eMedicine Specialties > Ophthalmology > Lid

Xanthelasma

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Updated: Dec 3, 2008

Introduction

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.

Xanthelasma 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.

The term xanthelasma is derived from the Greek xanthos (yellow) and elasma (beaten metal plate).

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 are 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.

Clinical

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 and soft, and they 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.

Differential Diagnoses

Workup

Laboratory 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 hyperlipidemic and normolipidemic xanthelasmas is cholesterol. Most of this cholesterol is esterified.

Treatment

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.¹
- 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 0.01 mL of 100% dichloroacetic acid with excellent results and minimal scarring.²
Electrodesiccation and cryotherapy can destroy xanthelasmas when they are superficial but may require repeated treatments. Cryotherapy may cause scarring and hypopigmentation.

Follow-up

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

For excellent patient education resources, see eMedicine's Cholesterol Center. Also, visit eMedicine's patient education articles High Cholesterol, Understanding Your Cholesterol Level, Lifestyle Cholesterol Management, and Understanding Cholesterol-Lowering Medications.

Miscellaneous

Medicolegal 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.

Multimedia

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.

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.

Media file 3: Xanthelasma. External view, 1 week after surgery. Sliding and rotational flaps from residual lateral dermatochalasis used for medial excisional gap.

Media file 4: Xanthelasma. Top image, 4 weeks after surgery; lower image, before surgery.

References

Doi H, Ogawa Y. A new operative method for treatment of xanthelasma or xanthoma palpebrarum: microsurgical inverted peeling. Plast Reconstr Surg. Sep 1998;102(4):1171-4. [Medline].
Haygood LJ, Bennett JD, Brodell RT. Treatment of xanthelasma palpebrarum with bichloracetic acid. Dermatol Surg. Sep 1998;24(9):1027-31. [Medline].
Basar E, Oguz H, Ozdemir H, et al. Treatment of xanthelasma palpebrarum with argon laser photocoagulation. Argon laser and xanthelasma palpebrarum. Int Ophthalmol. Jan 2004;25(1):9-11. [Medline].
Bergman R. Xanthelasma palpebrarum and risk of atherosclerosis. Int J Dermatol. May 1998;37(5):343-5. [Medline].
Egan CA, Patel BC, Morschbacher R, et al. Atypical lymphoid hyperplasia of the eyelids manifesting as xanthelasma-like lesions. J Am Acad Dermatol. Nov 1997;37(5 Pt 2):839-42. [Medline].
Gladstone, Geoffrey, Myint, Shoib. Xanthelasma. In: Roy FH and Fraunfelder FT, eds. Current Ocular Therapy. Vol. 5. 2000:452-3.
Howard GR. Xanthelasma. In: Roy FH, ed. Masters Technique in Ophthalmic Surgery. 1995:520-2.
Ozdol S, Sahin S, Tokgozoglu L. Xanthelasma palpebrarum and its relation to atherosclerotic risk factors and lipoprotein (a). Int J Dermatol. Aug 2008;47(8):785-9. [Medline].
Usatine RP. A cutaneous manifestation of a systemic disease. West J Med. Feb 2000;172(2):84. [Medline].
Ustunsoy E, Demir Z, Coskunfirat K, et al. Extensive bilateral eyelid ptosis caused by xanthoma palpebrarum. Ann Plast Surg. Feb 1997;38(2):177-8. [Medline].

Keywords

xanthelasma, xanthelasma palpebrarum, xanthoma, cutaneous xanthoma, xanthomatosis

Contributor Information and Disclosures

Author

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

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
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

James P Gills, MD, Founder, St Luke's Cataract and Laser Institute; Professor, Department of Ophthalmology, University of South Florida College of Medicine
James P Gills, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Tracey A Schmucker, MD, to the development and writing of this article.

Further Reading