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Eyelid pilomatrixoma masquerading as chalazion

Published:October 27, 2016DOI:https://doi.org/10.1016/j.jcjo.2016.08.020
      Pilomatrixoma is a benign skin neoplasm arising from the matrix cells at the base of hair. It was originally described as calcified epithelioma of sebaceous glands, but later the term pilomatrixoma was suggested to denote its origin.
      • Forbis Jr, R.
      • Helwig E.B.
      Pilomatrixoma (calcifying epithelioma).
      There are limited reports in the literature on eyelid pilomatrixomas. Most of them involve eyebrows and are seen as subcutaneous, painless nodules. The unusual clinical presentation of this tumour as a chalazion in the current case makes it worth reporting.

      Case Report

      A 60-year-old male patient came to the hospital because of a slowly growing, painless nodular mass in left upper eyelid for 8 months. The mass was diagnosed as chalazion previously, and conservative treatment with warm compresses, massage, and topical medicine was advised. However, the mass did not regress with this treatment. It gradually increased in size and hardened. The patient had no other systemic complaints or known illness.
      On examination, the best-corrected visual acuity was 6/6 OU, and ocular examination was unremarkable. The mass was located on the central pretarsal area of left upper eyelid, involving the eyelid margin, and was causing mild mechanical ptosis (Fig. 1A). It was yellow in colour. The overlying skin appeared normal. There was no destruction of the adjacent eyelid margin structures (Fig. 1B).
      Fig. 1
      Fig. 1(a) Clinical photograph of the patient showing an eyelid mass located on the central pretarsal area of the left upper eyelid, involving the eyelid margin and causing mild mechanical ptosis. (b) Clinical photograph (close-up) of the everted left upper eyelid showing preserved eyelid margin structures.
      On palpation, the mass was nontender, hard in consistency, and could not be moved over the underlying structures. The overlying skin was taut and could not be moved over the mass. The palpaebral conjunctiva appeared normal on eyelid eversion. As the mass was very hard in consistency and was increasing in size, chalazion was an unlikely diagnosis. Therefore, surgical excision with eyelid reconstruction using a direct closure technique was planned.
      Histopathological examination (Fig. 2) revealed a well-circumscribed lesion beneath the stratified squamous epithelium composed of peripherally located basaloid cells with scant cytoplasm and frequent mitotic figures. Shadow cells with eosinophilic cytoplasm were seen toward the centre. At places, dystrophic calcification was identified with focal giant cell reaction. These findings were diagnostic of pilomatrixoma.
      Fig. 2
      Fig. 2(a) Photomicrograph showing a large circumscribed lesion beneath the stratified squamous epithelium with basophilic cells at periphery (arrow) and eosinophilic material present in the centre (hematoxylin & eosin, original magnification ×100). (b) Photomicrograph showing a high-power view of the proliferating basaloid cells (red arrow) and the transition (*) from basophilic cells to eosinophilic shadow cells (arrowhead) extending over 6–8 layers (hematoxylin and eosin, original magnification ×200).

      Discussion

      Pilomatrixoma has been reported as the most common adnexal tumour of skin among the young. A bimodal presentation is described for pilomatrixomas in general, with the first peak in the first decade and the second peak in the sixth decade. Eyelid pilomatrixoma has been reported to occur in younger children in 39%–73% of cases.
      • Orlando R.G.
      • Rogers G.L.
      • Bremer D.L.
      Pilomatricoma in a pediatric hospital.
      More than 75% of cases of eyelid pilomatrixoma were reported to occur before 13 years of age in a study.
      • Levy J.
      • Ilsar M.
      • Deckel Y.
      • Maly A.
      • Anteby I.
      • Pe’er J.
      Eyelid pilomatrixoma: a description of 16 cases and a review of the literature.
      In our patient, eyelid pilomatrixoma occurred at a much older age of 60 years.
      The most common site for these tumours is head and face. Periorbital lesions were reported in only 17% cases in a large series of pilomatrixoma.
      • Orlando R.G.
      • Rogers G.L.
      • Bremer D.L.
      Pilomatricoma in a pediatric hospital.
      In the periorbital region, pilomatrixoma usually involves the eyebrows, possibly because of high density of hair follicles. Palpaebral eyelid is less commonly involved, and eyelid margin is usually spared by the tumour. The clinical diagnosis of a pilomatrixoma is usually difficult and they have variably been diagnosed preoperatively
      • Levy J.
      • Ilsar M.
      • Deckel Y.
      • Maly A.
      • Anteby I.
      • Pe’er J.
      Eyelid pilomatrixoma: a description of 16 cases and a review of the literature.
      as eyelid cysts (mainly sebaceous and dermoid cysts) and rarely as eyelid tumours such as papilloma, keratoacanthoma, sebaceous cell carcinoma, and basal cell carcinoma. Histopathologic diagnosis is based on the presence of basophilic and shadow cells, which may be associated with foreign body giant cells, calcification, and ossification.
      We could find only 1 case report in the English literature, wherein an eyelid pilomatrixoma was clinically confused for a chalazion.
      • Katowitz W.R.
      • Shields C.L.
      • Shields J.A.
      • Eagle Jr, R.C.
      • Mulvey L.D.
      Pilomatrixoma of the eyelid simulating a chalazion.
      However, this pilomatrixoma presented in a child and involved the preseptal part of the eyelid and therefore was unlikely to be confused with a chalazion by an ophthalmologist.
      In the current case, the tumour was fixed to the underlying tarsus, involved the eyelid margin, and had a yellowish surface. These features favoured the clinical diagnosis of a chalazion. However, the age of the patient, the increasing size of the tumour, and a very firm to hard consistency made us decide against an incision and curettage. An excision was done in order to obtain a histopathological diagnosis.
      The colour of the skin overlying pilomatrixoma, unlike in the current case, is usually reported to be normal or have a reddish or bluish discoloration because of hemorrhage. Also, eyelid margin is rarely involved by the tumour. To the best of our knowledge, there is only 1 case report in the literature of a pilomatrixoma involving the eyelid margin.
      • Izquierdo-Rodríguez C.
      • Mencía-Gutiérrez E.
      • Gutiérrez-Díaz E.
      • Suárez-Gauthier A.
      An unusual presentation of a pilomatrixoma in the eyelid.
      The purpose of this report is to highlight the unusual presentation of pilomatrixoma in an elderly patient as chalazion. We emphasize that the possibility of pilomatrixoma should be considered in the differential diagnosis of a painless, firm to hard, nodular eyelid mass that is progressively increasing in size. In such cases an excision to completely remove the tumour should be done rather than an incision and curettage to confirm the clinical diagnosis and rule out benign tumours that may mimic a chalazion, like pilomatrixoma.

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