What is the diagnosis and treatment for xanthelasma (yellowish patches on the skin, also known as xanthelasma palpebrarum)?

From the Guidelines

Xanthelasma patients should undergo cholesterol level checks as they may indicate underlying hyperlipidemia or other metabolic disorders, and their presence may signal increased cardiovascular risk, according to the most recent guidance from the international atherosclerosis society 1. Xanthelasma are yellowish, slightly raised cholesterol deposits that appear on the skin around the eyes, most commonly on the inner corners of the eyelids. These painless plaques result from lipid accumulation in macrophages and are often associated with elevated blood cholesterol levels, though they can occur in people with normal lipid profiles as well.

Key Considerations

• If you have xanthelasma, you should have your cholesterol levels checked, as they may indicate underlying hyperlipidemia or other metabolic disorders.
• Treatment options include surgical excision, laser therapy, chemical cauterization with trichloroacetic acid, or cryotherapy, though recurrence is common regardless of the method used.
• Cosmetic camouflage with makeup can effectively hide the lesions.
• While xanthelasma themselves are harmless, their presence may signal increased cardiovascular risk in some patients, making lipid management important.
• Lifestyle modifications including a low-fat diet, regular exercise, and smoking cessation may help prevent progression, while medications like statins can address underlying lipid abnormalities but typically won't resolve existing xanthelasma completely.

Screening and Detection

• Opportunistic detection of familial hypercholesterolaemia (FH) with LDL-cholesterol testing should be performed by dermatologists, rheumatologists, orthopaedic surgeons, ophthalmologists, optometrists, occupational physicians, and pharmacists, as suggested by the international atherosclerosis society guidance 1.
• Alerts and interpretive comments on laboratory reports of standard lipid profiles should be used to enable case detection, emphasizing the need to make a formal diagnosis and referral for further assessment of FH 1.

Associated Conditions

• Xanthelasma-like lesions can be seen in Erdheim-Chester disease, which can affect the skin in up to 30% of patients, with half of these patients having cutaneous involvement at diagnosis 1.
• Other conditions such as Langerhans cell histiocytosis and Rosai-Dorfman disease can also present with xanthomatous lesions, highlighting the importance of a thorough diagnosis and evaluation 1.

From the Research

Treatment Options for Xanthelasma

• Surgical excision, laser ablation, and chemical cauterization are available methods for managing xanthelasma, each with its own limitations and side effects 2
• Trichloroacetic acid (TCA) peeling and carbon dioxide laser ablation have shown significant clinical efficacy and tolerability in treating xanthelasma palpebrarum, with 70% TCA peeling being more effective than 35% and 50% TCA peeling 2
• Post-therapy erythema and hypopigmentation were more common with 70% TCA peeling, while post-therapy hyperpigmentation was more common with 50% TCA peeling 2

Relationship with Hyperlipidemia

• Xanthelasma palpebrarum is strongly associated with dyslipidemia, with 50% of patients having dyslipidemia, which is higher than the general population 3
• The recurrence rate of xanthelasma was 17.5%, with no statistical difference in recurrence rate between different treatment methods 3
• Patients with xanthelasma are recommended to check their lipid profile and receive diet control and lipid-lowering medications for lipid abnormalities 3

Clinical Characteristics and Lipid Profile

• Xanthelasma palpebrarum is more common in middle-aged females, with disease onset of less than 1 year, and without significant familial history of xanthoma 4
• The mean serum levels of cholesterol, triglyceride, and VLDL were significantly higher, and the median HDL level was lower in patients with xanthelasma palpebrarum compared to the control group 4
• Hypercholesterolemia and hypertriglyceridemia did not show a significant difference between the patient and control groups, suggesting that other factors may be involved in the pathogenesis of xanthelasma palpebrarum 4

Pathogenesis and Clinical Significance

• Only half of the patients with xanthelasma palpebrarum are hyperlipidemic, and the pathogenesis of xanthelasma palpebrarum is not fully understood 5
• The risk for atherosclerosis may be inferred from the associated lipoprotein and apolipoprotein abnormalities in hyperlipidemic patients with xanthelasma 5
• Determining the plasma lipoprotein and apolipoprotein levels in each normolipidemic patient with xanthelasma appears to be justified 5

Clinical Grading Model

• A scoring-based clinical grading model has been developed to predict treatment frequency and prognosis in patients with xanthelasma palpebrarum 6
• The model uses factors such as the number, area, and color of lesions, as well as hyperlipidemia, to predict the number of pingyangmycin injection treatments and prognosis 6
• The model has been validated to be effective in an external cohort and holds promise for broader application in clinical practice 6