Eyelid & Periocular Melanoma

Melanoma

Cutaneous melanoma of the eyelid is rare, accounting for ~1% of eyelid malignancies, but carries the highest mortality of all periocular skin cancers. It arises from melanocytes in the epidermis and may occur de novo or within a pre-existing nevus. The most common subtype on the eyelid is lentigo maligna melanoma (arising in a slowly enlarging, irregularly pigmented macule in sun-damaged skin of older patients), followed by superficial spreading and nodular melanoma.

Diagnosis: The “ABCDE” criteria apply: Asymmetry, Border irregularity, Color variation (multiple shades of brown, black, red, or white), Diameter >6 mm, and Evolution (change over time). Amelanotic melanoma lacks pigment and can mimic BCC or SCC — a high index of suspicion is required. Dermoscopy aids clinical assessment. Incisional or excisional biopsy with pathologic staging (Breslow depth, Clark level, mitotic rate, ulceration) is required before definitive surgery.

Treatment: Wide local excision with 5–10 mm margins (depending on Breslow depth) and sentinel lymph node biopsy for lesions >0.8 mm or with high-risk features. Lentigo maligna at the lid margin presents a reconstructive challenge because adequate margins may require full-thickness eyelid excision. Adjuvant systemic therapy (BRAF/MEK inhibitors for BRAF-mutant melanoma, anti-PD-1 immunotherapy) is used for high-risk or metastatic disease.