PERIORBITAL/EYELID

By Gary M. White, MD

Bags Under the Eyes

There are many causes of "bags under the eyes" or a darker coloration of the skin. Eczema is common, causing a darkening of the skin due to post-inflammatory hyperpigmentation. Sometimes the color is a result of thinner skin and more prominent underlying vasculature as shown here.
Prominent vasculature causing bags under the eyes.; width=

Atopic Dermatitis
atopic dermatitis

Congenital

Dacryocystocele. Bluish cystic lesion, seen in the first week of life, just inferior to the medial canthus.

Comedones

Favre-Racouchot Syndrome
Favre-Racouchot Syndrome

Cysts

Basal Cell Carcinoma (may look cystic).

Apocrine Hidrocystomas
Apocrine Hidrocystomas

Eccrine Hidrocystomas

Edema-Bilateral

Some cases of chronic periorbital swelling may represent primary lymphedema which may have its onset late in life (lymphedema tarda). Secondary lymphedema from other causes should be considered, e.g., rosacea, allergic contact dermatitis, XRT for brain cancer (pictured below), anaphylactic reactions, active temporal arteritis, various localized inflammatory processes (e.g. cellulitis, abscess, trauma, orbital pseudotumor), superior vena cava syndrome and hypoalbuminemia. Lymphatic dysfunction causing periorbital edema has been reported to occur in Noonan's syndrome. Angiosarcoma has been reported to occur in chronic eyelid swelling.

picture here

Lupus Erythematosus

Dermatomyositis
Dermatomyositis

Rosacea, so called Morbihan Disease

Trichinosis

Ascher Syndrome

Lymphoma: Rarely, chronic facial edema may be due to an underlying lymphoma J Clin Oncol. 2012 Sep 1;30(25):e233-6

Edema-Unilateral

Angioedema

Chagas Disease

Cutaneous Lupus Erythematosus Periorbital mucinosis. Periorbital swelling may occur secondary to dermal mucin deposition in lupus erythematosus For a picture, see JAAD April 2010 Volume 62, Issue 4, Pages 667–671

Periorbital Cellulitis

Itchy

See Eczema in "Red, Scaly" below.

Nodule(s)

Hordeolum

Sebaceous Carcinoma

Orange

Orange Palpebral Spots [Acta Derm Venereol 2011; 91: 211–212].

Papule(s)

Basal Cell Carcinoma
Basal Cell Carcinoma

Lupus Miliaris Disseminatus Faciei
Lupus Miliaris Disseminatus Faciei

Milia

Primary Systemic Amyloidosis

Syringomas
Syringomas

Molluscum of the eyelid. For a picture, see JAAD May 2014 Volume 70, Issue 5, Pages 795.e1–795.e25

Pigmented

See here for a general discussion of periorbital pigmentation and Familial Periorbital Melanosis
picture here

Nevus Of Ota
Nevus Of Ota

Benign nevus of eyelid margin (biopsied).
Benign Nevus of the Eyelid Margin

Purpura

Raccoon eyes. Raccoon eyes may be bilateral or unilateral. If bilateral, it is highly suggestive of basilar skull fracture, with a positive predictive value of 85%. Most often associated with fractures of the anterior cranial fossa. Raccoon eyes may also be a sign of disseminated neuroblastoma (for a picture, see Indian J Dermatol Venereol Leprol 2012;78:740-1) or of amyloidosis. Raccoon eyes always require urgent consultation and management.

Primary Systemic Amyloidosis

Red

Breast Carcinoma [JAAD 1997;37;362].

Lichen Planus. Red, violaceous papules and slightly scaly annular plaques on the eyelids is characteristic of this unusual localization of lichen planus. Typical lesions may occur elsewhere. Referral to an ophthalmologist to exclude ocular lichen planus (e.g., blepharitis, conjunctivitis) has been recommended.

Red, Scaly

The skin around the eyes is very sensitive. It may become inflamed from dry air, exfoliants and other face creams, or from airborne allergens e.g., pollens. See eyelid dermatitis.

A child with atopic dermatitis.
Atopic Dermatitis Under the Eye

Allergic Contact Dermatitis, here to nail polish. Courtesy Michael O. Murphy, MD
Allergic Contact Dermatitis to Nail Polish

Blepharitis

White

Vitiligo
Vitiligo

Vogt-Koyanagi-Harada Syndrome

Wrinkling

Blepharochalasis

Atopic Dermatitis (Dennie-Morgan folds).
Atopic Dermatitis

Periorbital Rhytides (Wrinkling)

Yellow

Normolipemic Plane Xanthomas

Xanthelasma
Xanthelasma

Yellow Skin Under the Eyes
Yellow Under Eyes

Yellow Nodules about the Eyes showing Xanthogranuloma on Biopsy

Adult orbital xanthogranulomatous diseases are collectively considered within the broader group of non-Langerhans histiocytic disorders. Clinical, laboratory and histologic features help make the diagnosis.

Disease Characteristics
Adult-onset Orbital Xanthogranuloma Absence of features below
Necrobitoic Xanthogranuloma Paraproteinemia and multiple myeloma
Erdheim-Chester disease Frequent impairment of visual acuity and fibrotic involvement of internal organs
Adult-onset asthma with periocular xanthogranuloma Adult-onset asthma and elevated levels of polyclonal IgG

Necrobiotic Xanthogranuloma Courtesy Theodore Sebastian, MD
Necrobiotic Xanthogranuloma

Adult-onset Orbital Xanthogranuloma
Multiple Periorbital Fibrous Histiocytomas

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