Xanthelasma are skin lesions characterised by yellowish papules and plaques caused by localised accumulation of lipid deposits in the fatty layer of the skin commonly seen on the eyelids. These skin lesions typically appear in the fourth and fifth decades of life. In around half of the cases xanthelasma can be associated with an underlying hyperlipidaemia (high levels of fat in the blood) and a presentation of xanthelasma prior to the age of 40 should prompt screening to rule out underlying inherited disorders of lipoprotein metabolism. The condition seems to affect women more than men.

There are 2 types of excessive fat in the blood (also called hyperlipidaemia): primary and secondary.

Primary hyperlipidaemia 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 per cent of those with familial hypercholesterolaemia . 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 hyperlipidaemia include certain physiological states and systemic diseases. Examples include pregnancy, obesity, diabetes mellitus, hypothyroidism, nephrotic syndrome and cholestasis. Certain medications such as oestrogens, tamoxifen, prednisolone, oral retinoids, cyclosporine and protease inhibitors, can also lead to a state of hyperlipidaemia. 

Xanthelasma are typically asymptomatic and treatment is sought for cosmetic reasons. There are a number of treatments available and these include trichloroacetic acid (TCA) at high concentration, laser treatment, cautery and surgical excision. 

Trichloroacetic acid treatment involves the application of 50-100% acid using a wooden spatula or cotton buds in a stroking layer until a white frosting is observed. The xanthelasma will subsequently become red and swollen and resolution can be expected in few days.

Laser treatment is commonly used in xanthelasma and typically involves what is called an ablative laser that removes layers of the skin. The 2 commonly used lasers in xanthelasma are the Erbium:YAG and carbon dioxide (CO2) lasers.  The treatment is done under local anaesthetic and the resultant wound will heal in few days. The treatment of choice will depend on the extent of the xanthelasma and the patient’s choice.

Dr. Firas Al-Niaimi has published on xanthelasma and its treatments and this publication can be found in the publications section of the website.