Synonym: xanthelasma palpebrum

The appearance 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

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

• About half of xanthelasma cases are associated with elevated plasma lipid levels.¹
• They may be associated with familial hyperlipidaemia.² Patients with these lesions therefore frequently also have corneal arcus (previously known as arcus senilis) and xanthomas in other areas of the body.
• The presence of xanthelasma and corneal arcus indicates a higher risk of developing ischaemic heart disease but not peripheral vascular disease.³
• Secondary hyperlipidaemia can also be an association, usually caused by underlying uncontrolled diabetes.¹
• 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 e.g. a higher BMI, waist circumference and LDL-C levels.⁴

Management

Patients should have their fasting lipid levels checked and those with hyperlipidaemia should have a formal cardiovascular risk assessment using appropriate charts - go to the primary cardiovascular risk calculator. If the ten-year risk of cardiovascular disease is assessed at greater than 10%, lifestyle intervention should be considered as per primary prevention of cardiovascular risk protocols . If the risk is 20% or greater, intervention might include the use of aspirin and lipid lowering drugs.⁵

The lesions can be left alone unless the patient wishes them removed for cosmetic reasons. Various options are available including surgical excision (± skin grafting for large lesions⁶), chemical treatment with trichloracetic acid, carbon dioxide and argon laser treatment and cryocautery.¹ They can 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 if harmless. Up to 40% of lesions recur after treatment.¹ Any associated comorbidity will of course affect prognosis.

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.