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Xanthelasma
Article Last Updated: May 17, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Tracey A Schmucker, MD, Staff Physician, Department of Ophthalmology, University of Arkansas for Medical Sciences
Coauthor(s):
Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Editors: Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; James P Gills, MD, Founder, St Luke's Cataract and Laser Institute; Professor, Department of Ophthalmology, University of South Florida College of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
xanthelasma palpebrarum, cutaneous xanthoma, xanthomatosis
Background
Xanthelasma are yellow plaques that occur most commonly near the inner canthus of the eyelid, more often on the upper lid than the lower lid. Xanthelasma palpebrarum is the most common cutaneous xanthoma. The term is derived from the Greek xanthos (yellow) and elasma (beaten metal plate). They can be soft, semisolid, or calcareous. Frequently, they are symmetrical; often 4 lids are involved. Xanthelasma have a tendency to progress, coalesce, and become permanent.
Pathophysiology
One half of these lesions are associated with elevated plasma lipid levels. Some occur with altered lipoprotein composition or structure such as lowered high-density lipoprotein (HDL) levels. They frequently occur in patients with type II hyperlipidemia and in the type IV phenotype.
Frequency
United States
Xanthelasma is rare.
International
Xanthelasma are rare in the general population.
Mortality/Morbidity
These lesions have no premalignant potential; however, see Differentials.
Sex
In case studies of patients with xanthomatosis, a predominance of xanthelasma in women has been seen; women, 32% and men, 17.4%.
Age
The age of onset ranges from 15-73 years, with a peak in the fourth and fifth decades.
History
- Xanthelasma are the most common type of xanthoma. They often present in the absence of xanthomas elsewhere on the body, although histologically they are the same.
- Once plaques are established, they will remain static or increase in size.
- Patients generally complain about aesthetic concerns.
Physical
- Xanthelasma or xanthoma palpebrarum usually are located on the medial side of the upper eyelids.
- Lesions are yellowish, soft, and form plaques.
- Generally, these lesions do not affect the function of the eyelids, but ptosis has been known to occur.
Causes
- Approximately one half of individuals with xanthelasma have a lipid disorder.
- Eruptive xanthomas can be seen in primary and secondary causes of hyperlipidemia.
- Examples of primary genetic causes include familial dyslipoproteinemia, familial hypertriglyceridemia, and familial lipoprotein lipase deficiency.
- Diabetes that is out of control is a common cause of secondary hyperlipidemia. However, most xanthelasma occur in normolipemic persons who may have low HDL cholesterol levels or other lipoprotein abnormalities.
Other Problems to be Considered
Familial hypercholesterolemia types IIa and IIb
Familial dysbetalipoproteinemia type III
Familial hypertriglyceridemia type IVOther lipid disorders, to include the following:Low HDL cholesterol levels as compared to low-density lipoprotein (LDL) levels
Diabetes, uncontrolled with associated hypertriglyceridemia
Necrobiotic xanthogranuloma
Tuberous xanthomata
Diffuse planar xanthoma
Orbital lipogranulomata
Juvenile xanthogranulomata
Erdheim-Chester disease
Wegener granulomatosis
Lipoid proteinosis
Primary systemic amyloidosis
Necrobiosis lipoidica
Sarcoid
Atypical lymphoid infiltrate
Lab Studies
- Since 50% of patients with xanthelasma have lipid disorders, it is recommended that their plasma lipid levels are obtained, as well as LDL cholesterol and HDL cholesterol levels.
- Xanthelasma usually is an obvious clinical diagnosis but rarely other lesions can simulate the appearance and may be associated with disorders of a more serious nature. If there is any doubt, surgical excision and pathologic analysis should be performed.
Histologic Findings
Xanthelasma are composed of xanthoma cells. These are foamy histiocytes laden with intracellular fat deposits primarily within the upper reticular dermis. The main lipid that is stored in both the hyperlipidemic and normolipidemic xanthelasmas is cholesterol. Most of this cholesterol is esterified.
Medical Care
Dietary restriction and pharmacologic reduction of serum lipids, although important in the overall care of a patient with abnormal lipids, show only limited response in the treatment of xanthelasma.
Surgical Care
Numerous options are available for the removal of xanthelasma palpebrarum including surgical excision, argon and carbon dioxide laser ablation, chemical cauterization, electrodesiccation, and cryotherapy.
- Surgical excision
- For small linear lesions, excision is recommended, as scarring should blend in with the surrounding eyelid tissue. Smaller bulging lesions can be "uncapped" and removed; then, the flap can be replaced and sutured.
- Doi recommends using a surgical microscope, undermining between the tumor and the orbicularis oculi with an 11 blade, raising the flap and carefully removing the tumor piece by piece with microscissors from the reverse side, and then suturing the flap with 7-0 nylon.
- In full-thickness excisions, the lower lid is more prone to prominent scarring as the tissue tends to be thicker. Simple excision of larger lesions risks eyelid retraction, ectropion, or the need for more complicated reconstructive procedures. Xanthelasma removal has been incorporated into cosmetic surgery; however, extending the incisional limits of a routine blepharoplasty increases the risk for ectropion formation.
- Carbon dioxide and argon laser ablation: Enhanced hemostasis, better visualization, lack of suturing, and speed have been cited as reasons to use this technique; however, scarring and pigmentary changes can occur.
- Chemical cauterization: The use of chlorinated acetic acids has been found to be effective in the removal of xanthelasma. These agents precipitate and coagulate proteins and dissolve lipids. Monochloroacetic acid, dichloroacetic acid, and trichloroacetic acid have been used with good results. Haygood used less than .01 mL of 100% dichloroacetic acid with excellent results and minimal scarring.
- Electrodesiccation and cryotherapy can destroy xanthelasmas when they are superficial but may require repeated treatments. Cryotherapy may cause scarring and hypopigmentation.
Further Outpatient Care
- Patients should receive follow-up care for medical and surgical treatment.
Prognosis
- Recurrence is common. Patients need to be aware that studies completed after surgical excision showed recurrence in up to 40% of patients. This percentage is higher with secondary excisions. Of these failures, 26% occurred within the first year and were more likely to occur in patients with hyperlipidemia syndromes and in those with all 4 eyelids affected.
Patient Education
Medical/Legal Pitfalls
- Since 50% of patients with xanthelasma have abnormal lipid levels, physicians need to be aware of the importance of identifying and treating this disorder to prevent arteriosclerosis.
| Media file 1:
Case presentation of excision of recurrent xanthelasma: recurrent xanthelasma bilateral upper lids; previous excision combined with blepharoplasty; patient insistent on repeat excision and blepharoplasty; advised of lagophthalmos risk due to medial position and lack of medial dermatochalasis. |
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| Media file 2:
Close-up view of recurrent xanthelasma right upper lid. Note the scar from previous excision by a plastic surgeon. Careful examination reveals subtle infiltration in the lateral
aspect of scar. |
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| Media file 3:
Xanthelasma. External view, 1 week after surgery. Sliding and rotational flaps from residual lateral dermatochalasis used for medial excisional gap. |
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| Media file 4:
Xanthelasma. Top image, 4 weeks after surgery; lower image, before surgery. |
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Xanthelasma excerpt Article Last Updated: May 17, 2006
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