What is xanthelasma

Xanthelasma also called xanthelasma palpebrarum, are yellow plaques that occur most commonly near the inner canthus of the eyelid and are often associated with atherosclerosis, dyslipidemia (high cholesterol or other fat levels in the blood), and coronary artery disease ¹, ². Xanthelasma, derived from ancient Greece where “xanthos” means yellow and “elesma” means plate ³. Palpebrarum is a Latin word that means “near or related to the eyelid.” Xanthelasma is a skin lesion caused by the accumulation of fat (mainly cholesterol) in macrophage immune cells in the skin and more rarely in the layer of fat under the skin. Xanthelasma is mostly semisolid yellowish deposits that are commonly found on the inner aspect of the eyes. It is often seen along the corners of the upper and lower eyelids. Xanthelasma palpebrarum is characterized by soft, yellowish papules and plaques that occur more commonly near the inner canthus of the eyelid more often at the upper eyelid. Lesions are usually symmetrical. There might be one or multiples ⁴.

Xanthelasmas are the most widely recognized type of xanthoma. They are yellowish deposits composed of a cholesterol-filled substance that appear mostly over the medial aspects of the eyelids. Several medical conditions associated with the appearance of xanthelasma including hyperlipidemia, diabetes and thyroid dysfunctions. It might appear in patients with normal lipid profile namely, cholesterol and triglyceride levels.

Xanthelasma palpebrarum is an uncommon skin lesion in the general population with a crude incidence of 1.2%. It is more common in women than in men ⁵. The age of onset ranges from 20 to 70 years, but it is most commonly seen between the age of 35 and 55 years ⁶, ⁷. Once xanthelasma has developed, it will not spontaneously disappear but will remain the same or increase in size. These deposits usually will not go away on their own and typically will grow larger with the time ⁸.

Xanthelasma palpebrum

• Most common type of xanthoma
• Lesions arise symmetrically on upper and lower eyelids
• Lesions are soft, velvety, yellow, flat papules or plaques
• Lesions start off as small bump and gradually grow larger over several months
• May or may not be associated with hyperlipidemia

Xanthelasma palpebrarum is a benign condition that never leads to serious consequences, but it is cosmetically bothersome, and most of the patients are unhappy about their image, and they seek medical advice. The patients visit dermatology offices, Reconstructive surgery clinics, and ophthalmology clinics looking for permanent solutions.

To confirm your diagnosis of xanthelasma, the doctor may want to perform a skin biopsy. The procedure involves:

1. Numbing the skin with an injectable anesthetic.
2. Sampling a small piece of skin by using a flexible razor blade, a scalpel, or a tiny cookie cutter (called a “punch biopsy”). If a punch biopsy is taken, a stitch (suture) or two may be placed and will need to be removed 6–14 days later.
3. Having the skin sample examined under the microscope by a specially trained physician (dermatopathologist).

Once the diagnosis of xanthelasma is confirmed, your doctor will likely check cholesterol levels in your blood (a lipid panel). If you have a lipid abnormality, exercise and dietary modifications will likely be recommended. Many people also require an oral medication to lower their lipids. Treatment of underlying lipid abnormalities does not cure every xanthelasma.

If the xanthelasma is cosmetically unappealing and if it does not respond to lipid-lowering therapies, treatments include ⁹, ¹⁰, ¹¹, ¹²:

• Freezing with liquid nitrogen (cryotherapy)
• Surgical excision
• Laser treatment
• Application of a specially formulated acetic acid solution to dissolve the xanthelasma
• Electric needle treatment (electrodesiccation)

All of these treatment options may cause scarring, and they do not keep the xanthelasma from coming back or prevent new lesions from developing ¹³, ⁹, ¹⁰, ¹¹, ¹².

Figure 1. Xanthelasma

[Source ¹⁴ ]

Xanthelasma causes

Xanthelasmas are the most widely recognized type of xanthoma. They are yellowish deposits composed of a cholesterol-filled substance that appear mostly over the medial aspects of the eyelids. Several medical conditions are associated with the appearance of xanthelasma, including hyperlipidemia, diabetes, and thyroid dysfunctions. Xanthelasma might appear in patients with normal lipid profile, namely, cholesterol and triglyceride levels.

About 50% of patients who develop xanthelasma have lipid disorder. Xanthelasma is commonly seen in patients with ¹³:

• Type 2 hyperlipidemia that includes type 2a, also known as familial hypercholesterolemia, and type 2b, which is commonly referred to as familial combined hyperlipidemia
• Type 4 hyperlipidemia, which is also known as familial hypertriglyceridemia
• Diabetes mellitus and insulin resistance
• Hypothyroidism
• Those with low levels of HDL (high density lipoprotein or “good” cholesterol)
• Fatty diet
• Excess alcohol intake
• Weight gain
• Obesity
• Cholestatic liver disease, such as primary biliary cirrhosis
• Nephrotic syndrome
• Medications, such as:
  • Estrogens
  • Tamoxifen
  • Oral retinoids
  • Prednisone or prednisolone
  • Ciclosporin.

