Introduction
Xanthoma is a dermal condition characterized by the deposition of fat or cholesterol under the skin.
What Is Xanthelasma Palpebrarum?
Xanthelesma palpebrarum is xanthoma affecting the eye. There is the localized deposition of fat under the skin surrounding the eye and eyelids. It is the most common cutaneous presentation of xanthomas.
How Common Is Xanthelasma Palpebrarum?
Xanthelesma palpebrarum accounts for four percent of all ocular diseases. The prevalence of xanthelasma is more in females in comparison to males. The age group in which there is the onset of the disease is between 37 to 73 years. If the disease presents at a younger age, it is indicative of hidden lipoprotein disorders.
What Causes Xanthelasma Palpebrarum?
Xanthelasma is mainly caused by the deposition of lipids in the skin due to an increase in the concentration of fat in the blood (hyperlipidemia). The causes of hyperlipidemia are of two types, primary and secondary. The primary cause of hyperlipidemia is mainly linked to genetic factors and has a familial presentation, while the secondary cause of hyperlipidemia is triggered by other factors.
What Are the Risk Factors Associated With Secondary Hyperlipidemia?
The secondary cause of hyperlipidemia is triggered by both the physiological status of the body and other systemic diseases. The aggravating factors include:
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Kidney disease.
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Certain drugs also trigger hyperlipidemia. The drugs causing increased fat accumulation are estrogen containing drugs (birth control pills), Prednisolone, Tamoxifen, and Cyclosporine.
What Is the Mechanism Involved Behind the Xanthelasma Palpebrarum?
The exact cause responsible for xanthelasma is not known. Xanthelasma is caused by the deposition of cholesterol-laden histiocyte cells known as foam cells in the eyelids.
How Does Xanthelasma Appear Clinically?
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Clinically, xanthelasma appears as a yellowish, violaceous, and reddish brown raised solid or fluid-filled cavity (papule) or plaque on or surrounding the eyelids. The lesions are more in the upper eyelids in comparison to the lower ones.
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Xanthelasma is asymptomatic and appears in the periorbital region. The distribution of the lesions are symmetrical.
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Lesions are single or multiple.
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The soft tissue overgrowth (nodule) is either hard or semi-hard in consistency.
What Are the Ocular Sites With Frequent Appearance of Xanthelasma?
Xanthelasma is most frequently seen in the upper eyelids, especially on the medial side of the eyelids.
What Are the Various Grades of Xanthelasma?
Xanthelasma is grouped into four grades based on the extent and location of the lesion:
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Grade I lesions are present in the upper eyelids only.
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Grade II lesions are located in the medial canthal area.
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Grade III lesions are present in the medial side of the upper and lower eyelids.
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Grade IV shows the involvement of the medial and lateral canthus of the eyes.
How Is Xanthelasma Diagnosed?
The diagnosis of xanthelasma is primarily clinically based. Laboratory tests are performed to detect hidden lipid and cardiac diseases.
The conditions that are to be considered before forming the diagnosis of xanthelasma palpebrarum are:
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Xanthelasma granuloma.
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Palpebral sarcoidosis.
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Nodular basal cell carcinoma.
What Are the Conditions That Might Arise in Patients of Xanthelasma?
Xanthelasma is prone to increase the risk of the following conditions:
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Ischemic heart disease.
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Triglyceride disorders.
What Are the Various Management Options for Treating Patients With Xanthelasma?
Xanthelasma is treated by both medical and surgical management. The treatment protocol for xanthelasma is aimed at cosmetic corrections.
Non-surgical Management of Xanthelasma:
Non-surgical or medical management of xanthelasma includes topical and systemic use of medicines.
Systemic Treatment of Xanthelasma:
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The administration of systemic antioxidants and monoclonal antibodies also play a vital role in reducing the lesions.
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Probucol is an antioxidant that prevents the formation of foam cells by inhibiting the atherogenesis process.
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Alirocumab is an anti-cholesterol therapy that helps in decreasing the concentration of cholesterol in the blood.
Topical Medical Management of Xanthelasma:
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Application of Trichloroacetic Acid (TCA): It is the most simple and inexpensive procedure used to treat xanthelasma. In this, the TCA is applied in a circular manner with an applicator or finger with the greatest quantity in the periphery of the lesion. The application of TCA is associated with the risk of postinflammatory hyperpigmentation and scar formation.
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Liquid Nitrogen Cryotherapy: Cryotherapy is the most effective way of treating xanthelasma. The application of liquid nitrogen causes the destruction of the cells or tissues by ischemia. The major drawback of cryotherapy is the development of intense eyelid swelling due to the laxity of the tissues.
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Pingamycin Application: The use of antitumor broad spectrum antibiotics intralesionally is used to correct the lesions.
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Low Energy Radiofrequency: Low energy frequency radiation ablation is also excellent for treating patients with xanthelasma. Though the number of radiofrequency sessions is less, the side effects of radio ablation are more.
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Laser Ablation: Targeted laser therapy is an ideal treatment choice for xanthelasma. The use of lasers also decreases the recurrence rate as they destroy the blood vessels of the dermis and prevent leakage of cholesterol into the tissue. Carbon dioxide and argon lasers with a longer wavelength of light absorption are ideal for treating epidermal lesions.
Surgical Management of Xanthelasma:
Surgical treatment of xanthelasma provides excellent cosmetic results. Surgical excision is recommended in the following cases:
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Advanced grades of the disease.
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Involvement of all four eyelids.
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Patients with higher recurrence rates.
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Patients with a history of familial hyperlipoproteinemia.
Xanthelasma is excised by the blepharoplasty (surgical correction of the droopy eyelids) procedure. Complications of surgery are only associated with surgery of grade III and IV cases. It leads to postoperative scar formation. Other treatment options include a combination of both medical and surgical treatment. Apart from all the above treatment modalities, management of the underlying cholesterol or cardiovascular disease is also essential.
Which Is the Best Treatment Strategy for Managing Xanthelasma?
The ideal choice for treating xanthelasma depends on the following:
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The patient's medical status.
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Underlying medical condition.
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Depth of penetration of the lesion.
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The onset of the lesion.
Can Xanthelasma Be Prevented?
Xanthelasma can be prevented by the following approaches:
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Avoid smoking and consumption of alcohol.
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Maintain a healthy weight.
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Limit the use of saturated fatty acids.
What is the Prognosis of the Disease?
The lesions of xanthelasma get completely resolved after treatment. However, the recurrence rate of the lesion is very high with any type of therapy.
Conclusion:
Xanthelasma palpebrarum is a benign dermal condition of the eyelids. It does not affect the functional capability of the eyes. Only the cosmetic appeal of the patient is compromised. The lesions are easily diagnosed clinically, and the lesions completely resolve after treatment.