What is the differential diagnosis and treatment approach for bumps on the lower eyelid?

Differential Diagnosis for Bumps on Lower Eyelid

The most common bumps on the lower eyelid are chalazion and hordeolum, but you must systematically rule out malignancy—particularly sebaceous carcinoma and basal cell carcinoma—in any chronic, unresponsive, or atypical lesion. 1, 2

Primary Differential Diagnosis

Benign Inflammatory Lesions

• Chalazion: Non-inflammatory retention cyst from blocked meibomian or Zeis glands, presenting as a firm, non-tender nodule within the tarsal plate 3, 4
• Hordeolum (stye): Acute bacterial infection of eyelid glands, presenting as tender, erythematous swelling with possible purulent discharge 3, 2
• Cysts: Including cysts of Moll, Zeis, and epidermoid cysts, typically presenting as smooth, mobile, translucent lesions 2

Malignant Lesions (Critical to Exclude)

• Sebaceous carcinoma: May masquerade as recurrent chalazion with hard, non-mobile tarsal mass, yellowish discoloration, and chronic unilateral blepharoconjunctivitis unresponsive to treatment 1
• Basal cell carcinoma: Most common eyelid malignancy, often misdiagnosed clinically as benign lesions including papilloma, cyst, or nevus 5
• Squamous cell carcinoma/Ocular surface squamous neoplasia: Presents with papillomatous or sessile nodules, may appear leukoplakic, associated with HPV and UV exposure 1
• Melanoma: Painless, flat or nodular, brown or fleshy-pink lesion that enlarges over time 1
• Conjunctival lymphoma: Painless, pink "salmon patch" lesion with indolent fleshy swelling, most mobile and non-lobulated 1

Infectious Etiologies

• Molluscum contagiosum: Shiny, dome-shaped umbilicated lesions on eyelid skin or margin, causing follicular conjunctivitis 1
• Herpes simplex virus: Vesicular eyelid lesions with possible dendritic keratitis 1, 6
• Varicella zoster virus: Dermatomal vesicular rash with pseudodendritic keratitis 1, 6

Clinical Examination Priorities

Red Flags Requiring Biopsy

• Gradual enlargement over weeks to months 2
• Central ulceration or induration 2
• Irregular borders 2
• Eyelid margin destruction or loss of lashes (ciliary madarosis) 1, 2
• Telangiectasia 2
• Chronic unilateral presentation unresponsive to standard therapy 1
• Recurrent "chalazion" in the same location 1
• Conjunctival cicatricial changes in affected eye 1

Key Physical Examination Findings

• Eyelid margin assessment: Look for vascularization, hyperemia, abnormal deposits, ulceration, vesicles, scaling, or scarring 1
• Meibomian gland evaluation: Assess orifice abnormalities (capping, pouting, obliteration), secretion character, and expressibility 1
• Tarsal conjunctiva: Evert eyelids to examine for papillary reaction, follicles, or gland abnormalities 1
• Lesion characteristics: Document size, mobility, consistency (firm vs. soft), tenderness, color, and surface features 2

Treatment Algorithm

For Presumed Benign Lesions (Chalazion/Hordeolum)

• Initial conservative management: Warm compresses, lid hygiene, and observation for 4-6 weeks 3, 4
• Persistent lesions: Consider intralesional triamcinolone acetonide injection or incision and curettage 4
• Critical caveat: If lesion persists beyond 6-8 weeks or recurs in same location, biopsy is mandatory to exclude malignancy 1, 3

For Suspected Malignancy

• Immediate biopsy with consultation to pathologist regarding need for frozen sections and mapping for pagetoid spread (sebaceous carcinoma) 1
• Fresh tissue may be required for special stains (oil red-O for lipid detection in sebaceous carcinoma) 1
• Complete ocular surface examination for conjunctival cicatricial changes suggesting ocular mucous membrane pemphigoid 1

For Infectious Lesions

• Molluscum contagiosum: Excision or curettage of umbilicated lesions resolves associated conjunctivitis 1
• HSV/VZV: Systemic antivirals (acyclovir or valacyclovir) for active infection 6

Critical Pitfalls to Avoid

Clinical diagnosis alone is insufficient—even experienced clinicians miss malignancy in approximately 2% of clinically benign-appearing lesions, with basal cell carcinoma being the most commonly missed diagnosis 5. All excised eyelid lesions require histopathologic confirmation 5.

Strong clinical suspicion of malignancy overrides initial benign histopathology—if your clinical impression suggests malignancy but initial biopsy returns benign, repeat biopsy is essential 5.

Marked asymmetry or unifocal recurrence demands biopsy—these features significantly increase malignancy risk and should never be observed indefinitely 1.

Multiple "chalazion" excisions in the same patient should raise suspicion for sebaceous carcinoma, which often presents with this history 1.