic conjunctivitis, will not be associated with the typical molluscum lesion. Other causes of
dermatitis, including infectious, allergic, or atopic dermatitis (Figure 33.9), will also not present with the typical molluscum lesion.
 Figure 33.2: Small epidermal inclusion cyst on the central lower eyelid lashline. (From Eyelid cystic lesions simulating neoplasms. In: Shields JA, Shields CL. Eyelid, Conjunctival, and Orbital Tumors: An Atlas and Textbook. 3rd ed. Wolters Kluwer; 2016:195-206. Figure 11.20.) |
 Figure 33.3: Hidrocystoma of the lateral canthus. Note the slightly blue hue, attributable to the cyst’s transparency. |
 Figure 33.4: Papilloma of the upper eyelid. (From Benign tumors of the eyelid epidermis. In: Shields JA, Shields CL. Eyelid, Conjunctival, and Orbital Tumors: An Atlas and Textbook. 3rd ed. Wolters Kluwer; 2016:3-18. Figure 1.2.) |
 Figure 33.5: Periocular syringomas. These typically present with innumerable lesions. |
 Figure 33.6: Chalazion of the upper eyelid. (From Eyelid inflammation. In: Penne R. Wills Eye Hospital Color Atlas and Synopsis of Clinical Ophthalmology: Oculoplastics. 3rd ed. Wolters Kluwer; 2019:24-29. Figure 2.1b.) |
 Figure 33.7: Basal cell carcinoma of the lower eyelid margin. Note the eyelash loss (madarosis). |
 Figure 33.8: Ulcerating squamous cell carcinoma of the lower eyelid margin. |
Management
Patients should avoid scratching the lesions to prevent spread and ocular irritation. Treatment of molluscum on the eyelid consists of surgical removal or waiting for natural resolution. Lesions typically self-resolve within 12 to 18 months. However, in the case of cosmetic disruption or other
symptoms (ie, conjunctivitis, dermatitis, irritation), curettage or excision is preferred. Topical options considered elsewhere on the body are typically unsafe for periocular use.
symptoms (ie, conjunctivitis, dermatitis, irritation), curettage or excision is preferred. Topical options considered elsewhere on the body are typically unsafe for periocular use.
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