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LESSONS FOR EYE CARE PRACTITIONERS

Alan G. Kabat, OD, FAAO Associate Professor

DERMATOLOGY 101:
COPE #19264-SD
Nova Southeastern University College of Optometry

(954) 262-1470 kabat@nsu.nova.edu

Course description: Lumps, bumps and rashes of the periocular skin are commonplace but often confusing in their diagnosis and management. This course presents some of the more common dermatologic conditions encountered in the optometric setting. Principles of differential diagnosis are discussed, as well as management considerations for each condition. Special attention is paid to malignant and premalignant lesions.

NOTE: This outline is intentionally truncated in order to meet the requirements of this meeting. Should you wish to obtain the comprehensive slide material and images presented in this lecture, please email me directly and I will be happy to provide it to you. - AGK

The Language of Dermatology


Primary Skin Lesions: - Macule - flat, nonpalpable circumscribed area of change in the skin; < 1-2 cm in size. - Papule - small solid elevation of skin generally < 5 mm in diameter. - Nodule - palpable, solid, round, or ellipsoidal lesion; depth of involvement and/or palpability differentiate it from a papule, although nodules are usually > 5 mm diameter. - Vesicle - (blister) circumscribed, elevated lesion containing serous (clear) fluid; < 5 mm in diameter. - Bulla - a vesicle with a diameter > 5 mm. - Pustule - superficial, elevated lesion that contains pus (i.e. pus in a blister). - Cyst - an epithelial lined cavity containing liquid or semisolid material - Plaque - palpable, plateau-like elevation of skin; usually > 2 cm in diameter, rarely > 5 mm in height. - Wheal - transitory, compressible papule or plaque of dermal edema.

Secondary Skin Lesions: - Scale - accumulation or abnormal shedding of keratin in perceptible flakes. - Ulcer - circumscribed area of skin loss extending through the epidermis and at least part of the dermis. - Crust - dried serum, blood, or pus on the surface of skin. - Erosion- moist, circumscribed, usually depressed lesion due to loss of all or part of the epidermis. - Excoriation - linear or punctate superficial excavations of epidermis caused by scratching, rubbing, or picking. - Lichenification - chronic thickening of the skin along with increased skin markings; results from scratching or rubbing. - Atrophy - paper-thin, wrinkled skin with easily visible vessels; results from loss of epidermis, dermis or both. - Scar - replacement of normal tissue by fibrous connective tissue at the site of injury to the dermis.

The ABCs of Suspicious Dermatologic Lesions - The good, the bad, and the ugly
A = Asymmetry B = Borders - b = bleeding C = Color - c = circulation D = Diameter E = Elevation

Basic types of dermatologic disorders


Allergic Inflammatory Papulosquamous Infectious Hyperplastic Neoplastic

Allergic disorders of the lids & adnexa


Contact dermatitis - Variable degrees of epidermal and conjunctival swelling, injection - May be profound itching and swelling - Chronic exposure to toxic agent; Type IV hypersensitivity Atopic dermatitis - Eczematous, Type I hypersensitivity reaction - History of using or starting a new cosmetic, perfume, nail polish, clothing detergent, contact lens solution, or ocular medication

Inflammatory & papulosquamous disorders of the lids & adnexa


Rosacea - idiopathic dermatological disorder affecting the sebaceous glands of the forehead, cheeks, chin, nose, and eyelids - more common in older patients, women, and those with fair skin - signs include chronic, unrelenting posterior blepharitis, skin flushing with thickening and telangiectasia, and rhinophyma (WC Fields nose) Seborrhea: - Blepharitis greasy crusts/scales on lashes; may also see similar scales on cilia of eyebrows and head minimal lid inflammation, thickening, erythema - Dermatitis Psoriasis - Scaly, silvery plaque formation with underlying erythema - Obvious on scalp, joints (elbows, wrists), extremities - May be poorly responsive to conventional treatments (e.g. corticosteroids)

Infectious disorders of the lids & adnexa


Bacterial: - Hordeolum Represents focal infection of meibomian or other gland May be internal or external - Pre-septal cellulitis Soft tissue infection of the lid anterior to the septum orbitale Significant pain, risk of spread to orbit and/or sinuses Requires systemic antibiotics Viral: - Verruca (a.k.a. viral papilloma, Verruca vulgaris) viral skin tumor, spread by physical contact variably pigmented or flesh-colored with keratinized surface two main types: Verruca plana round, flat-topped and slightly elevated with a granular surface appearance Verruca digitata cauliflower surface appearance on stalk of varying length; may have numerous finger-like projections. - Molluscum contagiosum: Raised, round, dome-shaped lesions of the lid margins & ocular adnexa. umbilicated center; filled with a cheese-like material more commonly seen in children produced by a large DNA poxvirus usually asymptomatic; may produce a follicular response typically resolves spontaneously over 3-12 months

Herpes simplex Classic type Erosive-ulcerative type Self-limiting - Herpes zoster shingles Painful, vesicular rash that follows the dermatome of V1 or V2 Requires oral antiviral agents (within 72 hours) to prevent post-herpetic neuralgia Exoparasitic: - Phthriasis Crab lice, crabs Predilection for pubic hair and eyelashes due to spacing between cilia. Clinical presentation pruritic lid margins, irritation and itching blepharoconjunctivitis

