History

Fact Explanation
Aesthetic concerns due to lesion or very rarely disturbance to vision. The typical lesions appear as soft, yellow plaques on the medial aspect of the eyelids. The fatty deposits may also take on a darker red or brown appearance and can vary in texture and firmness.This disorder typically presents in middle-aged and older adults, with an incidence of 1.1 percent in women and 0.3 percent in men. [1]
Chest pain Xanthelasma has been known to be associated with atherosclerosis and coronary artery disease. [2]
Osmotic symptoms like polyuria and polydipsia. Xanthelasma has been known to be associated with insulin resistance and diabetes mellitus. [2]
History of sudden onset paralysis, slurring of speech or any neurological deficit. Xanthelasma has been known to be associated with hypertension and stroke. [2]
Family history of hypercholesterolaemia or premature atherosclerosis. The appearance of xanthelasma before age 40 may be associated with an increased likelihood of familial hypercholesterolemia. [1]
References
  1. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B
  2. DEY ANUPAM, AGGARWAL RAMESH, DWIVEDI SHRIDHAR. Cardiovascular Profile of Xanthelasma Palpebrarum. BioMed Research International [online] 2013 December, 2013:1-3 [viewed 20 August 2014] Available from: doi:10.1155/2013/932863

Examination

Fact Explanation
Soft, yellow plaques on the medial aspect of the eyelids. Xanthelasmas are composed of xanthoma cells, which are foamy, lipid laden histiocytes. These tend to be found in the superficial dermis in perivascular and periadnexal locations, often with associated surrounding fibrosis and inflammation. [1]
Tuberous xanthomata and corneal arcus Extensor tendon xanthomas and a corneal arcus are typically associated with xanthelasma. [1]
Blood Pressure Xanthelasma is associated with hypertension. [2]
Measure weight and height and calculate Body Mass Index Xanthelasma is associated with obesity. [2]
References
  1. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B
  2. DEY ANUPAM, AGGARWAL RAMESH, DWIVEDI SHRIDHAR. Cardiovascular Profile of Xanthelasma Palpebrarum. BioMed Research International [online] 2013 December, 2013:1-3 [viewed 20 August 2014] Available from: doi:10.1155/2013/932863

Differential Diagnoses

Fact Explanation
Cirrhosis. Due to hypoproteinaemia can cause periorbital oedema which is similar. Clinical history and liver function tests will reveal the diagnosis. [1]
Hypothyroidism. Can cause periorbital oedema. Thyroid function tests along with clinical history will help in differentiating. [1]
Nephrotic syndrome. Due to hypoproteinaemia as a result of proteinuria. [1]
Erdheim-Chester disease. A systemic xanthogranulomatous disorder that displays more indurated-type lesions. [1]
Lipoid proteinosis. A rare autosomal recessive disorder characterizedby the perivascular deposition of hyaline material. These lesions usually appear as a string of nodules along the lid margin and also affect other cutaneous sites and mucous membranes. Histologic examination may be necessary to make an accurate diagnosis. [1]
References
  1. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B

Investigations - for Diagnosis

Fact Explanation
Histological examination of biopsy. Usually diagnosis is clinical. But if there is any doubt surgical excision and pathological examination can be done. Microscopically, xanthelasmas are composed of xanthoma cells, which are foamy, lipid-laden histiocytes. These tend to be found in the superficial dermis in perivascular and periadnexal locations, often with associated surrounding fibrosis and inflammation. [1]
References
  1. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B

Investigations - Fitness for Management

Fact Explanation
Lipid profile Xanthelasma often indicates an underlying plasma lipid disorder. Hyperlipidemia is reported to occur in approximately 50 percent of patients with xanthelasma. However, xanthelasma can occur in patients with a normolipidemic profile. Hypertriglyceridemia (triglyceride > 200mg/dl) is the commonest lipid abnormality. Total cholesterol also is expected to be above 240 mg/dl. LDL cholesterol also could be more than 160 mg/dl. [1,2]
Fasting blood sugar To exclude diabetes which is associated with xanthelasma. Diabetes is diagnosed if Fasting blood sugar is more than 126 m/dl. [2,3]
References
  1. LEE HOON YOUNG, JIN UNG SIK, MINN KYUNG WON, PARK YOUNG-OH. Outcomes of Surgical Management of Xanthelasma Palpebrarum. Arch Plast Surg [online] 2013 December [viewed 20 August 2014] Available from: doi:10.5999/aps.2013.40.4.380
  2. DEY ANUPAM, AGGARWAL RAMESH, DWIVEDI SHRIDHAR. Cardiovascular Profile of Xanthelasma Palpebrarum. BioMed Research International [online] 2013 December, 2013:1-3 [viewed 20 August 2014] Available from: doi:10.1155/2013/932863
  3. Diagnosis and Classification of Diabetes Mellitus. Diabetes Care [online] 2008 January, 31(Supplement_1):S55-S60 [viewed 20 August 2014] Available from: doi:10.2337/dc08-S055

