Journal of Dermatology 2017; 44: e93–e94

LETTER TO THE EDITOR

External chalazion as reddish and intractable lower eyelid
nodules in a child

Dear Editor,
A 3-year-old boy was referred to our hospital with a 3-month
history of lesions on his left lower eyelid. He did not have a
localized trauma at the lesion site. Before he was referred to
our hospital, the patient visited several ophthalmologists, but
the diagnosis was uncertain. Examination of the lesion
revealed two red, elastic, soft nodules with well-defined bor-
ders and decreased mobility of the eyelid; on his left eyelid
margin, one was 16 mm 9 9 mm and the other below was
13 mm 9 9 mm (Fig. 1a). The lesions were neither painful nor
itchy.
An excisional biopsy was taken from the nodule including
the orbicularis oculi under general anesthesia. Histopathologi-
cal examination revealed lymphohistiocytic granuloma with
many form cells and foreign body giant cells in the deep der-
mis, the subcutaneous fat and the orbicularis oculi, and some
of the giant cells had small clear spaces in their cytoplasm
(Fig. 1b–d). Caseous necrosis was absent. The bacterial, fungal
and mycobacterial cultures were also negative.
Considering the clinical and histological findings, we con-
firmed a diagnosis of chalazion.
Chalazion is a foreign body reaction characterized by
chronic lipogranulomatous inflammation of the meibomian
gland caused by an obstruction of the meibomian gland excre-
tory duct, and clinically presents as a single intradermal or
subcutaneous nodule within the eyelid.1 As the nodule grows,
if the inflammation spreads into the conjunctiva, a polypoid
granulomatous tumor develops on the conjunctiva. On the
other hand, if the inflammation perforates anteriorly from the
tarsal plate and spreads toward the eyelid surface, a reddish
intradermal nodule develops on the eyelid skin.2 This latter pat-
tern is rare, and consistent with our case.
Sometimes, ophthalmologists may fail to diagnose a cha-
lazion showing an unusual clinical presentation. In fact,

(a) (c)

(b)

(d)

Figure 1. (a) Reddish and elastic soft nodules on the patient’s left eyelid margin. The upper nodule was 16 mm 9 9 mm and the
lower nodule was 13 mm 9 9 mm. (b–d) Histopathological examination revealed lymphohistiocytic granuloma with many form cells
and foreign body giant cells in the deep dermis, the subcutaneous fat and the orbicularis oculi, and some of the giant cells had
small clear spaces in their cytoplasm. There is no caseous necrosis (hematoxylin–eosin).

Correspondence: Daisuke Sawamura, M.D., Department of Dermatology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki,
Aomori 036-8562, Japan. Email: m981027@hirosaki-u.ac.jp

© 2016 Japanese Dermatological Association e93

Letter to the Editor
although our patient consulted several ophthalmologists, none
were aware of this uncommon type of chalazion.
Initially, we ruled out ophthalmological diseases because he
had already visited several ophthalmologists. Because the
diagnosis was not immediately apparent, we considered the
possibilities of pilomatrixoma, tuberculosis or non-tuberculous
mycobacterial infection, bacterial or fungal infective granuloma,
and idiopathic facial aseptic granuloma (IFAG). Then, we per-
formed an excisional biopsy and had to select a general anes-
thesia because of the patient’s young age and periorbital lesion.
When encountering a case of eyelid nodules, distinguishing
a chalazion from IFAG is often difficult. IFAG is an unexplained
dermatological disease that commonly presents specifically in
childhood as one or a few nodules on the cheeks or eyelids,
and the histopathological findings of IFAG resemble that of
chalazion.3–5 Histopathological findings of IFAG are neu-
trophilic, lymphohistiocytic granulomas with foreign body reac-
tion in the dermis only. In contrast, the histopathological
inflammation of a chalazion is not restricted to the dermis but
spreads widely in the subcutaneous tissue5 and that was con-
sistent with our case.
In conclusion, when intractable nodular eruption on the
lower eyelids is observed, both dermatological and ophthalmic
e94
diseases must be considered. Even invasive testing methods
including skin biopsy will be required to diagnose the related
diseases such as chalazion and IFAG.
CONFLICT OF INTEREST: None declared.
Ayumi KOREKAWA, Koji NAKAJIMA, Eiko
MAKITA, Hajime NAKANO, Daisuke SAWAMURA
Department of Dermatology, Hirosaki University Graduate School of
Medicine, Hirosaki, Japan
doi: 10.1111/1346-8138.13650
REFERENCES
1 Williams HC, Aclimandos WA, Salisbury J. Bilateral external chalazia
presenting as granulomas of the lower eyelids. Clin Exp Dermatol
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2 Shuichiro E. Hordeolum and chalazion. Ganka 2013; 55 (5): 549–554.
(Japanese)
3 Prey S, Ezzedine K, Mazereeuw-Hautier J et al. IFAG and childhood
rosacea: a possible link? Pediatr Dermatol 2013; 30 (4): 429–432.
4 Ozer PA, Gurkan A. Eyelid nodule in a child: a chalazion or idiopathic
facial aseptic granuloma? Eye (Lond) 2014; 28 (9): 1146–1147.
5 Boralevi F, Leaute
-Labre
ze C, Lepreux S et al. Idiopathic facial asep-
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matol 2007; 156 (4): 705–708.
© 2016 Japanese Dermatological Association
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