Eyelid Tumors - Altuğ Çetinkaya, MD, FEBO

What Are Eyelid Tumors?

Eyelid tumors are abnormal growths that develop on the skin of the eyelids. The term "tumor" may sound alarming, but it is important to remember that not all eyelid tumors are cancerous; in fact, 80% of them are benign. A tumor simply refers to an abnormal growth, and its nature—whether benign or malignant—is determined by examining a sample under a microscope.

Although many are benign (non-cancerous),some may be malignant (cancerous) and require urgent medical intervention. Understanding the types, causes, and treatment options for eyelid tumors is crucial for maintaining eye health and overall well-being.

What Causes Eyelid Tumors?

The exact cause of eyelid tumors is not always clear, but several factors may contribute to their development:

Sun Exposure: Prolonged exposure to ultraviolet (UV) rays is a significant risk factor for both benign and malignant eyelid tumors. The harmful effects of the sun are often linked to childhood and adolescent UV exposure. Those who experience extensive sunburns or work outdoors for long hours—such as farmers and fishermen—are at higher risk. Frequent and prolonged use of tanning beds is also a major risk factor.
Age: The risk of developing eyelid tumors, especially malignant ones, increases with age.
Smoking: Harmful substances in cigarettes have been shown to contribute to the development and progression of certain skin cancer types.
Skin Type: Fair-skinned, blonde-haired, and light-eyed individuals are more prone to eyelid tumors. Their natural protective pigments are lower, making them more vulnerable to UV damage.
Genetic Predisposition: A family history of skin cancer or eyelid tumors increases the likelihood of developing such growths. Any suspicious lesion, regardless of size, should be monitored closely if there is a family history.
Immune System Disorders: A weakened immune system makes individuals more susceptible to tumors.

Types of Eyelid Tumors

Eyelid tumors are generally classified into two groups: benign (non-cancerous) and malignant (cancerous).

Benign Eyelid Tumors

These are non-cancerous growths that do not spread to other parts of the body. Common types include:

Chalazion: Also known as a stye, these lumps result from the blockage of an oil gland in the eyelid. They can be painless or cause significant discomfort. Often mistaken for infections, chalazions are actually composed of hardened oils and inflammation rather than bacteria or viruses. They are not contagious but may appear in multiple areas if several glands are affected. They are more common in individuals with underlying eyelid conditions such as meibomitis and tend to occur when the immune system is weakened or stress levels are high. Treatment primarily includes warm compresses, omega-3 supplements, and ointments or oral medications like erythromycin/tetracycline to regulate oil oxidation.
Papilloma: Resembling warts, papillomas appear as small, skin-colored growths that can be either pedunculated or sessile. Some are associated with the human papillomavirus (HPV) and may spread. Distinguishing them from malignant lesions is essential.
Nevus (Mole): Usually harmless but should be monitored for changes. Some moles may begin as non-pigmented lesions or lose pigmentation over time. Any mole that grows rapidly, bleeds, ulcerates, or contains multiple colors should be biopsied for pathological examination. Contrary to popular belief, surgical removal does not increase the risk of malignancy. While simple, small moles have a low cancer potential, regular monitoring by an experienced specialist is recommended.
Xanthelasma: Yellowish plaques formed due to fat accumulation under the skin, often linked to high cholesterol levels. However, around 50% of affected individuals have normal cholesterol levels. The underlying issue is the leakage of thick cholesterol molecules through defective blood vessels in the eyelid skin. Treatment options include surgical removal, laser/plasma treatments, or chemical peeling, but the affected blood vessel-containing muscle tissue must also be removed to prevent recurrence.
Epidermal Inclusion Cysts: These cysts are commonly found on the eyelid and result from the accumulation of keratin—the outermost layer of the skin—within an enlarged pore, forming a capsule. These cysts can be squeezed like pimples but quickly refill. They should be surgically removed intact to prevent recurrence.
Hidrocystoma: Fluid-filled cysts that originate from sweat glands and appear in two forms: a single enlarging cyst or multiple small cysts. Treatment involves surgical excision without rupturing the cyst.
Syringoma: Often misdiagnosed, these small, firm growths result from the overgrowth of sweat glands. Typically appearing as one or two lesions around ages 10-20, they increase in number and size over the years. The most effective treatment is removal using plasma devices.

Malignant Eyelid Tumors

These are cancerous growths that can spread if left untreated. The most common types include:

Basal Cell Carcinoma (BCC)

The most common malignant eyelid tumor, usually caused by sun exposure. It has a characteristic appearance with pearl-like raised edges and a central depressed area. These tumors do not metastasize but grow slowly. However, if untreated, they can damage surrounding tissues and the eye itself. The slow growth often leads patients to overlook the condition, resulting in late-stage diagnoses. Early treatment is much easier and prevents recurrence, whereas delayed treatment may require more extensive tissue removal and reconstructive surgery, potentially affecting vision and the eye.

Squamous Cell Carcinoma (SCC)

Less common but more aggressive than basal cell carcinoma, SCC has the potential to spread to other areas if not treated early. These cancers are more frequently seen in UV-damaged skin, previously healed wounds, or burn scars and can develop from actinic keratosis, which presents as red, scaly lesions. Typically affecting fair-skinned individuals with light-colored eyes, SCC initially appears as persistently scaly, itchy, red patches that gradually enlarge. It has a high risk of spreading through the lymphatic system, blood vessels, or along nerves, making an oncological evaluation necessary upon diagnosis. Surgical removal should be planned urgently to prevent metastasis.

