The Eyelid

By Emily Tierney, MD, and C. William Hanke, MD, MPH

The eyelid region is one of the most common sites for nonmelanoma skin cancers. In fact, skin
cancers of the eyelid, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC),
and melanoma, account for five to 10 percent of all skin cancers. Ninety five percent of these
tumors are basal cell carcinomas or squamous cell carcinomas.
1,2

The rapid rate of skin cancer increase is of great concern to dermatologists and patients alike.
Nonmelanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma, have
the highest incidence rates of any cancers in the US.
3
Also of concern is the rising incidence of
melanoma, which is currently the sixth most common cancer for men, the seventh most common
for women, and one of only three cancers with an increasing mortality rate in men.
According to the National Cancer Institute, in 2008 there were 62,480 new cases of melanoma
and 8,420 deaths.
4
It is estimated that 1 in 55 Americans will develop a melanoma in their
lifetime and 1 in 5 will develop skin cancer.
3

Nonmelanoma skin cancers have low rates overall for spread to lymph nodes and distant sites
(metastasis),
1,2
but with eyelid skin cancers there is a significant risk for tissue damage to nearby
vital ocular structures
1,2,5
and even blindness; the skin around the eyelid is thin and contains little
subcutaneous tissue,
1,2,5
and anatomic connections to the underlying bone in the region facilitate
rapid local tumor spread into the nasal and orbital cavities (the area behind the eye).
1,2,5
Tumors
must be removed to prevent continued growth and invasion into adjacent structures. Early
detection is essential, but is often difficult to achieve due to the growth pattern of these tumors,
which tend to infiltrate inwards along the deeper layers of the skin and orbital margin; eyelid
tumors often grow under the skin for years before presenting on the surface.
1,2,5

Basal cell carcinomas and squamous cell carcinomas adjacent to the eye are usually treated with
microscopically controlled surgery (Mohs micrographic surgery), due to the tissue-sparing nature
of the procedure and high cure rates.
1,2

Table 1. Anatomic Distribution of
100 Eyelid Skin Cancers in Indiana

Number % Total
BCC 83 83.0%
SCC 17 17.0%
Total 100

Patients with Eyelid Tumors
GENDER Number % Total
To assess the areas around the eye that are
most susceptible to skin cancer - the upper
and lower eyelids, eyebrow, inner and outer
junction of the eyelid (canthi) and lid
margins - we prospectively evaluated 100
patients with skin cancers in the eye region.
The specific type of skin cancer, the precise
location, and the gender of the patient were
recorded.
The majority of eyelid tumors (n=83, 83
percent) were basal cell carcinomas. The
study population consisted of 100 patients,
77 of whom had basal cell carcinoma (77
percent) and 23 of whom had squamous cell carcinoma (23 percent). Sixty two patients (62
percent) were
male; 38 (38
percent) were
female(Table
1).




Figure 1 exhibits the normal anatomy of the eyelid region and Figure 2 illustrates the most
common locations for skin cancer on the eyelids: lower eyelid (n=44, 44 percent); medial (inner)
canthus (n=19, 19 percent); eyebrow (n=17, 17 percent); upper eyelid (n=16, 16 percent); and
lateral (outer) canthus (n=4, four percent)(Table 1). There were no significant gender differences
in the allocation of either type of skin cancer or location.
The results are similar to previously published studies on eyelid cancer distribution. For
example, in a report in theBritish Journal of Ophthalmology, the most common sites of eyelid
skin cancers were the lower lid (37.6 percent), medial canthus (38.4 percent), eyebrow (9.4
percent), and lateral canthus (7.1 percent).
5

Recurrence rates for eyelid skin cancer range from 5-30 percent when managed by standard
modalities, including standard surgical excision and radiation therapy.
1,2,5
These recurrence rates
are some of the highest recorded for skin cancer.
1,2,5
Since the risks for local spread are high and
reconstruction of the eyelids is complicated by the complex three-dimensional anatomic
Women 38 38.0%
Men 62 62.0%
Distribution of Eyelid Tumors
ANATOMIC SITE Number % Total
Lower eyelid 44 44.0%
Medial canthus 19 19.0%
Eyebrow 17 17.0%
Upper eyelid 16 16.0%
Lateral canthus 4 4.0%
Total 100

relationships that need to be restored after tumor removal, awareness of the early signs of eyelid
skin cancer is essential.
The presenting signs of eyelid skin cancers are highly variable.
2
Given their infiltrative growth
pattern, they often present with a scar-like appearance or texture.
2
This differs from the typical
presentation of nonmelanoma skin cancer as a "rodent ulcer" (a non-healing, bleeding sore).
2
In a
study at Johns Hopkins School of Medicine, Baltimore, the most common presenting symptoms
for skin cancer on the eyelids included a mass, or tumor (42 patients); ulceration, or sore (33
patients); altered appearance (10 patients); a red spot (five patients), and trichiasis, or ingrown
eyelashes (two patients).
2

