Melanocytic Lesions

## **Chapter 4** Combined Nevi

*Jelena Stojkovic-Filipovic and Miljan Vlahovic*

### **Abstract**

Combined nevi (CN) are clinically defined as melanocytic lesions comprising two or more distinct melanocytic nevus components, and from the cytological point of view, CN are determined by the presence of two or more different nevus cell types in one biopsy specimen. They are very uncommon and represent less than 1% of all biopsied melanocytic nevi. CN comprise any melanocytic nevi, but the most prevalent combination is CN that consist of blue nevus associated with common melanocytic nevus. CN owe their diversity to combination of different nevi, that are variously combined. Consequently, they can have variable clinical aspects and dermatoscopic features. Because of the presence of at least two distinct subtypes of nevomelanocytes, dermatoscopically CN can show multicomponent, unspecific, and peculiar patterns. Therefore, CN can mimic melanomas, their most important differential clinical, dermatoscopical and histopathological diagnosis.

**Keywords:** combined nevi, combined blue nevi, melanoma, dermatoscopy, dermoscopy

### **1. Introduction**

Combined nevi (CN) are specific, uncommon type of melanocytic nevi, and they represent less than 1% of all biopsied melanocytic nevi [1, 2]. Clinically, they are defined as melanocytic lesions comprising two or more distinct melanocytic nevus components [3]. From a histopathologic point of view, combined nevi are determined by the presence of two or more different nevus cell types in one biopsy specimen [4]. Based on their clinical and histopathological features, CN represent a subcategory of so-called collision or compound tumors, which are defined by the occurrence of two distinctive neoplastic skin lesions, that collide concurrently within the same specimen [5].

Combined nevi can be comprised by any melanocytic nevi. Although any collision is possible, it is most likely that CN present a combined variant of blue nevus, acquired nevus (Clark nevus), superficial congenital nevus, Spitz nevus or deep penetrating nevus [1]. The most frequent combination that is seen in practice is that of blue nevus associated with common melanocytic nevus and Spitz nevus [4].

#### **2. Clinical features**

Combined nevi are mainly congenital, although they are not always visible at birth, but later in life [6]. Although CN could be seen in childhood, as well as at an old age, they are most frequent in young adults (median age reported from 29 to 47) [1, 4, 7, 8]. In early studies of CN, a slight predominance in females was reported

#### **Figure 1.**

*Combined nevus clinical presentation: Slightly raised, round lesion; small black spot in the center, surrounded by brown area (Targetoid combined blue nevus type).*

[1, 4, 8], with the female: male ratio 1.1:1 [1]. Newer study with larger number of observed CN, has shifted that ratio towards male predominance 0.6:1 [7].

In the view of distribution, the predilection site has not been officially established, but literature data show that this nevus type does most frequently appear on the trunk [1, 4, 7–9] and head and neck region [7], and it is less common on the extremities [7].

Since CN are composed of distinct nevi, their clinical appearance could be very diverse. In practice, CN are usually small, flat, or minimally raised lesions [1, 7], often characterized by a small blue or black spot (corresponding to the blue nevus component) in the context of a larger area of brown color (corresponding to the common nevus) surrounding the blue nevus part [10] (**Figure 1**). The latter is known as the targetoid combined blue nevus type [11].

#### **3. Dermatoscopic features**

Since CN are composed of at least two different nevus types in various combinations, their dermatoscopic features are characterized by mostly multicomponent, unspecific, and random patterns. Typically, multicomponent structure of CN exhibit reasonably symmetrical appearance [3, 7] (**Figure 2**), which is consistent with already established findings that benign nevi tend to exhibit symmetry [12]. This is one of the most distinguishing features when differentiating CN from melanomas, as chaos (asymmetry of structure or colors) is principally imperative of a malignant neoplasm [6, 13].

