Combined treatment of a giant palpebral keratoacanthoma

Abstract

Aims/Purpose: To highlight the relevance of a therapeutic approach adapted to the clinical characteristics of the eyelid lesion found at the time of surgery to ensure an optimal functional and aesthetic result.Methods: Clinical case assessed, intervened and followed up at our centre.Results: A 76‐year‐old woman consulted for a nodular umbilicated lesion of recent appearance on the outer third of the upper eyelid of the left eye (UELE) measuring 0.5 cm in greatest diameter and 0.5 cm in elevation. The patient was placed on the waiting list for surgical excision and subsequent pathological examination (PE) of the lesion to confirm the initial clinical suspicion of keratoacanthoma (KA). One month later, the patient went to the operating room for surgery. During this time the lesion increased its initial size by more than 4 times, had a large necrotic centre, active borders and generated an evident left mechanical ptosis. As an alternative to the complete excisional surgery initially proposed, we offered the injection of neoadjuvant intralesional chemotherapy (CT) with the aim of reducing the size of the lesion to obtain a better functional and aesthetic result. The patient accepted this therapeutic alternative. KA was treated with weekly intralesional injections of 1 mL of methotrexate (MTX) 12.5 mg/mL. In our case, 3 injections were necessary to achieve a 78% reduction in the diameter of the lesion to allow reconstruction of the UELE with grafting of the contralateral upper eyelid. One week after the third injection of MTX, reconstruction of the UELE was performed after excisional surgery with wide margins for PE. One week later, the PE result ruled out malignancy and the graft had a pink appearance with complete vascular permeability, so the sutures were removed. Two weeks after reconstruction, the functional and aesthetic results were satisfactory.Conclusions: Therefore, in our experience, we recommend the above combined treatment for giant palpebral KA and stress the relevance of a therapeutic approach adapted to the clinical characteristics of the palpebral lesion at the time of surgery to ensure an optimal functional and aesthetic outcome.