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Suspicious, growing lesion on lower lid
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Images: Lundgren Z
A 65-year-old white male presented to the eye clinic with concerns regarding a bump on his right lower lid. The patient reported that his right eye had been watering and irritated for several weeks due to the bump rubbing on his glasses. He also noted that the bump had grown larger recently but he was unable to provide a timeline. He denied any vision changes.
The patient’s ocular history was significant for spectacle correction and early nuclear sclerotic and cortical cataracts. The patient denied any significant family ocular history.
His past medical history was significant for hypertension, hyperlipidemia and erectile dysfunction. His medications included 10 mg of amlodipine daily, 5 mg of terazosin at bedtime, 40 mg of lisinopril daily, 50 mg of sildenafil as needed, 81 mg of aspirin daily, ibuprofen as needed, multivitamin daily and methylcellulose eye drops as needed. The patient had no known drug allergies.
His entering visual acuity was 20/20 in both left and right eyes at distance with spectacle correction. The patient’s intraocular pressures were measured with an iCare tonometer (iCare, Raleigh, N.C.) and found to be 10 mm Hg OD and 9 mm Hg OS. His pupils were equal, round, reactive to light and showed no afferent pupillary defect.
Anterior segment evaluation revealed a raised, pigmented, nonvascular lesion located medially on the lower right eyelid that approached within close proximity to the eyelid margin. The lesion was 10 mm by 3.5 mm and appeared to have a “stuck-on” appearance. Its borders were irregular, and the lesion was slightly amoeboid shaped. The lesion was not painful to touch and moved upon palpation. Apart from the early nuclear sclerotic and cortical cataracts in both eyes, the rest of the patient’s anterior segment examination was unremarkable.
Due to the ocular irritation and the recent growth of the lesion, we proceeded to do a shave biopsy. The area was sterilely prepped and draped. An injection of 2 mL of lidocaine 2% with 1:100,000 epinephrine was administered beneath the lesion. A #11 Bard-Parker blade was used to perform a deep shave biopsy. Cautery was used on the site of the biopsy to control bleeding. The biopsy specimen was placed in formalin and sent to pathology. Sutures were not used, and the biopsy site was left to heal by secondary intention. Erythromycin ophthalmic ointment was applied postsurgically as a prophylactic antibiotic, and the patient was instructed to continue using the ointment twice a day.
Histology showed a basaloid cell proliferation causing thickening (acanthosis) of the epidermis. Also present were horn cysts (cysts filled with keratin) as well as pseudohorn cysts (infoldings of the epidermis). The lesion was well demarcated.
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The pathology report indicated a pigmented benign seborrheic keratosis with negative margins, indicating the lesion was completely excised. The histology report also indicated it to be an acanthotic type of seborrheic keratosis.
Epidemiology
Seborrheic keratosis (SK) is one of the most commonly diagnosed benign epidermal tumors affecting nearly 83 million Americans (Jackson et al.). There is no gender predilection, and the prevalence increases with age. SK is more prevalent in Caucasians, but a variant of SK, termed dermatosis papulosa nigra, affects darker skinned populations more frequently.
The etiology of SK is unknown, but associated risk factors for developing SK include increasing age and ultraviolet light exposure. In one study, 69% of 50- to 59-year-olds, 86% of 60- to 69-year-olds and 90% of 70- to 79-year-olds had at least one SK (Hafner et al.). Typically, patients with numerous SK lesions have a family history of SK; therefore, genetic predisposition was thought to be a risk factor. However, the lack of validated data made the claim of a possible hereditary component unsubstantiated.
Diagnosis
SK routinely presents as a sharply demarcated, raised, pigmented plaque that is commonly described as having a “stuck on” appearance. The clinical presentation is quite variable, making it difficult at times to differentiate it from other similarly presenting lesions such as common warts, lentigines, melanocytic nevi and actinic keratosis. These misdiagnoses are usually inconsequential due to the small difference in prognosis and management of these disorders.
Other more serious conditions such as basal cell carcinoma, squamous cell carcinoma and malignant melanoma require more serious deliberation. In one case study it was found that just less than 1% of SK diagnosed clinically were found to be malignant melanoma when evaluated histologically (Izikson et al.).