Hyperplastic & neoplastic disorders of the lids & adnexa


Hyperplastic lesions - Squamous papilloma usually benign, non-infectious skin polyp round or oval, multilobular, usually stalked lesion may be densely pigmented in dark-skinned individuals must differentiate from verruca and other malignant tumors - Cystic formations Sudoriferous Cysts of Moll small, round translucent nodules found most commonly on lid margins Sebaceous Cyst of Zeiss small, round elevated nodules containing sebum, a cheesy substance; appear less translucent than cysts of Moll. Milia very small sebaceous cysts which occur in large clusters on the lid surface; appear as small, yellowish papules which have a central drainage core upon closer inspection - Xanthelasma cutaneous deposition of cholesterol and other lipids oval, slightly elevated, yellow plaques typically bilateral presentation more common in females - Cutaneous Horns represent extreme hyperkeratosis of the epidermal skin layer may develop from actinic keratoses, seborrheic keratoses, verrucae or sebaceous cell carcinomas appear as a conical projection of grayish-brown, scaly tissue; lesion may be made up of multiple horns

Vascular Hemangioma Pyogenic granulomas Common, benign lesion of skin and mucosa - misnamed -- neither infectious nor granulomatous - solitary, glistening red papule prone to bleeding and ulceration. usually occurs in children and young adults evolves rapidly over a few weeks; may be related to mechanical trauma Neoplastic Benign Seborrheic keratosis appears as a well-circumscribed, rough-surfaced round or oval lesion with uneven pigmentation in early stages the mass is flat or slightly elevated; later, the lesion becomes dome shaped and more wart-like with a stuck-on quality most commonly affect the upper lids and adnexa Nevus (nevi) Represent benign hamartomas (nests) composed of melanocytes typically start formation during early childhood. May be congenital or acquired Large congenital nevi have a low (~5%) risk for malignant transformation and the development of melanoma Pre-malignant Actinic keratosis most common in fair skinned individuals predilection for sun-exposed areas; related to chronic UV exposure appears slightly elevated, scaly reddish-brown; may present with central ulceration may be a precursor of squamous cell carcinoma in some cases Keratoacanthoma relatively common lesion of the pilosebaceous glands solitary, firm, skin-colored or reddish dome-shaped nodules with a smooth shiny surface and a central ulceration or keratin plug characterized by rapid growth over weeks to months, followed by spontaneous resolution over 4-6 months rarely progresses to invasive or metastatic carcinoma surgical (or other) removal is indicated due to potential malignancy

Malignant Basal cell carcinoma most common malignant tumor / most common eyelid neoplasm (~90%) predominant in elderly, fair-skinned individuals chronic sun exposure most significant risk factor predilection for lower lid/medial canthus slowly progressive & rarely metastatic characteristic appearance: - translucent, raised nodule with "pearly" margins (nodular) - over time, telangiectatic vessels may develop - ulceration may occur at the lesion's center (ulcerative) - Morpheaform variety lies under surface very difficult to assess Squamous cell carcinoma less common than basal cell carcinoma (5 - 10%) predominant in elderly, fair-skinned, sun-exposed individuals prediliction for lower lid & lid margin may convert from benign lesions (e.g., actinic keratosis) slightly more aggressive than BCC; low rate of metastasis differential diagnosis: - actinic, follicular, or seborrheic keratosis - keratoacanthoma - sebaceous gland carcinoma - basal cell carcinoma characteristic appearance: - a roughened, scaly patch, mildly elevated and red - may have crusted and/or bloody margins - patients describe the lesion as a scab that wont heal Melanoma Currently the seventh most common cancer in the U.S. Significant tendency toward growth, metastasis: Melanoma is responsible for 75% of skin cancer deaths in the United States. Primary risk factors: - Changing nevus - Increased age (> 60 years) - Large numbers of moles (common acquired and atypical) - Fair complexion - History of multiple atypical moles - Family history of melanoma - Geographic location in sunny climates Kaposis sarcoma (KS) Historically found in elderly white males of Mediterranean / Ashkenazic Jewish descent; now most common in patients infected with HIV (endemic KS).

Purplish to bright red highly vascular macules, nodules, or plaques with surrounding telangiectatic vessels. -

Ophthalmic KS may affect eyelids, conjunctiva, caruncle, or lacrimal sac. - Potential cosmetic / mechanical concern; generally responds to chemotherapy, anti-HIV therapy Metastatic carcinoma

Treatment Options for Benign Lid Conditions


Since the aforementioned lesions represent non-malignant entities and have little capacity for morbidity, treatment is indicated only for: - cosmetic concerns - large lesions interfering with lid function or vision - suspicion of malignant transformation (especially actinic keratoses) Lesions which are not suspicious and do not present a cosmetic concern to the patient may be photodocumented for size and location and monitored periodically Suspicious lesions should be referred to an oculoplastics specialist for evaluation and biopsy Lesions requiring treatment may be managed by: - curettage and drainage - Cysts of Moll - Cysts of Zeiss chemical cautery bichloracetic acid; commonly employed for: - xanthelasma - squamous papilloma - verrucae - cutaneous horns cryosurgery liquid nitrogen; preferred for: - seborrheic keratoses - actinic keratoses laser photoablation Argon or CO2 laser; can be used for: - xanthelasma - squamous papilloma - verrucae surgical excision may be used for any of the aforementioned lesions, particularly if there is any suspicion of malignancy; biopsy should be performed on all suspicious lesions.

Treatment Options for Malignant Neoplasms


treatment of choice for biopsy proven malignancies is surgical wide margin excision with frozen section Mohs technique lid reconstruction may be necessary exenteration in extreme cases (mostly SGC) cryotherapy, radiation, and chemotherapy for surgically intolerant

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