Looking at the color, simultaneous occurrence of different colors (primarily brown and blue, rarely black, and white) is common appearance in CN, where the pigmentation originates from both junctional and dermal portion of the skin [6]. Since blue nevus is the most common component of CN, structureless blue part of the lesion is frequently presented [7], usually covering about 30% of the lesion (**Figure 2A** and **B**). Being such a regular finding, structureless blue area is an important element in the dermatoscopic analysis of this nevus type [7], even

#### **Figure 2.**

*Combined nevus dermatoscopy: A. well defined structureless blue area in the center of the lesion, pigmented globules at the periphery; B. ill-defined structureless blue area in the center of the lesion, brown reticular lines at the periphery.*

#### **Figure 3.**

*Combined nevus dermatoscopy: A. diffuse distribution of structureless blue area, structureless brown at the periphery; B. patchy distribution of structureless blue area.*

reported as a hallmark of CN [14]. Both well and ill-defined structureless blue areas (**Figure 2A** and **B**) are presented in CN. It is important to remember that the presence of ill-defined structureless blue area in any lesion must always raise suspicion, since it may resemble the "blue veil", common characteristic of melanomas with the blue part [7].

Regarding the position of the structureless blue areas and their proximity to the edge of the lesion, in the majority of observed cases, these areas do not touch the edge of the lesions (**Figure 2A** and **B**) [7]. Diffuse and patchy type of structureless blue areas distribution appears in only less then 10% CN and cannot be considered as a specific feature for this nevus type (**Figure 3A** and **B**). Structureless blue area could be presented either eccentrically (**Figure 4**) or in the central part of CN, whereas central distribution is more common (**Figure 2A** and **B**) [7, 9], distinctive for benign lesions and reflects benign nature of these nevi. If located centrally, blue structureless area is surrounded by another pattern, mostly brown clods (**Figure 2A**), or reticular pattern (**Figure 2B**), which was previously stated as the stereotypical appearance of CN [15]. Within and around the structureless blue area of CN brown

#### **Figure 4.**

*Combined nevus dermatoscopy: Eccentric structureless blue area, at the edge of the lesion.*

dots may be present [14, 16]. Yet, this cannot be considered as a dermatoscopic clue specific for CN, since it could be found in melanomas as well.

Curved lines at the periphery of the lesion can be contemplated as additional specific dermatoscopic features of CN [9, 14]. The other dermatoscopic features like radial circumferential or segmental lines, branched lines, as well as blue and gray clods and dots are not specific for CN [7, 17]. In some cases, when blue nevus is associated with a dermal nevus, gray-blue pigmentation could be distributed irregularly [9].

In cases where CN exhibit chaotic appearance, featuring eccentric structureless, particularly blue area (**Figure 4**), CN lack clues such as white lines, gray structures, pseudopods/radial lines, thick reticular lines, ulcerations, and polygons which are typical for melanomas [7]. Lesions with multicomponent pattern and eccentric, particularly structureless blue area, lacking specific dermatoscopic features of melanoma do not require excision.

#### **4. Differential diagnosis**

Due to their variable nature and different nevus types combined in variety of patterns, clinical and dermoscopic determination of CN could be challenging. For that reason, differential diagnoses may include several benign or malignant neoplasms. Combined nevus may resemble blue nevus, common nevus, Spitz nevus (pigmented type), pigmented spindle cell nevus, plexiform spindle cell nevus, benign vascular tumors, hemosiderotic variant of dermatofibroma, pigmented basal cell carcinoma, cutaneous metastases [6, 9, 18, 19]. Despite this broad similarity to the various skin lesions, CN usually simulate melanoma, which is the most common differential diagnosis. Due to their inconsistent, atypical and irregular clinical and dermatoscopic appearance, CN are frequently misdiagnosed as melanomas [1] and careful histologic examination to exclude melanoma is occasionally required.

#### **5. Histopathology**

The term "combined" can be both used in cytological and dermatoscopic context. Histopathological features of CN depend on nevi that are combined within the lesion, and vary depending on the nevi types present.