An additional report indicated a different potential type of malignancy termed as a “collision tumor.” A collision tumor is a lesion composed of two separate neoplasms that emerge together, such as SK and basal cell carcinoma (Cascajo et al.). Currently, there is no evidence supporting that it is not merely coincidence as opposed to an actual relationship between malignancy and the typically benign lesion, but it should, nonetheless, be considered when evaluating suspicious lesions.
It is important to note that if there is any implication of potential malignancy such as rapid growth, bleeding, impaired healing or other suspicious skin findings, a biopsy and histological evaluation should be performed. Our patient expressed concern about the rapid growth of his lesion and, therefore, a biopsy was performed in-office the same day.
Biopsy, diagnosis
There are currently three main techniques of acquiring a biopsy of a suspicious skin lesion. The first technique is a punch biopsy, which is typically reserved for small lesions (3 mm to 9 mm in diameter) and offers a quick and easy method of biopsy as well as lesion removal. Punch biopsy was not chosen for this particular case because of the location and size of the lesion but should be considered in cases in which the lesion is small and there is a concern for cosmetic appearance.
The second type of biopsy technique is an excisional biopsy. These are often chosen due to the larger size of a suspected lesion as well as the ability to perform multiple studies (culture, histopathology, immunofluorescence, electron microscopy) from one biopsy site. This biopsy typically requires an ellipse marking that is three times as long as it is wide and a 2- to 5-mm margin of normal skin to be included within the biopsy. Excisional biopsy remains the gold standard for suspected malignant melanomas per the American Academy of Dermatology but they are being performed less frequently (Zager et al.). It may be that the low incidence of accuracy when diagnosing malignant melanomas has led to the infrequent use of excisional biopsy. The reported accuracy of diagnosing malignant melanoma was just 42% for primary care practitioners and 80% for dermatologists. Many practitioners are switching to the third biopsy technique, shave biopsy, to diagnose their suspicious lesions.
Shave biopsy
A shave biopsy represents an adaptive technique that is routinely performed on lesions that are elevated above the skin, such as the lesion on our patient, and can be quickly performed in-office. Generally, a shave biopsy can be either performed deep, also known as a deep scallop shave biopsy, or superficially. A deep shave biopsy was performed on our patient.
Shave biopsies are typically not performed on suspected malignant melanomas due to the inadequate staging of the lesion, but many practitioners are seeing the benefit of shave biopsies and, more specifically, deep scallop shave biopsies in diagnosing suspicious lesions. In a retrospective study, 97% of deep shave biopsies were accurate and reliable in diagnosing and microstaging melanoma (Petrou).
The biggest drawback of performing a shave biopsy is the possibility of not excising the necessary amount of tissue needed to accurately assess for malignancy. With a deep shave biopsy, this is less of a concern. If the biopsy is at least 1 mm in depth, it does not compromise the ability to follow the National Comprehensive Cancer Network’s guidelines for managing malignant melanomas (Zager).
Practitioners who utilize deep shave biopsies point to the time-sparing nature of the procedure along with the lack of morbidity as reasons to consider this technique. Excisional biopsies require increased patient preparation and scrubbing-in before the biopsy can be performed as well as suturing of the biopsy site, resulting in increased time constraints in a clinician’s busy schedule. Shave biopsies rarely require suturing and are usually left to heal by secondary intention if not too large. Ultimately, a deep shave biopsy can be a quick and accurate technique to be used in-office for suspicious skin lesions and encourages the liberal use of biopsies to facilitate earlier diagnoses of malignancies.
Treatment, management
Due to the benign nature of SK, treatment is not always mandatory. In most cases it is simply the cosmetic or mechanical irritation that motivates treatment of the benign lesions. In our case, the patient’s concern over the growing lesion prompted removal via deep shave biopsy. This ensured that the patient’s growing fears of potential malignancy were put to rest along with the added benefit of resolving the mechanical irritation the patient was experiencing.
SK lesions can be removed via curettage, cryotherapy, electrodessication and, in some cases, ablative lasers such as Nd:YAG and CO2. Drug therapy has been moderately successful at removing SK lesions as well. In one study, a vitamin D analog applied once or twice daily was successful in removing one-third of lesions over a course of 3 to 12 months (Hafner et al.). The other methods of removal are still favored over drug therapy at this time.
