Medical Care

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. In patients with severe hypertriglyceridemia, a major goal is to prevent pancreatitis.

Treatment of the hyperlipidemia includes 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. Tendinous xanthomas take years to resolve or may persist indefinitely.

Pravastatin, probucol, and colestipol may help in reducing the size of lesions in tendinous xanthomas and xanthelasmas in patients with hypercholesterolemia.^{[91, 92, 93, 94, 95]}Xanthelasma palpebrarum may respond to systemic interleukin 1 blockade and plane xanthomas to cyclosporine A therapy.^{[96, 97]}

Familial hypercholesterolemia may be treated with combinations of probucol, cholestyramine, clofibrate, and compactin.^[93]New hypolipidemic agents for familial hypercholesterolemia include PCSK-9 inhibitors, lomitapide, and mipomersen.^[98]

There are no treatment guidelines for xanthoma disseminatum and verruciform xanthomas, but surgical treatment, although challenging, may be appropriate for lesions that are disfiguring or impair function. Xanthoma disseminatum has been described to respond to azathioprine, prednisolone, cyclophosphamide, 2-chlorodeoxyadenosine, simvastatin, or to a combination of lipid-lowering agents.^{[99, 100, 101]}Partial resolution in verruciform xanthomas has been described with use of chloroxylenol surgical scrub.^[102]Laser ablation, electrodessication, and radiotherapy have also been tried with variable results. A persistent case despite medical management was reported in 2020.^[5]

Oral probucol is an alternative treatment to surgical excision for diffuse-plane xanthomatosis.^[103]

For cerebrotendinous xanthoma, first-line therapy includes chenodeoxycholic acid (synthetic). Management also includes cholic acid and oral bile replacement.^[13]

Surgical Care

The definitive management for all types of xanthomas is surgical.

Xanthelasmas may be treated with topical trichloroacetic acid 50-100%, topical bichloracetic acid, excision, skin flap with blepharoplasty, 1450-nm diode laser, ultrapulsed carbon dioxide laser, argon laser, 1064-nm Q-switched Nd:YAG laser, low-voltage radiofrequency, and fractional carbon dioxide laser.^{[104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115]}Factors that predict recurrence are systemic hyperlipidemia, involvement of all four eyelids, and previous history of recurrent xanthelasma.^[116]Er:YAG laser treatment may be recurrence-free for up to 12 months.^[117]

Nonablative 1450-nm diode laser treatment may achieve satisfactory results for patients with xanthoma disseminatum.^[118]Wide excision with skin grafting and carbon dioxide laser ablation may be performed for verruciform xanthomas.^{[54, 79]}

An interesting case of liver transplantation in a patient with familial hypercholesterolemia resulted in regression of cutaneous xanthomas and atherosclerotic plaques.^[119]This may be considered an option in similar patients.

Complications

Complications may arise from surgical, laser, chemical, and medical management.

Transient erythema, infections, scarring, and postinflammatory hyperpigmentation may occur with all surgical treatment alternatives. Delayed wound healing, erythema, and pain may be managed accordingly.

Myalgia and, rarely, rhabdomyolysis and necrotizing autoimmune myopathy, may occur with HMG-CoA reductase inhibitor therapy; hence there is a need for proper disclosure and monitoring.

Those with underlying systemic abnormalities may have the potential to develop acute pancreatitis and coronary artery disease; prompt recognition and treatment is essential.^[1]

Diet

Adjunct low-fat, low-cholesterol, and low-glycemic index diet is recommended.

Prevention

Recurrence is the rule despite physical destruction or complete surgical removal. Continuous medical management may reduce further cutaneous lipid deposition.

Long-Term Monitoring

Adequate counselling and long-term follow up are advised.

Questions

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Media Gallery

Xanthelasma. Courtesy of Duke University Medical Center.
Eruptive xanthomas. Courtesy of Duke University Medical Center.
Tuberous xanthomas. Courtesy of Duke University Medical Center.
Microscopic image of a xanthelasma. The lesion is composed of lipid-laden macrophages located in the superficial dermis. Courtesy of Duke University Medical Center.

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Author

Kara Melissa Torres Culala, MD Training Officer, Dermatology Department, Tondo Medical Center; Faculty, Dermatology Department, Jose R Reyes Memorial Medical Center, Philippines

Kara Melissa Torres Culala, MD is a member of the following medical societies: Philippine Dermatological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Additional Contributors

Ponciano D Cruz, Jr, MD Professor and Vice-Chair, Paul R Bergstresser Chair, Department of Dermatology, University of Texas Southwestern Medical Center

Ponciano D Cruz, Jr, MD is a member of the following medical societies: Texas Medical Association

Disclosure: Received consulting fee from RCTS for independent contractor; Received honoraria from Mary Kay Cosmetics for consulting; Received grant/research funds from Galderma for principal investigator.

Acknowledgements

Kevaghn P Fair, DO Consultant Pathologist and Founder, Dominion Pathology Laboratories

Kevaghn P Fair, DO is a member of the following medical societies: American Society for Clinical Pathology, American Society of Dermatopathology, and College of American Pathologists

Disclosure: Nothing to disclose.