Xanthelasma

Synonym: xanthelasma palpebrum

What is xanthelasma?

The appearance of xanthelasma is of yellow flat plaques over the upper or lower eyelids, most often near the inner canthus. They represent areas of lipid-containing macrophages but the exact pathophysiology is not known. In other areas of the body the individual lesion would be called a xanthoma; xanthelasma is the most common xanthoma.^{1 2}

Xanthelasma

By Klaus D. Peter, CC-BY-3.0, via Wikimedia Commons

Xanthelasma diagnosis

This is usually not a problem, since colour and site are characteristic. They occur a little more often in women than in men and the peak incidence is in the fourth to fifth decades. Once the plaque is established, it tends to remain static in size or grow slowly; it does not regress. Generally, eyelid function remains unimpaired. Ptosis is rare.

Differential diagnosis

• Sometimes syringomas and milia may be misdiagnosed as xanthelasma.

• Syringomas are small papules on lower eyelids and are skin-coloured.

• Large milial cysts are white and spherical.

• Xanthomas in other areas may appear more orange-yellow.

• The list of differentials for lipid disorders also needs to be considered.

Associated diseases

• Xanthelasma may represent a localised skin condition without any systemic abnormalities of lipoprotein metabolism or may be associated with an increase in the cholesterol-rich beta-lipoproteins (LDLs).³ See the separate Hyperlipidaemia article.

• Some patients exhibiting xanthelasma have normal lipid levels but this is less common in younger patients. Although these patients are not at increased risk of carotid atherosclerosis, they are more commonly found to have other risk factors for cardiovascular disease - eg, a higher BMI, waist circumference and LDL-C levels.⁴

Xanthelasma treatment and management

Lesions are typically asymptomatic and treatment is sought for cosmetic purposes. Treatments include topical trichloroacetic acid, liquid nitrogen cryotherapy, and various lasers. Surgical excision has also been used.²

• Patients should have their fasting lipid levels checked and those with hyperlipidaemia should have a formal cardiovascular risk assessment using appropriate charts, with measures for prevention of cardiovascular disease as indicated.

• The lesions can be left alone unless the patient wishes them removed for cosmetic reasons (not usually available on the NHS).

• Various options are available including surgical excision (with or without skin grafting for large lesions), chemical treatment, laser treatment and cryocautery.⁵ Full-thickness skin grafting obtained via blepharoplasty is available.⁶ Xanthelasmas may recur after any of these interventions.

• Lipid-lowering medication and diet modification have a limited (if any) effect on these lesions.

Prognosis

The condition itself is harmless. The prognosis depends on any association with underlying lipid abnormalities and cardiovascular risk.

When to refer

Surgical excision and cryocautery may be available in some primary care settings but it is likely that the other treatment options will require secondary care referral.