After successful removal of a lesion, the management depends upon the surgical outcome. The site of removal or biopsy is often left to heal by secondary intention. The excision site will usually granulate in within 2 to 3 weeks, depending on the size. To prevent infection, erythromycin ointment was prescribed twice daily for 5 to 7 days. Healing by secondary intention resulted in a cosmetically and functionally favorable outcome in the case of our patient.
Healing by secondary intention
Healing by secondary intention is the most primitive form of wound management but is often beneficial to both the clinician and patient. The skin is left open without the use of sutures, staples or glue and is allowed to heal through granulation and re-epithelialization. Historically, this type of wound management has been seen with contaminated and infectious wounds across multiple specialties in medicine. Wound etiologies can be intentional, accidental or secondary to the disease process.
Whatever the etiology, the healing is similar. Wound management involves a number of different factors that predict optimal healing. Nutrition, hypoxia, infection, immunosuppression, chronic disease, age, genetics and surgical technique all influence wound healing and overall outcome.
Healing by secondary intention is a safe and effective alternative to surgical reconstruction after a shave excision on the lid margin, such as in the case of our patient. In a retrospective analysis, healing by secondary intention following periocular lesion removal was found to be an effective alternative to primary closure or staged reconstruction (Shankar et al.). It was found that, particularly in the elderly, where there is redundant tissue, healing by secondary intention was a realistic alternative to skin flaps, full-thickness skin grafts and skin mobilization that historically is not without cosmetic and functional limitations.
In one study it was found that 92% of periocular lesion removals healed both functionally and cosmetically well via secondary intention (Shankar et al.). Other advantages of secondary intention healing include a shorter surgical time and fewer follow-up appointments. Our case represents another successful healing process through the course of secondary intention and should be considered in cases such as this that involve superficial lesion removal.
- References:
- Alguire PC, et al. J Gen Intern Med. 1998;doi:10.1046/j.1525-1497.1998.00009.x.
- Cascajo CD, et al. Am J Dermatopathol. 1996;18(3):278-282.
- Chang M, et al. Journal of Craniofacial Surgery. 2013;doi:10.1097/SCS.0b013e31829030ad.
- Hafner C, et al. J Germ Soc Dermatol. 2008;doi: 10.1111/j.1610-0387.2008.06788.x.
- Izikson L, et al. Arch Dermatol. 2002;doi:10.1001/archderm.138.12.1562.
- Jackson JM. J Drugs Dermatol. 2015 Oct;14(10):1119-25.
- Roh NK, et al. Ann Dermatol. 2016;doi: 10.5021/ad.2016.28.2.152.
- Shankar J, et al. Eye. 2002;doi:10.1038/sj.eye.6700057.
- Young A, et al. Surgery. 2011; doi:10.1016/j.mpsur.2011.06.011.
- Zager JS, et al. J Am Coll Surg. 2011;doi:10.1016/j.jamcollsurg.2010.12.021.
- For more information:
- Zachary Lundgren, BA, is a fourth-year optometry intern from Pacific University College of Optometry in Forest Grove, Ore. He can be reached at lund3237@pacificu.edu.
- Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, practices at the Mayo Clinic Health System in Albert Lea, MN, and is a member of the Primary Care Optometry News Editorial Board. He can be reached at Mayo Clinic Health System; skorin.leonid@mayo.edu.
- Maria Joan Spadaro, CNP, is a nurse practitioner on an emergency medicine nurse practitioner fellowship at Mayo Clinic in Rochester, Minn. She can be reached at spadaro.maria@mayo.edu.
- Edited by Leo P. Semes, OD, FAAO, a former professor of optometry, University of Alabama at Birmingham, and a member of the Primary Care Optometry News Editorial Board. He can be reached at leopsemes@gmail.com.
Disclosures: Semes is an advisor or on the speakers bureau for Alcon, Allergan, Bausch + Lomb, Genentech, Maculogix, OptoVue, Shire and ZeaVision. He is a stockholder with HPO. The authors report no relevant financial disclosures.