Sebaceous Gland Carcinoma

A highly aggressive tumor originating from the oil glands of the eyelid. It grows rapidly and is the most common eyelid cancer in India; however, it is fortunately rare in our country. In its early stages, it can be mistaken for a chalazion, leading to delays in diagnosis and treatment. It has a high potential for metastasis and is sometimes associated with gastrointestinal cancers. Diagnosis requires evaluation by an experienced ophthalmologist or oculoplastic surgeon. Recurring chalazions in the same location or unilateral eyelid margin disease should raise suspicion, and an appropriate biopsy is crucial. Due to its infiltrative nature, multiple biopsy samples should be taken, and extensive tissue removal is often necessary.

Malignant Melanoma

A rare but serious type of skin cancer that can also develop on the eyelid. It may arise independently or from pre-existing suspicious nevi or precursor pigmented lesions called lentigo maligna. Nearly half of these tumors are amelanotic, meaning they appear skin-colored rather than pigmented. They often present as raised, irregularly bordered lesions with multiple colors and rapid growth. A deep biopsy is essential, and treatment should not be delayed. Once a certain depth is reached, the tumor has a high risk of metastasizing and becoming life-threatening.

Symptoms to Watch for in Eyelid Tumors

Eyelid tumors can present with various symptoms, including:

A visible lump or slow-growing, painless swelling on the eyelid
Thickening or irregular discoloration of the eyelid
Persistent irritation, redness, or swelling
Recurrent scaling of the affected area
Loss of eyelashes in the affected region
Ulceration or bleeding
Abnormal blood vessel formation on the surface

If you notice any of these symptoms, consult an ophthalmologist with expertise in oculoplastic surgery for a comprehensive evaluation.

Diagnosis and Treatment of Eyelid Tumors

The diagnosis of eyelid tumors typically involves a clinical examination, and sometimes a biopsy to determine whether the growth is benign or malignant. Imaging tests may be used to assess the spread of the tumor. Treatment options depend on the type, size, location, and whether the tumor is benign or malignant. Common treatment options include:

Surgical Removal:

For malignant tumors, the most common approach is to ensure complete removal of the tumor. In suspicious cases, a small sample of the tumor may be taken for biopsy, providing valuable information regarding the size of the surgery and the need for additional treatment afterward. If a tumor is identified as malignant, it is necessary to remove 3-5mm of healthy-looking tissue surrounding the tumor, as cancer cells often spread beyond what is visible. Once the cancerous tissue is completely removed and the tissue margins are confirmed to be clean, your surgeon will ensure both functional and aesthetic outcomes with appropriate reconstruction techniques. Post-surgery, close monitoring for recurrence and the possibility of new tumors in other areas is crucial.

Cryotherapy:

Freezing the tumor to destroy abnormal cells was widely used years ago but is no longer a commonly used method.

Radiation Therapy:

Used when surgery is not possible or in cases of recurrence for certain malignant tumors. While it may provide effective improvement in basal cell carcinoma, recurrence is almost inevitable when used alone, so it should not be preferred as a first-line treatment unless necessary. In cases where no other alternatives exist, it may be used for temporary therapeutic success.

Topical Medications:

For some benign tumors, early-stage basal cell carcinoma, or early recurrences, special creams may be prescribed.

Chemotherapy:

In some types of cancer, systemic medications may be used to shrink the tumor or in cases where surgery is no longer possible. The most common drug used in basal cell carcinoma is vismodegib. The use of these systemic drugs, which have side effects, should begin after a detailed evaluation and a committee report.

Tips for Preventing Eyelid Tumors

Although not all eyelid tumors can be prevented, you can reduce your risk by:

Wearing UV-protective sunglasses and a wide-brimmed hat when outdoors
Applying sunscreen to your face and eyelids (products specifically designed for the eye area should be used)
Increasing sun protection during beach or skiing vacations, and avoiding prolonged sun exposure, especially during midday hours
Avoiding smoking and tobacco products
Regularly checking your eyelids for any changes or unusual growths
Planning regular eye exams with your ophthalmologist

When to Seek Medical Help?

If you notice new growths, persistent irritation, or changes in vision on your eyelids, don’t delay seeking medical advice. If you have growing lesions or masses with lost normal skin characteristics, bleeding, or scaling, consult your eye doctor as soon as possible. Early diagnosis and treatment are key to preserving eye health, preventing complications, and achieving the best outcome.

Which Doctor Should You Consult for Eyelid Tumors?

For the diagnosis and surgical treatment of eyelid tumors, it is best to consult ophthalmologists specializing in eyelid disease (oculoplastic surgeons). They will help differentiate between benign and malignant tumors, determine appropriate treatment, and provide surgery that preserves both the health and integrity of the eye, ensuring a safe and close-to-original tissue reconstruction.

The experience of the pathologist evaluating the tissue margins during the removal of malignant tissue, and, if available, a dermatologic surgeon trained in Moh’s surgery, is very useful for both safety and tissue conservation.