Investigations - Screening/Staging

Fact Explanation
Genetic testing (Polymerase Chain Reaction or Western blot for genes LDLR, APOB, PCSK9) The appearance of xanthelasma before age 40 may be associated with an increased likelihood of familial hypercholesterolemia. Genetic testing most commonly involves the three genes LDLR, APOB, and PCSK9, as mutation of one of these genes accounts for approximately 60%-80% of familial hypercholesterolaemia. [1,2]
References
  1. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B
  2. Youngblom E, Knowles JW. Familial Hypercholesterolemia. 2014 Jan 2. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2014. Available from: http://www.ncbi.nlm.nih.gov/books/NBK174884

Management - General Measures

Fact Explanation
Thyroid hormone replacement In some cases, treatment of the underlying medical disorder can cause regression, as in hypothyroidism. [1]
Risk modification If hypercholesterolaemia, diabetes or any other risk factor is detected they should be treated to reduce risk of future atherosclerotic disease. However xanthelasma itself is unlikely to undergo regression with that. [2]
References
  1. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B
  2. LEE HOON YOUNG, JIN UNG SIK, MINN KYUNG WON, PARK YOUNG-OH. Outcomes of Surgical Management of Xanthelasma Palpebrarum. Arch Plast Surg [online] 2013 December [viewed 20 August 2014] Available from: doi:10.5999/aps.2013.40.4.380

Management - Specific Treatments

Fact Explanation
Surgical resection If the xanthelasma lesion is smaller than 3 mm and within the range of blepharoplasty incision, blepharoplasty or modified blepharoplasty can be performed. If the xanthelasma lesion is smaller than 3 mm and outside the range of blepharoplasty incision, direct elliptical incision can be used. If the xanthelasma lesion is larger than 3 mm, serial excision can be used. [1]
Ablation with carbon dioxide laser The advantages of this method are the accurately controlled ablation of thin skin layers, the option for a repeated application in case of recurrences, the unproblematic and safe treatment in delicate regions of the periorbital area, and the low risk of visible scarring, as well as the low recurrence rate. [2]
Erbium-YAG This can be used to treat both big and small lesions. [3]
Nd-YAG The Q-switched Nd:YAG (532 and 1,064 nm) laser treatment of xanthelasma palpebrarum cannot be generally recommended and should be applied with caution. [4]
Tricholoracetic acid peels This can be used for small (<3 mm) lesions. [3]
References
  1. KIM JUNGMIN, KIM YU JIN, LIM HYOSEOB, LEE SE IL. Bilateral Circular Xanthelasma Palpebrarum. Arch Plast Surg [online] 2012 December [viewed 20 August 2014] Available from: doi:10.5999/aps.2012.39.4.435
  2. RAULIN CHRISTIAN, SCHOENERMARK MATTHIAS P., WERNER SASKIA, GREVE BAERBEL. Xanthelasma palpebrarum: Treatment with the ultrapulsed CO2 laser. Lasers Surg. Med. [online] 1999 December, 24(2):122-127 [viewed 20 August 2014] Available from: doi:10.1002/(SICI)1096-9101(1999)24:2<122::AID-LSM7>3.0.CO;2-6
  3. ROHRICH RJ, JANIS JE, POWNELL PH. Xanthelasma palpebrarum: a review and current management principles. Plast Reconstr Surg [online] 2002 Oct, 110(5):1310-4 [viewed 20 August 2014] Available from: doi:10.1097/01.PRS.0000025626.70065.2B
  4. KARSAI SYRUS, SCHMITT LAURENZ, RAULIN CHRISTIAN. Is Q-Switched Neodymium-Doped Yttrium Aluminium Garnet Laser an Effective Approach to Treat Xanthelasma Palpebrarum? Results from a Clinical Study of 76 Cases. Dermatologic Surgery [online] 2009 December, 35(12):1962-1969 [viewed 20 August 2014] Available from: doi:10.1111/j.1524-4725.2009.01314.x