Recognising Suspicious Lesions in the Periorbital Region

By Miss Jennifer Doyle and Mr Richard Scawn / 05 Mar 2020

Ophthalmologists Miss Jennifer Doyle and Mr Richard Scawn explore which lesions should be treated with caution in the periorbital area

With the removal of benign skin lesions no longer being widely funded by the NHS,the public are turning elsewhere to seek the removal of skin lesions for cosmetic purposes. Whilst this can be done surgically,2 cryotherapy may offer a cost effective accessible therapy.3 Cryotherapy was traditionally used by dermatologists and general practitioners with specific training in diagnosing skin lesions.3 However, cryotherapy devices are now widely available to aesthetic practitioners who may have limited experience in the area.

Importance of appropriate recognition

The periorbital region is a common location for skin cancer, with non-melanoma skin malignancies of the periorbital region making up 5-10% of all skin cancers.4,5 Early detection of cancerous lesions is particularly important in the periorbital region, with invasion of the orbit in 2-4% of cases leading to extensive morbidity and even proving fatal.4,6 It is important for practitioners to be able to recognise lesions that may be cancerous, so that they are not erroneously removed. With half of all malignancies involving the skin, and an estimated 5-10% of these involving the eyelid,4,5 periocular skin cancer is common and may present by way of aesthetic clinics.

Cryotherapy devices are becoming increasingly popular in aesthetic clinics and are being marketed as a good way of expanding one’s aesthetic practice.7,8 If used correctly they can be a safe and cost-effective method of removing unsightly benign skin conditions including acrochordons viral infections, actinic keratosis, solar lentigines and seborrheic keratoses.9,10,11 Being a relatively quick and simple procedure to perform, cryosurgery has many advantages, with minimal post-operative wound care and a low risk of complications such as infection and scarring.11 The more difficult aspect of utilising cryosurgery safely comes in identifying which lesions are appropriate to be removed in this manner. For any lesion where there is doubt in the diagnosis, cryotherapy is not suitable because histological examination and assurance of complete excision are not possible.3 Cryotherapy therefore does not offer an actual diagnosis compared to a surgical excision biopsy. Practitioners in an aesthetic clinic should therefore only remove lesions that they are 100% sure are benign. Experience levels with dermatological lesions will vary between aesthetic practitioners depending on their background, and we would recommend that if practitioners are in any doubt as to the nature of a lesion, they do not attempt removal with cryosurgery. 

It’s important to note that even in experienced hands, clinical diagnosis is not 100% accurate,12,13,14 and histological analysis of a biopsy specimen is the only way of determining the exact nature of the lesion. The Royal College of Ophthalmologists has issued guidelines stating that all small lid biopsy tissue should be sent for histopathological examination, with the exception of chalazions with no atypical features, and excess skin removal after blepharoplasty or other cosmetic procedures unless there is any clinical abnormality.15 Skin lesions on the face are particularly troublesome to patients given their prominent position and difficulty to cover up the lesion. The periocular region is an aesthetically important unit and is frequently treated for cosmetic concerns.16 It’s therefore vital that practitioners understand the risks of treatment, how to diagnose and when to refer.

Risk factors for malignant lesions

Malignant skin lesions encountered in the periocular region include basal cell carcinomas, squamous cell carcinomas and melanoma. UV radiation is a key risk factor in the development of malignant skin lesions, and it can be difficult to apply sunscreen to the periocular region, leaving it exposed.17 It is important to identify any risk factors that may increase your suspicion of a lesion being malignant. These include:17

  • Age
  • Previous skin cancer
  • Evidence of sun damage
  • History of excess sun exposure
  • Lighter Fitzpatrick skin type
  • Immunosuppression

Non-pigmented malignant skin lesions

For non-pigmented skin lesions, worrying features include changes in appearance, growth, bleeding and ulceration.23,24 It is important to check for any of these features before attempting removal with cryosurgery, as this can lead to delayed diagnoses, increased morbidity and even mortality. 

Figure 1: Example of basal cell carcinoma. Many would think the BCC is the nodular lesion, however it is actually the subtle ulcerated area medial to this.

Basal cell carcinomas

Basal cell carcinomas (BCC) are the most common form of skin cancer in Europe, Australia and the US.17 They make up 90% of all eyelid malignancies.18 Around the eye they are most commonly found on the lower lid, followed by the medial canthus, eyebrow, upper lid and lastly the lateral canthus.17 They can vary widely in their presenting features and can be categorised into nodular, cystic, superficial, morphoeic, keratotic and pigmented variants.17 Due to this variation in presentation, a biopsy to confirm a histological diagnosis is recommended for all suspicious lesions.17 

Squamous cell carcinomas

Figure 2: Example of squamous cell carcinoma

Squamous cell carcinomas (SCC) are the second most common form of periocular skin cancers, making up for approximately 5% of eyelid malignancies.19 Like BCCs they can vary in presentation from nodules, ulcerations or plaques.20 They are particularly important to recognise in the periocular region as they can cause significant morbidity and even mortality due to local invasion or distant spread.21,22


NICE guidelines state that all patients with a suspicious pigmented skin lesion, with a skin lesion that may be a high-risk BCC, SCC or MM, or where the diagnosis is uncertain, should be referred to a doctor trained in the specialist diagnosis of skin malignancy.27

Figure 3: Example of a patient with multiple pigmented lesions in the periocular region. A detailed assessment as per the NICE 7-point checklist will be necessary to elucidate whether onward referral is warranted.


If practitioners have any doubt about the diagnosis of the lesion, they should refer it for an expert opinion. Do not attempt removal with cryosurgery in these cases as, if it is a malignant lesion, it could lead to a delay in diagnosis. This is particularly important in the periocular region as we want to minimise tissue loss in order to achieve the best outcome.17 Be aware of the risk factors for developing malignant skin lesions and check for them in patients seeking removal of lesions with cryotherapy, as it may heighten suspicions as to the nature of the lesion.

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