The term papilloma refers to a group of various benign epithelial proliferations that can affect the eyelid skin. These lesions are not necessarily associated with the papillomavirus. These lesions are not dangerous but can cause mild irritation or be cosmetically unfavorable for the patient. Also, it is important to be able to differentiate a benign lesion like a papilloma from a potentially malignant lesion on the eyelid. The lesions which fall into this classification include, but are not limited to seborrheic keratosis, pseudoepitheliomatous hyperplasia, verruca vulgaris, squamous papilloma (acrochordon/skin tag), basosquamous acanthoma, and squamous acanthoma. Some types of papillomas are described below.
Squamous papilloma is also known as acrochordon or skin tag. This is a soft, flesh-colored lesion that is smooth, round and/or pedunculated.
This is a benign proliferation of cells. Classically has a “stuck on” appearance and can have varying degrees of pigmentation. Lesions tend to vary from a pink or flesh color to dark brown. These lesions are well circumscribed and are usually slightly elevated. Normally these lesions are benign, but the sudden appearance of multiple seborrheic keratoses in a region of the body could indicate a paraneoplastic process. These lesions often have an inflamed base. This is called Leser-Trelat sign.
This is flesh colored skin growth caused by human papillomavirus. This lesion is rare on the eyelid.
Papilloma etiology depends on the type of epithelial proliferation. Squamous papillomas and seborrheic keratosis are idiopathic benign cellular proliferation. There is no known definitive cause of these lesions. However, malignant skin lesions that can look like papillomas are often associated with chronic ultraviolet (UV) exposure and sun-damaged skin. Verruca vulgaris is caused by human papillomavirus type 6 or 11.
Seborrheic keratosis is typically found in middle-aged or elderly patients. Squamous papillomas do not have a strong predilection for a particular race or sex. They tend to increase in frequency with older age but can occur at any age.
Seborrheic keratosis displays hyperkeratosis, acanthosis, and some degree of papillomatosis on histological preparation. By definition, the squamous cells that make up the lesion do not show dysplasia. One characteristic finding in some seborrheic keratosis are the pseudo-horn cysts. These are circular collections of surface keratin in the acanthotic epithelium of the seborrheic keratosis lesion.
When evaluating a skin lesion on the eyelid, the following questions are important to ask the patient:
When performing the physical exam, it is important to perform the following evaluations:
Physical exam finding for papillomas will vary slightly depending on the type.
Squamous papilloma: This is a soft, flesh-colored lesion that is generally smooth, round and/or pedunculated.
Seborrheic keratosis: Classically has a “stuck on” appearance and can have varying degrees of pigmentation. Lesions tend to vary from a pink or flesh color to dark brown. These lesions are well circumscribed and are usually slightly elevated.
Verruca vulgaris: Flesh colored skin growth. The superior portion of the lesion can have very tiny, fingerlike projections that are sometimes visible without magnification.
Consider documenting lesion with photo or drawing.
If lesion displays any characteristics that are concerning for malignancy, consider performing a biopsy. Typically an incisional biopsy is performed in these cases.
Lesions that are found to be eyelid papillomas can be observed. If the papilloma is causing irritation or is cosmetically unacceptable for the patient, it can be removed. Most papillomas can be removed with a bedside shave excision. See technique described below. Verruca vulgaris typically responds better to cryotherapy.
One study found intralesional interferon to treat a large eyelid papilloma successfully. A larger study involving 64 patients with eyelid papilloma-like lesions found that using a radiofrequency unit for lesion removal was safe and effective. In this study, 72% of the lesions treated were squamous papillomas.
Papilloma Excision Technique
Instill topical tetracaine drop in the ipsilateral eye to prevent eye irritation from the cleaning solution. Use the full strength povidone-iodine solution to clean papilloma area and surrounding eyelid tissue. Place small sterile drape with a hole cut out to isolate eyelid lesion.
Instill 1 mL to 2 mL of lidocaine with epinephrine directly underneath papilloma. Use the least amount of local anesthetic necessary to provide adequate patient comfort.
Using 0.5mm forceps, grasp tissue and elevate gently while using a 15 blade or iris scissor to remove the lesion. Be sure to start cutting at the base of the lesion to remove fully. There should be no need to enter into deeper tissues. A handheld cautery tool can be used to achieve hemostasis. Typically the remaining defect is small and does not require suturing to approximate the skin. Prescribed antibiotic (i.e., Erythromycin ophthalmic ointment) for the patient to place on healing incision three to four times daily for 1 to 2 weeks until healed to prevent infection.
Consider sending tissue specimen to pathology for evaluation if it has any suspicious characteristics.
Differential diagnoses include: chalazion/hordeolum, epidermal inclusion cyst, molluscum contagiosum, xanthelasma, squamous cell carcinoma, nevus, actinic keratosis, basal cell carcinoma, sebaceous gland carcinoma.