#### *Combined Nevi DOI: http://dx.doi.org/10.5772/intechopen.99768*

Histopathologically, there are several types of CN, characterized by the combination of any morphological expression of congenital and/or acquired nevi. Superficial congenital nevus combined with blue nevus, either common or cellular type are most common combination seen in practice. Less frequent are Spitz nevus combined with Clark nevus ("SPARK"), superficial congenital nevi combined with deep penetrating nevus, and blue nevus combined with Spitz nevus ("BLITZ") [7].

The most common histopathological finding in diagnosis of CN is a compound or dermal nevus with a dermal population of enlarged nevus cells (**Figure 5A**), either admixed with or overlie pigmented epithelioid and/or spindled melanocytes component in association with melanophages [19] (**Figure 5B** and **C**).

In the case of blue nevus, dendritic, cellular blue or deep penetrating nevus are present, with melanin in the deeper dermal portions [1]. Common blue nevus is characterized by elongated, often slightly wavy melanocytes with long, branching dendrites, either grouped together or in bundles in the upper and mid dermis, parallel to the epidermis, with variable numbers of macrophages and increase amount of collagen [1]. Melanocytes could extend into the subcutaneous tissue or approach the epidermis, but they never alter the epidermis structure [1, 19]. In case of cellular

#### **Figure 5.**

*Combined nevus histopathological findings: A. epidermal and dermal nests of common melanocytic nevus, no signs of atypia or mitotic activity: B, C. slender spindle cells and melanophages in the center of the lesion.*

#### *Dermatoscopy*

blue nevus, deeply pigmented dendritic melanocytes are visible in addition to nests and fascicles of spindle-shaped cells with abundant pale cytoplasm containing little or no melanin. These melanocytes also frequently penetrate the subcutaneous tissue. Some of the cells may appear atypical, with nuclear pleomorphism accompanied by multinucleated giant cells, rare mitoses, and inflammatory infiltrates. In addition to this, overlapping features of common and cellular blue nevi could be seen in some lesions [19].

If Spitz nevus is present, nests of large epithelioid cells, spindle cells or both can be seen, usually extending from the epidermis into the reticular dermis, within hyperplastic epidermis and mononuclear and multinucleate giant epithelioid cells infiltrating dermal collagen. In some observed cases, necrotic cells, mitotic figures and intraepidermal eosinophilic globules were found [19].

#### **6. Management**

Better and more uniformed description of clinical and dermatoscopic features of CN, together with improvement in routine differentiation between CN and melanomas can significantly reduce the number of excisions and biopsies performed. Biopsy should still be considered for any suspicious lesion. If distinction from melanoma cannot be clearly made, complete surgical excision is recommended.

### **Author details**

Jelena Stojkovic-Filipovic1,2\* and Miljan Vlahovic3,4

1 Clinic of Dermatovnereology, University Clinical Center of Serbia, Belgrade, Serbia

2 Faculty of Medicine, University of Belgrade, Belgrade, Serbia

3 Department of Health NSW, Sydney, NSW, Australia

4 Monash University, Melbourne, VIC, Australia

\*Address all correspondence to: sf.jelena@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Scolyer RA, Zhuang L, Palmer AA, Thompson JF, McCarthy SW. Combined naevus: a benign lesion frequently misdiagnosed both clinically and pathologically as melanoma. Pathology. 2004;36(5):419-27

[2] Strungs I. Common and uncommon variants of melanocytic naevi. Pathology. 2004;36(5):396-403

[3] Barnhill RL. Combined naevus. In: LeBoitPE, Burg G, Weedon D, Sarasin A, eds. World Health Organization Classification of Tumours Pathology & Genetics Skin Tumours. Lyon: IARC Press, 2006; 100-102

[4] Baran JL, Duncan LM. Combined melanocytic nevi: histologic variants and melanoma mimics. Am J Surg Pathol. 2011;35:1540-8.