As it allows for the total microscopic control of excised tissue, Mohs micrographic surgery is the
most effective treatment for these skin cancers.
6
Mohs surgery is performed by removing thin
layers of affected tissue, freezing them, and microscopically examining the edges and
undersurface of each layer using the frozen sections.
6,7
The reliability of this method for eyelid
skin cancers is attested to by five year cure rates of 99 percent in 1,773 cases of basal cell
carcinoma and 98.1 percent in 213 cases of squamous cell carcinoma.
8
Also, in Mohs surgery,
the minimum amount of tissue necessary is removed. This allows one to achieve the best
cosmetic result and maximally preserve function.
6-8

Ultraviolet B (UVB) radiation, at 290-320 nanometers (nm, or billionths of a meter on the
electromagnetic spectrum) appears to be the most directly carcinogenic of the various UV
wavelengths.
9
However, recent attention has been given to the role of UVA (320 nm-400 nm) in
tumor development and photoaging. Given that 95 percent of the UV radiation that reaches the
earth is UVA, photoprotection with a sunscreen protecting against both the UVA and
UVB wavelengths is critical.
10
For optimal protection, a physical blocker containing zinc oxide
or titanium dioxide, and/or chemical blockers such as avobenzone, oxybenzone or
Mexoryl
TM
should be used.
11
Application of sunscreen to the upper and lower eyelids is
complicated by potential irritation when sunscreen is inadvertently rubbed into the eye. Thus,
people often skip sunscreen application to the eyelids, and UV damage continues to occur.
Many studies have shown a photoprotective effect from both prescription eyeglasses
and sunglasses.
12
The protective effects of eyeglasses depend on many factors, including the
composition and size of the lenses, and the position in which the glasses are worn.
11
Sunglasses
may be composed of (a) crown glass (good optical glass with a crown-like shape), which absorbs
most UVA and UVB; (b) plastic polymethyl methacrylate, which absorbs little or no UV light, or
(c) plastic polycarbonate, which absorbs light in the UVB and part of the UVA spectrum (under
380nm).
11
The American National Standards Institute (ANSI)'s criteria for sunglasses and
fashion eye wear require less than one percent transmission of wavelengths under 310nm.
However, these recommendations are not uniformly followed by all manufacturers.
11

Rosenthal and colleagues
13
studied the effectiveness of 32 pairs of inexpensive sunglasses in
filtering UVR. They found that all sunglasses studied transmitted less than two percent of
UVB.
12
Sunglasses were more effective in blocking UV than prescription eyeglasses,
12
but
moving the glasses a small distance from the forehead (further out on the nose) resulted in a
significant increase in the amount of UV reaching the eye.
12
Analysis of epidemiologic data in
this study demonstrated also that sunglasses provide a photoprotective effect against both
cataracts and periorbital (the area surrounding the eye) basal cell carcinoma.
12

The eyelid region is one of the most common sites for nonmelanoma skin cancers, but with early
diagnosis and treatment using Mohs micrographic surgery, the prognosis is good, with some
recurrence rates below five percent (compared to up to 30 percent with standard surgical
excision). Epidemiologic data suggest that wearing sunglasses that block 99-100 percent UV
radiation is an important way to prevent cataracts and skin cancers in areas around the eye, and
that a broad spectrum, SPF 15+ sunscreen should be applied to the eyelid region as well as to all
exposed areas of the body.

Dr. Tierney is currently a Mohs micrographic surgery and procedural dermatology fellow
under the direction of Dr. C. William Hanke at St. Vincent Hospital, Carmel, Indiana, at the
Laser and Skin Surgery Center of Indiana.
Dr. Hanke is director of the Laser & Skin Surgery Center of Indiana in Carmel, IN. Dr. Hanke
is a senior vice president of The Skin Cancer Foundation.

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