A lump on the eyelid that is not a stye: skin tags, seborrhoeic keratosis and papilloma

Most lumps on the eyelid are not infections. A stye is a painful, infected oil gland at the lash line and a chalazion is a blocked one, but a large share of what people find on the lid is a harmless growth of the surface skin: a skin tag, a papilloma or a seborrhoeic keratosis. The difficulty is that a few dangerous lumps look just like them. This article explains the common benign growths and how a surgeon decides when a lump needs a biopsy, which means a small piece of tissue, or the whole lump, sent to a laboratory.

What is a lump on my eyelid if it is not a stye?

It is often a benign growth of the skin itself. The American Academy of Ophthalmology describes a stye as very painful and usually at the lid edge, and a chalazion as not usually painful and farther back on the lid. A lump that fits neither, with no tenderness and no redness, is a different question. The stye and chalazion story is in my guide to the eyelid lump that is a chalazion, and I do not repeat it here.

Skin growths are common. A study from a large eye centre in South China reviewed 5,146 eyelid lesions that had been removed and examined under the microscope between 2000 and 2018. Of these, 4,378 (85.1%) were benign and 768 (14.9%) were malignant. That figure needs care: every lesion in it was one a surgeon had chosen to remove, so it does not tell you how likely your own lump is to be cancer. It does show that most of what comes off an eyelid is benign, and that the benign group is wide, with nearly 40 types.

Neighbouring territory is covered elsewhere: tiny pearls, clusters of small bumps and cysts, and flat yellow plaques called xanthelasma. This page covers what those do not name: the rough, warty or dangling growths of older skin.

What is a seborrhoeic keratosis, and why does it look stuck on?

A seborrhoeic keratosis is a harmless, warty growth of the top layer of skin that looks as if it was stuck on with glue. EyeWiki, the American Academy of Ophthalmology's clinical wiki, describes lesions that are beige, brown or black, usually 3 to 20 mm across, with a velvet or wart-like surface. DermNet, a dermatology reference, says they are common and harmless, and that over 90% of adults over the age of 60 have one or more.

On the eyelid, EyeWiki says the typical lesion is a coin-shaped brown patch, and because lid skin is thin it may look more wrinkled than the same growth on the forehead. Pathology reports often use another name, basal cell papilloma, which DermNet lists as a synonym. In the South China series, basal cell papilloma was the third most common benign diagnosis, 418 lesions or 9.55% of the benign group, at an average age of 62.

It is harmless, but not always quiet. EyeWiki says these growths are slow growing, do not usually go away by themselves, and can thicken with time. A thick one on the lid can irritate the surface of the eye or weigh the lid down enough to mimic ptosis, the medical name for a droopy lid. Age, sun exposure and family tendency are associated with them.

One point deserves a plain sentence. A sudden crop of many new seborrhoeic keratoses is called the sign of Leser-Trelat, and EyeWiki and DermNet both say that, very rarely, it can accompany an internal cancer. A single brown lump on a lid is not that. Dozens appearing within weeks, anywhere on the body, is a reason to see a doctor soon.

What are skin tags and papillomas on the eyelid?

A skin tag is a small, soft, harmless piece of skin that hangs off the surface. DermNet describes skin tags as skin-coloured or darker, from 1 mm to 5 cm, with no known cause. They are more numerous in people with obesity and type 2 diabetes, and friction is one contributor.

Papilloma is the pathologist's general word for a benign growth of surface skin, and squamous papilloma is the common eyelid form. In the South China series it was the second most common benign diagnosis after the mole: 539 lesions, or 12.3%, at an average age of 53. In a 20-year series from South India, papilloma was the second most common benign neoplastic lesion, again behind the mole. A wart is a relative: DermNet describes it as a benign lesion caused by human papillomavirus, with a filiform type made of fine fronds on a narrow base, usually found on the face.

These names overlap in everyday use, which is why the laboratory report, not the mirror, usually settles which one a growth is. In the South India series, the clinical diagnosis agreed with the microscope in 730 of 809 benign lesions (90.2%). That is good, and it also means about one in ten was called something else.

What about a hard horn, or a small yellow bump?

These two need care for opposite reasons. A cutaneous horn is a hard, cone-shaped projection of compact keratin, the protein of nails and hair. DermNet says that around half of horns sit on a benign base, such as a seborrhoeic keratosis or a wart, and half on a premalignant or malignant one, such as actinic keratosis or squamous cell carcinoma. The horn is the part you see. The base is what matters, and DermNet states that examining the base under the microscope is crucial to rule out malignancy. They are uncommon: 2 of 994 lesions in the South India series.

Sebaceous hyperplasia is the reassuring case. It is a collection of enlarged oil glands, which DermNet describes as small yellow bumps up to 3 mm across, each with a central hair follicle, in middle-aged and older people, on the forehead or cheeks. It is harmless and needs no treatment. DermNet also notes it is sometimes confused with basal cell carcinoma, the commonest skin cancer of the lid, so a small yellowish bump on the lid is one where a surgeon wants certainty rather than a guess.

When does an eyelid lump need a biopsy?

A lump needs a biopsy when any feature suggests it might not be benign, or when the diagnosis is uncertain. EyeWiki lists the features that should prompt one: ulceration, irregular or pearly borders, visible small blood vessels called telangiectasias, growth, inflammation, or destruction of nearby tissue. It also advises a biopsy in any case of diagnostic uncertainty, and when a lesion keeps coming back after treatment.

The reason is that appearance alone is not reliable enough. EyeWiki says a seborrhoeic keratosis can closely resemble a precancerous patch, can become inflamed and look like basal cell or squamous cell carcinoma, and that a basal cell carcinoma arising within one has been reported. In the South India series, the clinical diagnosis was accurate for only 67.6% of the malignant lesions, against 90.2% for the benign ones. The authors of the South China series write that some malignant lesions masquerade as benign ones.

The American Academy of Ophthalmology adds that a stye or chalazion that keeps coming back may lead an ophthalmologist to take a tiny tissue sample. A lump that is changing, bleeding, crusting without healing, or turning a different colour is worth an examination whatever it is called. The features that separate a suspicious mark from normal ageing are in my article on eyelid skin cancer warning signs, and what follows a confirmed cancer is in the page on basal cell carcinoma and its surgery.

How are these growths removed, and why does the method matter near the lash line?

Many need no removal at all. EyeWiki says seborrhoeic keratosis does not typically need treatment, and that most people seek it for cosmetic change or irritation. Removal is a decision, not a reflex, and a lump with any warning feature is not one to remove casually.

The methods are well known. For seborrhoeic keratosis, EyeWiki lists freezing with liquid nitrogen, shaving the growth off at skin level, electrical cautery with scraping, and laser. For skin tags, DermNet lists freezing, snipping with scissors, electrosurgery and tying off the stalk. On the eyelid, EyeWiki says surgical excision is the treatment of choice for most ophthalmologists.

Two cautions from EyeWiki shape that preference. Freezing does not allow the tissue to be examined, so it should be used only on lesions with low suspicion of cancer. And freezing near the eye can cause notching of the lid, contour irregularity or an outward-turning lower lid, called cicatricial ectropion. Whoever removes a lump near the lash line should be able to say what the method will do to the lid, whether the tissue will go to a laboratory, and what happens if the result is unexpected.

If you are unsure which kind of lump you have, start with an examination, ideally by an eye doctor who deals with eyelids. The wider map is in the eyelid conditions section and in my hub article on why eyes look tired. How a small cyst or bead is taken off is in the page on small eyelid bumps.