[5] Cosme Alvarez Cuesta C, Vazquez Lopez F, Perez Oliva N. Dermatoscopy in the diagnosis of cutaneous collision. Clin Exp Dermatol 2004;29:199-200.

[6] Kittler H, editor. Dermatoscopy. Pattern analysis of pigmented and non-pigmented lesions. Vienna: Facultas Universitatsverlag, 2nd edition. 2016.

[7] J. Stojkovic-Filipovic, D. Tiodorovic, A. Lallas, et al. Dermatoscopy of combined blue nevi: a multicentre study of the International Dermoscopy Society. JEADV 2020;….: 900-905

[8] Schweizer A, Fink C, Bertlich I et al. Differentiation of combined nevi and melanomas: Case-control study with comparative analysis of dermoscopic features. J Dtsch Dermatol Ges. 2020;18:111-118.).

[9] de Giorgi V, Massi D, Salvini C et al. Dermoscopic features of combined melanocytic nevi. J Cutan Pathol. 2004;31:600-4.

[10] Dermoscopy of melanocytic neoplasms: combined blue nevi. Arch Dermatol. 2004;140:902.

[11] Argenziano G. Dermoscopy of melanocytic neoplasms: Targetoid combined blue nevi. Arch Dermatol. 2004;140:1576.

[12] Kim JK, Nelson KC. Dermoscopic features of common nevi: a review. G Ital Dermatol Venereol. 2012;147(2):141-8.

[13] Rosendahl C, Cameron A, McColl I, Wilkinson D. Dermatoscopy in routine practice – 'chaos and clues'. Aust Fam Physician. 2012;41:482-7.

[14] Ferrari A, Lozzi GP, Fargnoli MC, Peris K. Dermoscopic evolution of a congenital combined nevus in childhood. Dermatol Surg. 2005;31 (11 Pt 1):1448-50.

[15] Zalaudek I, Manzo M, Savarese I et al. The morphologic universe of melanocytic nevi. Semin Cutan Med Surg. 2009;28:149-56.

[16] Piccolo D, Altamura D, Lozzi GP, Peris K. Blue-whitish veil-like structure as the primary dermoscopic feature of combined nevus. Dermatol Surg. 2006;321176-8.

[17] Yaginuma A, Nobeyama Y, Miyake-Nakano S et al. Case of combined nevus showing a speckled distribution pattern. J Dermatol. 2018;45:e232-e233

[18] Cabo H. Combined nevi. In H. P. Soyer, G. Argenziano, R. Hofmann-Wellenhof, R. H. Johr (Eds.). Color Atlas of Melanocytic Lesions of the Skin. Springer. 2007; 97-101.

[19] Bolognia J, Scaffer JV, Cerroni L. Dermatology. St Louis: Mosby Elsevier; 2018.

Section 4 Special Sites

#### **Chapter 5**

## Pigmented Lesions of the Eyelid Margin

*Wojciech Adamski and Kinga Adamska*

#### **Abstract**

The eyelid area poses a diagnostic and therapeutic challenge due to its specific anatomy. The eyelid is composed of skin, orbicularis muscle, tarsus, and the eyelid margin is continuous with palpebral conjunctiva. Among pigmented tumors, benign lesions such as epidermal or intradermal nevi, freckles, lentigo, or seborrheic keratosis are the most common. Melanoma is relatively rare in this location. A suspicious lesion may be biopsied or excised. Surgery in the eyelid area requires special considerations to maintain a safe surgical margin, vital function of the eyelid, and acceptable cosmetic effect due to the exposure of the eyelid region of the face.

