XANTHELASMA

Placoid xanthelasma lesion. (Courtesy Drs. Julie Tyler and Alexandra Espejo)

Xanthelasma are seen clinically as oval or elongated yellowish plaques just beneath the skin of the periorbital region. Most commonly, they are noted near the inner canthus of the upper eyelid, although they may be seen on the lower lid as well; they are generally symmetrical in presentation. Inspection and palpation may reveal a soft, semisolid, or calcified texture.

Patients with xanthelasma are typically over 40 years of age, and women are affected nearly twice as often as men.¹ The condition may be seen in light-skinned and dark-skinned individuals. Patients with xanthelasma may present because of a cosmetic concern, or the condition may be detected on routine ocular examination. The lesions are neither inflammatory nor painful, and there is no tendency toward malignancy, although the lesions may enlarge and/or coalesce over time. In very rare instances, abnormally large xanthelasmas can interfere with lid function, causing ptosis or lagophthalmos.

Pathophysiology

Xanthelasma palpebrarum represents a common form of xanthoma, a cutaneous deposit of fatty materials. The term "xanthelasma" is extremely descriptive; it is derived from the Greek xanthos (meaning yellow) and elasma (meaning plate). Histological evaluation of these lesions reveals an accumulation of lipid-laden macrophages, termed histiocytes, within the dermis.

Although a link has been suggested between xanthelasma and hyperlipidemia, only about half of patients with these lesions demonstrate elevated serum lipid levels. However, younger individuals with xanthelasma have a proportionally greater likelihood of hyperlipidemia and hypercholesterolemia than do older individuals.^2,3

Management

In most cases, xanthelasma is diagnosed by the clinical appearance alone, though atypical presentations may prompt the clinician to obtain a biopsy. Laboratory testing of serum lipids is also recommended.

While xanthelasma is essentially benign, many patients consider the condition to be cosmetically unacceptable, and opt for removal. Treatment modalities are quite numerous, and include such diverse options as: (1) use of chemocautery agents, such as trichloracetic acid; (2) electrodessication; (3) cryotherapy; (4) CO₂ or argon laser ablation; or (5) surgical excision. Scar formation and pigmentary changes are the most common complications of laser or chemotherapy. Chemical cautery and surgical excision tend to produce better results with less risk of subsequent scarring.

Clinical Pearls

• While we know that xanthelasma may be an indication of abnormal lipid levels, it is equally important to realize that other metabolic disorders can lead to increased serum lipids, particularly diabetes and cirrhosis of the liver.⁴ There-fore, appropriate testing includes not only a serum lipid profile, but also a fasting plasma glucose and liver function tests (both of which are part of a comprehensive metabolic panel, or CMP, the single most common blood panel ordered by physicians).
• Patients should be aware that, despite effective local treatment for xanthelasma, recurrences can and often do occur.
• Although dietary modification and medications to reduce hyperlipidemia may be beneficial for other co-morbidities, there is no evidence that this form of therapy has any impact on the appearance or resolution of xanthelasma.⁵

Other reports in this section

• Floppy Eyelid Syndrome
• Herpes Simplex Blepharitis
• Dacryocystitis
• Dermatochalasis & Blepharochalasis
• Xanthelasma