Flesh-Colored Growths Under the Eyes
Flesh-colored growths under the eyes most commonly represent benign lesions such as xanthelasma, syringomas, milia, or sebaceous hyperplasia, but you must urgently exclude malignant conditions—particularly sebaceous carcinoma and amelanotic melanoma—which can present as flesh-colored masses and carry significant mortality risk if missed.
Differential Diagnosis by Clinical Features
Benign Lesions (Most Common)
Xanthelasma presents as yellowish-white plaques on the eyelids, typically near the inner canthus, and represents lipid deposits in the dermis 1.
Milia appear as small (1-2mm), white-to-flesh-colored, dome-shaped cysts containing keratin, commonly seen on the periocular skin 1.
Syringomas manifest as small, flesh-colored papules around the eyes, representing benign eccrine sweat gland tumors 1.
Epidermoid cysts present as mobile, flesh-colored nodules that can occur on the eyelid or periocular area 1.
Malignant Lesions (Critical to Exclude)
Sebaceous carcinoma is the most dangerous masquerader—it may appear as a hard nodular, nonmobile mass with yellowish discoloration, or as a subconjunctival multilobulated yellow-to-flesh-colored mass that resembles a chalazion 2. This occurs predominantly in the fifth to ninth decades of life with fairly rapid progression 2. Warning signs include unilateral presentation, history of multiple chalazion excisions, chronic unresponsive inflammation, and focal lash loss (ciliary madarosis) 2.
Amelanotic (flesh-colored) melanoma presents as a painless, flat or nodular, fleshy-pink lesion on the bulbar or palpebral conjunctiva or caruncle 2. Enlargement of the lesion, development of blood vessels, or thickening are urgent warning signs 3, 4.
Ocular surface squamous neoplasia can present with papillomatous or sessile nodules that may appear flesh-colored or gelatinous, often at the limbus with a sentinel vessel 2.
Diagnostic Approach
Immediate Clinical Assessment
Perform slit-lamp biomicroscopy to evaluate location, depth, elevation, vascularization, and associated findings of any periocular growth 3.
Assess for high-risk features:
- Unilateral presentation (suggests malignancy) 2
- Progressive enlargement or thickening 3, 4
- Development of intrinsic blood vessels 3, 4
- Recurrence in the same location after previous excision 3
- Loss of normal eyelid margin anatomy 2
- Focal lash loss (ciliary madarosis) 2
- Chronic inflammation unresponsive to standard therapy 2
When to Biopsy
Obtain biopsy immediately for:
- Any atypical features or marked asymmetry 2, 3
- Recurrent lesions in the same location 3
- Elderly patients with history of multiple chalazion excisions 2
- Unifocal recurrent chalazia not responding to therapy 2
- Any growth showing progressive enlargement 3, 4
Critical pitfall: Before obtaining biopsy for suspected sebaceous carcinoma, consult with a pathologist regarding the need for frozen sections and conjunctival mapping to search for pagetoid spread, as fresh tissue may be needed to detect lipids using special dyes such as oil red-O 2.
Management Algorithm
For Lesions with Benign Features
- Small, stable, bilateral, symmetric lesions without concerning features can be observed 1
- Surgical excision is the primary treatment for symptomatic or cosmetically concerning benign lesions 1
- Laser therapies are available for select benign lesions 1
For Lesions with ANY Concerning Features
Proceed directly to excisional biopsy with clear margins 3. Do not observe or treat empirically as inflammation.
For suspected sebaceous carcinoma: Complete excision with margin assessment is mandatory, as this tumor carries risk for orbital invasion and regional/distant metastases 2.
For suspected melanoma: Complete excision is required, as melanoma tends to spread to other adnexal structures and metastasize 2.
Critical Clinical Pitfalls
The most dangerous error is misdiagnosing sebaceous carcinoma as chronic blepharoconjunctivitis or recurrent chalazion 2. Sebaceous carcinoma is often chronic and mistreated as unresponsive inflammation for extended periods before correct diagnosis 2.
Unilateral chronic inflammation unresponsive to therapy should always raise suspicion for carcinoma 2. The possibility of carcinoma must be considered in patients with chronic blepharitis unresponsive to therapy, especially when only one eye is involved 2.
Flesh-colored melanoma (amelanotic) is easily missed because clinicians expect melanoma to be pigmented 2. Always consider amelanotic melanoma in the differential for any flesh-colored periocular growth 2.