**Keywords:** eyelid, margin, nevus, melanoma, seborrheic keratosis

#### **1. Introduction**

The main functions of the eyelid are to provide protection for the moist surface of the eye. Due to its function and exposition to outside factors such as sunlight, it has distinctive anatomy and requires a unique approach. Because of its location

**Figure 1.** *A hand dermatoscope with a contact plate designed for difficult anatomical locations.*

**Figure 2.** *A small junctional nevus visualized with a contact plate designed for difficult locations.*

and morphology, it often poses a challenge for contact dermatoscopy in diagnosis and requires distinct surgical methods when such an approach is necessary. Lesions located in the eyelid area may be visualized using a non-contact dermatoscope. More accessible areas of this region may be visualized with contact dermatoscopy using a non-alcoholic medium and a special contact plate designed to be used in difficult anatomical locations (**Figures 1** and **2**). Due to a close relation with sensitive conjunctiva, the examination may be preceded by applying local anesthetic drop (e.g. Proxymetacainum) into the conjunctival sack in order to prevent pain reflex and eyelid closure. To reduce the risk of irritation, an ophthalmic gel may be used instead of the immersion fluid. Another less recommended approach may involve a dry dermatoscopy, without a contact plate or with a contact plate, but without immersion fluid.

#### **2. Relevant anatomy**

The eyelid can be divided into four layers. Eyelid skin is continuous with the skin of the face, although it is substantially thinner. Underneath the skin lies the striated muscle called the orbicularis muscle, which is responsible for eye closure. Deeper lies the tarsus, a strong plate of dense connective tissue with meibomian glands. The innermost layer of the eyelid is the conjunctiva. The eyelids contain various glands like the eccrine sweat glands of the eyelid skin and the accessory lacrimal gland of Krause and Wolfring in the conjunctiva, the gland of Moll (an apocrine gland), and the sebaceous glands–the Meibomian glands and the glands of Zeiss.

Benign and malignant tumors may originate in all of the mentioned layers, although they are usually of skin origin, mostly epidermal [1].

Although the most numerous epithelial tumors of the eyelid margin like basal cell carcinoma except for its pigmented variant, epithelial cysts, or actinic keratosis will mainly not be discussed in this chapter.

### **3. Benign melanocytic eyelid tumors**

### **3.1 Freckles**

Freckles are small (1–5 mm in diameter), flat brown skin spots located in skin exposed to sunlight. They are usually multiple lesions in one site. Histologically, there is hyperpigmentation of the basal cell layer but no elongation of the rete ridges. They tend to darken after exposition to sunlight and lighten when devoid of it. With time they may clinically disappear. Dermoscopic features include evenly distributed pigmentation and a moth-eaten border [2, 3].

#### **3.2 Simple lentigo**

Simple lentigo (lentigo simplex) is a skin lesion with well-demarcated borders, light to dark brown. Arise due to melanocyte proliferation in the basal layer of the epidermis. They do not darken when exposed to sunlight which differentiates them from freckles. Multiple appearances of lentigo simplex lesions are called lentiginosis [4]. Dermatoscopic features include structureless homogenous pigmentation. These lesions may be congenital and may be associated with genetic syndromes like Peutz-Jeghers Syndrome, Carney Complex, or LEOPARD Syndrome [5]. Dermatoscopic features include a uniform thin brown, black or blue network (**Figures 3** and **4**).

#### **3.3 Nevi**

Nevus is commonly found in the area of the eyelids. It is a heterogeneous group of lesions with a wide array of clinical and histological presentation.

### **3.4 Congenital nevus**

A congenital nevus is found in the skin of the eyelids in about 1% of newborns. It may vary in size, from small to large. Large lesions have a higher rate of malignant transformation. Histologically a congenital nevus is similar to an acquired nevus.

**Figure 3.** *Lentigo simplex of the lower eyelid.*

#### **Figure 4.** *Lentigo.*

#### **3.5 Kissing nevus**

A kissing or split nevus is a rare subtype of a congenital nevus that appear on both the upper and lower eyelid. Its unique morphology indicates that it developed early in utero, before the 20th week of gestation, when the eyelids are divided [6, 7]. Due to its difficult location involving both eyelids and usually a large diameter as well as typically benign nature, those type of nevi are not usually surgically treated [7].

