Xanthelasmas are localized accumulation of lipid deposits on the eyelids. Lesions are typically asymptomatic and treatment is often sought for cosmetic purposes. Unfortunately, there is paucity of strong evidence in the literature for the effective treatment of normolipidemic xanthelasmas. A literature search using the term “xanthelasma” was carried out in PubMed and Medline databases. Only articles related to treatment were considered and analyzed for their data. Commonly cited treatments include topical trichloroacetic acid, liquid nitrogen cryotherapy, and various lasers including carbon dioxide, Er:YAG, Q-switched Nd:YAG, and pulse dye laser. However, traditional surgical excision has also been used. This article reviews these currently accepted modalities of treatment.

Keywords: Normolipidemic xanthelasmas, xanthelasma, xanthelasma palpebrarum, xanthelasma treatment
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Introduction
Xanthelasmas are yellowish papules and plaques caused by localized accumulation of lipid deposits commonly seen on the eyelids.

The prevalence is estimated at 4%,[1] with an incidence of 1.1% in women and 0.3% in men.[2] The age of onset can range from 15 to 73 years, although typical peaks are seen in the fourth and fifth decades. In around half of the cases, it can be associated with an underlying hyperlipidemia, and a presentation prior to the age of 40 should prompt screening to rule out underlying inherited disorders of lipoprotein metabolism.[3]

Although the exact pathogenic mechanism is not fully understood, cutaneous xanthelasma represents the deposition of fibroproliferative connective tissue associated with lipid-laden histiocytes, also known as foam cells. Histologically, these foam cells are typically found in the middle and superficial layers of the dermis in perivascular and periadnexal locations, with associated fibrosis and inflammation.[4]

Primary hyperlipidemia is caused by genetic defects in the receptors or enzymes involved in lipid metabolism. Inherited disorders of low-density lipoprotein (LDL) cholesterol metabolism are typical examples that are seen in 75% of those with familial hypercholesterolemia.[2] The pathogenesis in this cohort of patients is thought to be secondary to elevated serum lipoprotein levels, which leads to extravasation of the lipoprotein through dermal capillary blood vessels and subsequent macrophage engulfment.

Secondary causes of hyperlipidemia include certain physiological states and systemic diseases. Examples include pregnancy, obesity, diabetes mellitus, hypothyroidism, nephrotic syndrome, and cholestasis.[5,6,7,8] Certain medications such as estrogens, tamoxifen, prednisolone, oral retinoids, cyclosporine, and protease inhibitors can also lead to a state of hyperlipidemia.[9,10,11]

The most common cutaneous presentation is xanthelasma palpebrarum (XP).[2] They present as soft symmetrical, bilateral, yellow, thin polygonal papules and plaques typically in the periorbital area. Other sites that may be affected include the neck, trunk, shoulders, and axillae.[2] There is no association between xanthelasmas and high-density lipoprotein or triglyceride levels.

Christoffersen et al.[12] found that independent of well-known cardiovascular risk factors, the presence of XP appeared to be a predictor of risk for myocardial infarction, ischemic heart disease, severe atherosclerosis, and death in the general population. Contrary to common belief, arcus senilis of the cornea is not an independent predictor of risk.[12]

Persistent XP should be distinguished from a chalazion, sebaceous hyperplasia, syringoma, nodular basal cell carcinoma, and necrobiotic xanthogranuloma (NXG). NXGs, a form of non-Langerhans histiocytosis, are red-brown, violaceous, or yellowish cutaneous papules and nodules that evolve to form infiltrated plaques, commonly in the periorbital region. They are frequently associated with monoclonal gammopathy and other hematological malignancies.[13]

XP is typically asymptomatic and treatment is often sought for cosmetic purposes. Unfortunately, there is paucity of strong evidence in the literature for the effective treatment of XP. A literature search using the term “xanthelasma” was carried out in PubMed and Medline databases. Only articles related to treatment were considered and analyzed.

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