Derm Dx: Skin-colored papules on the lower eyelids - Clinical Advisor

Derm Dx: Skin-colored papules on the lower eyelids

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  • Syringoma 1_1113 Derm Dx

  • Syringoma 2_1113 Derm Dx

A 55-year-old Asian male presents requesting evaluation of skin-colored papules on his bilateral lower eyelids.

A syringoma is a small benign adnexal neoplasm of the eccrine or apocrine sweat gland ducts, typically seen on the lower eyelids and upper cheeks. It is a common tumor with no malignant potential but may be removed for cosmetic...

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A syringoma is a small benign adnexal neoplasm of the eccrine or apocrine sweat gland ducts, typically seen on the lower eyelids and upper cheeks. It is a common tumor with no malignant potential but may be removed for cosmetic reasons.

Clinically, syringomas manifest as small (1-2mm), firm, flesh-colored or yellow-white, round and flat-topped papules. There are usually multiple and can appear anywhere on the body, most frequently over the lower eyelids and upper cheeks. Less commonly, they involve the forehead, axillae, umbilicus, upper chest, and vulva.

An eruptive variant presents with lesions in large numbers and in successive crops on the anterior trunk and extremities, sometimes including the palms and soles. Its onset is usually earlier, during childhood or puberty.

Syringomas are common. Women seek treatment more often then men; however, there is no clear predilection for gender. Lesions can appear at any age, but tend to initially appear during the third and fourth decades of life. Typically, few lesions will appear, followed by the gradual appearance of more over time. There is an increased incidence in Asian populations.

Associations have been made with the disorder and a number of syndromes, including Down, Marfan, Ehler-Danlos and Nicolas-Balus. A clear cell variant is associated with diabetes mellitus. Hereditary syringomas are currently debated.

Definitive diagnosis is made histopathologically. Syringomas are small, circumscribed and confined within the superficial to mid-dermis. Lesions display multiple small duct-like structures encompassed by a sclerotic stroma. Epithelial cells form relatively uniform, small solid nests, cords, and tubules with central ductal differentiation. Aggregates of cords and nests may form the prototypical ‘comma’ or ‘tadpole’ configuration. The clear cell variant has a predominance of pale epithelial cells. Syringomas typically lack keratinization and follicular differentiation and the presence of these should prompt a search for an alternative diagnosis.

Xanthelasma are soft, polygonal yellow-orange papules and plaques often located on the upper and lower eyelids and around the inner canthus. Typically, they appear after 50 years of age as small spots and slowly enlarge over the ensuing months to years. They are often an isolated finding but may be related to hypercholesterolemia.

Fibrous papules are a type of angiofibroma, which typically present as a solitary, firm, flesh-colored papule on or around the nose in middle age.

Fibrofolliculomas are benign follicular hamartomas, present as multiple, small, flesh-colored papules on the face, neck, scalp and upper trunk. Onset is often in the third to fourth decade of life.

Birt-Hogg-Dubé syndrome is an autosomal dominant condition characterized by fibrofolliculomas, fibrous papules, spontaneous pneumothorax and renal tumors.

Syringomas are benign and have negligible malignant potential. As such, there is no indication for treatment unless evidence of adnexal carcinoma exists.

Cosmetic removal may be achieved with acetic acid, cryotherapy, electrodessication and curettage, or excision with curved scissors or a #11 scalpel blade. Laser ablation may be most appropriate for widely disseminated lesions. 

Andrew S Fischer, BA, and Christopher B. Rizk, BA, are medical students at Baylor College of Medicine.  

Adam Rees, MD, is a graduate of the University of California Los Angeles School of Medicine and a resident in the Department of Dermatology at Baylor College of Medicine also in Houston.

References

  1. Bolognia J, Jorizzo JL, Rapini RP. “Chapter 111: Adnexal Neoplasms.” Dermatology. St. Louis, Mo.: Mosby/Elsevier, 2012. pp 1840-1841.
  2. Habif TP. “Chapter 20: Benign Skin Tumors.” Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Philadelphia: Mosby/Elsevier, 2010. p 800. 
  3. Klaus W, Johnson RA, Suurmond D et al. “Section 9: Benign Neoplasms and Hyperplasias.” Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. New York: McGraw-Hill, 2013. p 181.
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