#### **3.6 Nevus of Ota**

Nevus of Ota (oculodermal melanocytosis) is a benign melanocytic lesion involving the face and eyelid region, specifically the area supported by the ophthalmic and maxillary branches of the trigeminal nerve. It is usually congenital but may appear in puberty. It appears due to the entrapment of melanocytes in the upper third of the dermis. The deeper location of melanocytes gives this lesion a blue/gray appearance. The cause of the failure of migration of the melanocytes to their typical location in the basal layer of the epidermis remains unknown. In addition to covering the eyelids nevus of Ota may also involve the conjunctiva as well as the sclera, increasing the risk of developing glaucoma. It also affects the uveal tract of the eye, increasing the risk of uveal melanoma. Histologically distinct dendritic melanocytes can be found in the affected areas [8]. It is usually unilateral. Some authors use the term "nevus of Hori" for a bilateral involvement [9].

#### **3.7 Acquired nevus**

Acquired nevus appears commonly in the eyelid area. The lesions usually appear in childhood and may increase in size during patient growth.

Histologically there are three main types of acquired nevus, according to the location of melanocyte proliferation: the junctional nevus, located in the dermo-epidermal junction, the intradermal nevus, located only in the dermis, and the compound nevus, which involves both of these locations. Junctional appears mainly among younger patients and presents as a flat, evenly colored spot. Dermatoscopic features include reticular or globular patterns, interrupted by the presence of follicular openings, the intradermal nevus is located deeper in the dermis and may be elevated

#### *Pigmented Lesions of the Eyelid Margin DOI: http://dx.doi.org/10.5772/intechopen.101376*

or papillomatous in shape. It might be slightly pigmented or have no pigmentation (achromic) at all. Dermatoscopic features may include comma vessels, globular pattern, centered coma, and occasionally arborizing vessels in case of repetitive trauma. A compound nevus combines the characteristics of the previous lesions.

A distinct subtype of intradermal nevus appearing in the face and neck region is called the Miescher's nevus. Its dermatoscopic features may include a homogeneous globular pattern with the focal and symmetric arrangement of globules arranged in a cobblestone pattern.

Some achromic intradermal nevus located on the eyelid margin may be misdiagnosed as basal cell carcinoma, which is typically found in the lower eyelid. Madarosis is often associated as a sign of malignancy, brown structureless

#### **Figure 5.**

*A subtle junctional nevus close with a line of Meibomian glands. Courtesy of Pawel Pietkiewicz MD, PhD.*

**Figure 6.** *A junctional nevus of the eyelid margin.*

**Figure 7.** *Compound nevus of the eyelid margin with a junctional nevus of the conjunctiva.*

**Figure 8.** *Intradermal nevus of the eyelid margin – So called Miescher's nevus.*

**Figure 9.** *An achromic intradermal nevus of the eyelid margin.*

*Pigmented Lesions of the Eyelid Margin DOI: http://dx.doi.org/10.5772/intechopen.101376*

**Figure 10.** *An achromic intradermal nevus of the upper eyelid.*

#### **Figure 11.**

*An achromic kissing nevus of the upper and lower eyelid.*

**Figure 12.** *An intradermal nevus as seen in dermatoscope.*

**Figure 13.** *An intradermal nevus of the eyelid margin.*

pigmentation and brown globules are on the other hand more frequent in a nevi. Basal cell carcinoma has a more shiny and smooth surface, deprived of hair, whereas dermal nevus is more papilomatous with visible skin markings and hair follicles (**Figures 5**–**14**) [10].

#### **3.8 Spitz and blue nevus**

A Spitz and blue nevi are distinct types of melanocytic nevi. Their location in the eyelid area is extremely rare, and only a handful of cases have been described in the literature so far [11, 12].

