Xanthomas Treatment & Management

Xanthomas not always associated with underlying hyperlipidemia, but when they are, diagnosing and treating underlying lipid disorders is necessary to decrease the size of the xanthomas and to prevent the risks of atherosclerosis. Treatment of the hyperlipidemia initially consists of diet and lipid-lowering agents such as statins, fibrates, bile acid–binding resins, probucol, or nicotinic acid. The lipid-lowering effects of these agents have been well documented, but few studies mention the efficacy of these drugs for resolving xanthomas. Eruptive xanthomas usually resolve within weeks of initiating systemic treatment and tuberous xanthomas usually resolve after months, but tendinous xanthomas take years to resolve or may persist indefinitely.

The main goal of therapy for hyperlipidemia is to reduce the risks of atherosclerotic cardiovascular disease. In patients with severe hypertriglyceridemia, the goal is to prevent pancreatitis. The detailed therapy of hyperlipidemia is beyond the scope of this article.

• Inazu et al^[7] investigated whether pravastatin or probucol was better at regressing tendon xanthomas and xanthelasma in patients with primary hypercholesteremia. In both the pravastatin and probucol groups, xanthelasma regressed in 2 of 4 patients. Achilles tendon xanthoma regressed in 4 of 5 patients treated with pravastatin and 2 of 5 patients treated with probucol.
• Fujita and Shirai^[8] studied 54 patients treated with probucol or pravastatin. Xanthelasma regressed in 13 of 36 patients treated with probucol and in 1 of 18 patients treated with pravastatin. Total cholesterol levels decreased in both treatment groups, while HDL cholesterol levels decreased only in those treated with probucol.
• Yamamoto et al^[9] examined 51 patients with familial hypercholesterolemia. Patients were treated with combinations of probucol, cholestyramine, clofibrate, and compactin. The size of Achilles tendon xanthomas was decreased in all patients who received probucol.
• Kuo et al^[10] investigated 21 patients with atherosclerosis and cutaneous, tendinous, or corneal xanthomas who were followed for up to 7.5 years. Patients were placed on a low-fat, low-cholesterol diet and colestipol, a bile acid–binding resin. This regimen caused tendinous xanthomas to disappear in 2 of 11 patients and improve in 9 of 11 patients. Xanthelasma disappeared in 2 of 4 patients and improved in 2 of 4 patients.

Surgery or locally destructive modalities can be used for idiopathic or unresponsive xanthomas. Xanthelasmas are often treated with topical trichloroacetic acid, electrodesiccation, laser therapy, and excision; however, recurrences can occur. Care must be taken to protect the eyes during any procedure used to treat xanthelasma. Such procedures should be performed only by individuals who are thoroughly familiar with and skilled in the procedure.

• Mendelson and Masson^[11] studied surgical excision of xanthelasma performed in 100 patients. Of patients who were having their lesions treated for the first time, 26 (40%) of 68 recurred. Factors that predicted recurrence were systemic hyperlipidemia, involvement of all 4 eyelids, and a previous history of recurrent xanthelasma.
• Raulin et al^[12] studied 23 patients with 52 xanthelasmata treated with an ultrapulsed carbon dioxide laser, which delivers high energy in short pulses and reduces the risk of scarring and hyperpigmentation seen with continuous-mode carbon dioxide lasers. All xanthelasmata were completely removed. One patient experienced mild erythema for 4 months, but no permanent hyperpigmentation or ectropion developed. Three patients had recurrent lesions at an average follow-up time of 10 months.
• Borelli and Kaudewitz^[13] studied 15 patients with 33 xanthelasmas treated with an Er:YAG laser. All xanthelasmas were completely removed. Postoperative erythema resolved within 2 weeks. No scarring or ectropion developed. No lesions recurred over a 7- to 12-month follow-up period.
• Basar et al^[14] studied 24 patients with 40 xanthelasmas treated with an argon laser. Complete removal of all lesions occurred with 1-4 sessions at intervals of 2-3 weeks. Six lesions recurred over 8-12 months and required re-treatment. Erythema persisted for 1 month in 8 lesions. Hyperpigmentation occurred in 1 patient and persisted for 3 months, while hypopigmentation occurred in 2 lesions. No bleeding, infections, or ectropion occurred.
• Haygood et al^[15] studied 13 patients with 25 lesions. Ten patients had complete clearing with bichloracetic acid application. Five lesions recurred and required a second treatment to achieve complete resolution. No infections, scars, or complications were reported.