Xanthelasma palpebrarum are observed also in patients who had previous erythroderma, generalized cutaneous inflammatory dermatosis, and in cases who had previous contact dermatitis. Xanthelasma palpebrarum may be a predictor of ischemic heart disease, myocardial infarction, or systemic atherosclerosis ¹⁵.

Xanthelasma signs and symptoms

The most common locations for xanthelasma include:

• One or both upper eyelids, especially near the nose
• One or both lower eyelids

Typically, xanthelasma palpebrarum patient presents with soft, yellow-to-orange patch or bump over the medial canthus of the upper lid. Sometimes it might be solid, semi-solid, or firm. These papules cannot be squeezed. Xanthelasma range in size from 2–30 mm, xanthelasma is flat-surfaced and has distinct borders (well-defined). Once present, xanthelasma does not usually go away on its own. In fact, lesions frequently grow larger and more numerous with the time ¹³, ¹⁶, ¹⁷.

Xanthelasma is usually not itchy or tender. Individuals with xanthelasma are usually most concerned with their cosmetic appearance.

Xanthelasma diagnosis

Since a high number of individuals with xanthelasma have a lipid disorder, measurement of serum lipid profile is recommended. Also, liver panel, thyroid function test, fasting blood glucose can be done, or if the patient is diabetic, the glycosylated hemoglobin level measures the blood sugar control over the last 3 months. In most of the cases, cholesterol and triglyceride levels are elevated, and the high-density lipoprotein (HDL) level is reduced. To measure the lipid profile accurately, the patients should fast for at least 12 hours.

To confirm your diagnosis of xanthelasma, the doctor may want to perform a skin biopsy. The procedure involves:

1. Numbing the skin with an injectable anesthetic.
2. Sampling a small piece of skin by using a flexible razor blade, a scalpel, or a tiny cookie cutter (called a “punch biopsy”). If a punch biopsy is taken, a stitch (suture) or two may be placed and will need to be removed 6–14 days later.
3. Having the skin sample examined under the microscope by a specially trained physician (dermatopathologist).

Once the diagnosis of xanthelasma is confirmed, the physician will likely check cholesterol levels in your blood (a lipid panel). If you have a lipid abnormality, exercise and dietary modifications will likely be recommended. Many people also require an oral medication to lower their lipids. Treatment of underlying lipid abnormalities does not cure every xanthelasma.

Xanthelasma treatment

The treatment of xanthelasma involves changes in lifestyle and taking medications to lower serum lipids. Even though a low-fat diet and statins are often recommended, they have a limited effect on xanthelasmas once they have developed. If the lesions are a cosmetic concern, they can be excised by simple surgical procedure, cauterized, or removed with liquid nitrogen sessions. Surgery around the eyelids is fraught with complications and can result in ectropion, eyelid retraction, and injury to the eye itself. Use of cryotherapy and chemical cauterization can lead to severe scarring and skin discoloration ⁴.

Unfortunately, xanthelasma can’t be cured through diet alone but you should still make sure you:

• Eat a healthy, balanced diet, prepare most meals from vegetables, salads, cereals and fish
• Minimize saturated fats (found in meat, butter, other dairy produce, coconut oil, palm oil)
• Minimize intake of simple, refined sugars found in fizzy drinks, sweets, biscuits and cakes
• Maintain a healthy weight. If obese or overweight, aim to slowly reduce weight by reducing caloric intake and increasing exercise.
• Do plenty of exercise.

Other methods include chemical peels utilizing trichloroacetic acid (TCA) in a high percentage of 50% or above to reach to the optimum depth for the cholesterol deposits in the reticular dermis; similar substances like salicylic acid might be used as well. Deep peels may be complicated by hyperpigmentation, especially in dark-skin individuals, so the treating physician should pay attention to this point very well.

Lasers can be used to treat selected cases of xanthelasma palpebrarum using carbon dioxide, erbium, pulsed dye, argon, and Nd:YAG lasers. Most of the patients might accept laser treatments since they are not associated with tissue destructions or loss, and its better alternative for surgery. Complications of laser therapy include pain, erythema, pigmentations, scars, and eyes injuries. Fractionated Er:YAG and/ or fractionated CO2 lasers are the most commonly used machines to treat xanthelasmas.

Radiofrequency machines can be used to treat some cases of xanthelasma because it is a very safe method compared to other modalities but it is less effective, and it might be expensive.

Even after removal, recurrence of xanthelasma is common especially due to genetics and high cholesterol levels. Lipid-lowering medications can be used in patients with high cholesterol and triglyceride levels to prevent ischemic attacks and further deposits.

Xanthelasma prognosis

Unfortunately, the recurrence rate of xanthelasma is high despite the treatment mode. Furthermore, it is important to treat the underlying medical conditions like hyperlipidemia, liver diseases, diabetes, and thyroid disorders.

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