### **4. Other benign lesions**

#### **4.1 Seborreheic keratosis**

This benign skin lesion is a proliferation of basaloid cells. Although it is not composed of melanocytes, it may be pigmentary in appearance due to a transfer of melanin from them to the keratinocytes. It is usually a well-demarcated plaque or papilla [13]. Dermatoscopic features include fingerprinting or cerebrilike (brain-like) structures, comedo-like openings or pseudocomedones, moth-eaten borders, sharp demarcation and milia-like cysts, and centered looped vessels (**Figure 15**) [14].

#### **4.2 Cystic lesions**

The eyelid skin is rich with glandular tissue which may produce cystic lesions like epidermal inclusion cysts, hidrocystomas which appear when a gland duct is occluded. Those benign lesions may sometimes be misdiagnosed as malignant, especially when filled with blood or blood components that give them a pigmented appearance. The most typical dermatoscopic findings include the structureless pattern with cystic intradermal space filled with fluid and the presence of arborizing vessels (**Figures 16** and **17**) [15].

#### **4.3 Malignant lesions**

#### *4.3.1 Melanoma*

Melanoma of the eyelid region is sporadic, comprising less than 1% of all malignant eyelid lesion [16]. Due to the fact that the lower eyelid is much more exposed to ultraviolet light, melanoma appears much more commonly in this region compared to the upper eyelid [17]. It affects mainly patients with blond or red hair, pale skin, and the presence of multiple skin lesions, a tendency to burn and tan poorly, and a history of sunburn in childhood as well as artificial tanning before 25 years old.

The most common histological variants of melanoma in the eyelid area are lentigo maligna melanoma and superficial spreading melanoma [18, 19]. The most common dermatoscopic features include a higher number of dermatoscopic structures, and colors. The most prevalent pattern of melanoma in the face include gray

**Figure 15.** *Verruca seborrhoica.*

**Figure 16.** *Inclusion cyst filled with blood.*

**Figure 17.** *Inclusion cyst of the eyelid margin.*

color (homogenous areas, globules, dots, and circles), annular-granular pattern (dots aggregated around hair follicles), rhomboidal structures, and finally, obliterated hair follicles in invasive melanoma. Additional features include a shiny white line and a blue-whitish veil (**Figures 18** and **19**)**.**

#### *4.3.2 Basal cell carcinoma*

Basal cell carcinoma (BCC) is the most common malignant skin lesion, accounting for 86% of all cutaneous malignancies. BCC is typically located in the lower eyelid or medial canthus. Clinically and histologically, the most common variants are the nodular, superficial, micronodular, morphiform, and pigmented. Pigmented BCC (pBCC) it is uncommon in light skin types, and more common in darker

*Pigmented Lesions of the Eyelid Margin DOI: http://dx.doi.org/10.5772/intechopen.101376*

**Figure 18.** *A suspicious compound nevus of the eyelid margin.*

**Figure 19.** *Superficial spreading melanoma of the eyelid margin with a vertical nodular growth.*

ones. The reason for the pigmented appearance of these lesions is that, that histologically they are composed of basaloid tumor cells intermingled with dendritic melanocytes. The melanocytes themselves usually do not demonstrate any atypical characteristics. No prognostic differences in pBCC are noted in comparison with clinically nonpigmented lesions [20]. Dermatoscopic features may vary. The most common dermatoscopic findings include arborizing vessels as well as mentioned above intense pink homogenous areas or yellow collor corresponding to ulceration. The vascular patterns may be different depending on the type of BCC. Nodular BCC usually presents with classical arborizing vessels while short telangiectasia suggests superficial BCC. Additional features may include leaf-like areas, spoke wheel-like areas, milia-like cysts, large ovoid nests, and target-like areas. Up to 10% of BCCs may contain pigmented structures like globules or dots [21–23]. Accurate dermatoscopic examination of the lesion borders may help plan surgical margins which may prove different than the ones observed surgically (**Figures 20** and **21**).

#### **4.4 Conjunctival lesions**

Infrequently, conjunctival lesions may also affect the eyelid margin. In the case of diffuse conjunctival infiltration, the involvement of eyelid skin should be

**Figure 20.**

*Pigmentary basal cell carcinoma of the eyelid presenting shiny pearly-like surface.*

considered a poor prognostic factor. When noticing a melanocytic lesion of the eyelid margin, one should perform a precise assessment of the conjunctiva and conjunctival fornix, both the lower and the upper. Dermoscopic features of conjunctival melanoma were characterized as structureless areas, irregular dots, and a high prevalence of gray coloration [15]. Authors suggest that typical dermatoscopic features of skin melanoma may be also present in conjunctival melanoma such as atypical pigment network, irregular dots, and globules, regression structures, as well as blue-white veil (**Figure 22**) [24].

#### **5. Lacrimal caruncle**

While not specifically part of the eyelid region, the caruncle remains an interesting aspect. Although it may be confused with conjunctival tissue due to its proximity, it is, in fact, a skin fold covered with sebaceous and sweat glands located in the

medial canthus of the eye. Due to its nature, although infrequently, it may be a point of origin for various skin lesions, mainly nevi or papillomas (**Figure 23**) [15, 25].

#### **Figure 22.**

*Melanoma in situ of the conjunctiva, affecting the eyelid margin presenting black-brown-gray homogeneous area sparing hair follicle openings.*

**Figure 23.** *Junctional nevus of the caruncle.*

#### **6. Approach to pigmented eyelid lesions**

Because of the distinct anatomy of the eyelid, pigmented lesions of this area require a specific approach. Due to the eyelid being a very important cosmetic feature of the face, some patients pay special attention to lesions appearing in this region. Benign pigmented lesions may be removed by an ophthalmologist or an oculoplastic surgeon using surgery or other destructive methods such as cryotherapy or laser treatment after a careful dermatoscopic examination. Suspicious lesions require an incisional or excisional biopsy to determine their nature. Incisional biopsy should be chosen for large lesions, while small may undergo excisional biopsy.

Basal cell carcinoma with its pigmented variant may require Mohs micrographic surgery to safely assess its margins with the least healthy tissue traumatization.

General guidelines for the management of melanoma located in different areas of the body, where wide surgical excision is performed with margins according to the Breslow scale are not perfectly suitable for eyelid skin. It is caused by the specific

#### *Dermatoscopy*

anatomy of skin in this region and by the proximity of critical structures and difficulties with reconstructive surgery of large eyelid defects. Because of that, most surgeons suggest 3–5 mm surgical margins, however, this issue remains controversial, as some authors use up to 10 mm of safe surgical margin [17, 18, 26]. Long-term observations suggest a high rate of recurrence in the area of the head and neck.

Diffuse melanoma of the conjunctiva with the involvement of the eyelid region may require orbital exenteration which includes removal of the eyelids, the eyeball, and all surrounding tissues and remains a very traumatizing surgical procedure.

#### **7. Conclusion**

Because of the distinct anatomy of the eyelid, pigmentary lesions of this area require a specific, multidisciplinary approach including a dermatologist, ophthalmologist, oculoplastic surgeon, and oncologist.

### **Acknowledgements**

All photographs presented in this chapter, unless stated otherwise, have been captured in Ocular Oncology Service, Department of Ophthalmology, Poznan University of Medical Sciences.

### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Wojciech Adamski1 and Kinga Adamska<sup>2</sup> \*

1 Department of Ophthalmology, Poznan University of Medical Sciences, Poznan, Poland

2 Psoriasis and Dermatology Modern Therapy Department, Poznan University of Medical Sciences, Poznan, Poland

\*Address all correspondence to: kingabyczkowska@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Pigmented Lesions of the Eyelid Margin DOI: http://dx.doi.org/10.5772/intechopen.101376*

#### **References**

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