What is Xanthelasma?

Xanthelasma is a deposit of cholesterol (i.e. lipids or fats) in white blood cells located in the deeper layers of skin and sometimes eyelid muscle. Lesions can range from 0.5mm to 4.5mm in thickness [1]. While previously thought that lesions were located in the superficial skin, recent data show that 58% involve deeper skin (dermis) and 27% infiltrate into underlying muscle [1].

Who is at Risk?

Xanthelasma is more common in patients with high levels of cholesterol, which occurs in approximately 50% of patients. Other risk factors including female sex (related to higher estrogen levels), tobacco use, or medical conditions such as high blood pressure, obesity, or diabetes. The condition is also more common in individuals of Asian or Mediterranean descent. Other causes include medication side effects that can increase circulating lipids in the blood such as prednisone, estrogen, anabolic steroids, blood pressure medications, retinoids, cyclosporine, tamoxifen, cimetidine or some seizure medications, or excessive alcohol intake.

Xanthelasma Testing:

Given the association with elevated blood cholesterol, it is necessary for patients to be screened with a fasting lipid panel (and other screening labs such as HbA1c, liver panel, and thyroid function test) performed with a primary care physician. Lack of screening with an undetected high lipid level can result in serious illness, heart attack or stroke. If you have adult-onset asthma, a diagnosis of Erdheim-Chester disease should be screened for with a lesion sample sent to pathology.

Xanthelasma Treatment Options:

Surgical Excision – Direct excision of the lesion can be performed. This is most ideal if the patient has excess eyelid skin to spare, where the wound can be closed without tension. This allows for faster healing and decreased scarring compared to other methods. Note most patients are not a candidate for this option. Downsides: Risk of scarring if deeper excision is needed. If the wound is left open to heal (to prevent eyelid crease distortion), the wound can take weeks to months to fully heal, and scars will be larger.
Needle Electrocautery – This electrical device shaves down the lesion without any bleeding while also slightly shrinking the tissue, making for a smaller open wound compared to other techniques. This technique can target deeper lesions, even into muscle. Downsides: Given the use of heat, there is a higher risk of scarring, particularly in patients of darker skin complexion.
Erbium or CO2 Laser – This uses laser energy to ablate the skin to destroy the lesion. Downsides: Given the use of heat, there is a higher risk of scarring, particularly in patients of darker skin complexion. Laser may not be sufficient if the lesions are deeper, as these lasers are typically used for more superficial skin treatments.
Chemical Peels – Dissolves the treated skin and fat with a chemical burn. Best for small superficial lesions. Downsides: Can only remove the top-middle layers of skin. If the lesion is deeper, which is the case in at least 1/3 of patients, this type of treatment may potentially lead to incomplete treatment. This treatment type may require multiple treatments due to its superficial nature.

Recurrence Risk:

Xanthelasma recurs in roughly 40% of patients, however this can be higher if lesions are present on all four eyelids. If the lesion(s) recur, this can happen soon after removal or even several years later. Risk of recurrence can be minimized if risk factors are minimized or well controlled above, such as lowering systemic lipid levels if elevated.

Procedure Expectations:

Most xanthelomas can be removed with a relatively quick 30-60 minute in office procedure with a local anesthesia. For patients with procedure anxiety, we are happy to offer oral sedation or IV sedation. Learn more about how we priority your safety and comfort with our anesthesia options.

Wound Healing and Post Procedure Care:

Unfortunately, most options to remove xanthelasma result in a deep wound in the skin, potentially down to muscle, involving thermal injury or chemical burns. The first 2 days after the procedure cool (not ice cold) compresses can decrease inflammation and swelling. Any incision will be pink and firm for about 3-4 months, then it will soften and fade as the wound matures over 6 months to a year.

Contrary to popular belief, wounds heal best in a moist environment. Dry wounds can both crack and itch, with scabs falling off too soon. Large or deep wounds may require topical antibiotic ointment for a few days following the procedure. Small or shallow wounds may just be treated with topical Vaseline (or other petroleum jelly-based products).

The area should be protected from damaging UV sunlight using daily sunblock (mineral sunblock SPF 30-50 with titanium dioxide preferred). SPF protecting sunglasses and hats are also recommended for outdoor conditions for 1 year after the procedure. It can’t be stressed enough that sun protection is critical to optimizing the appearance of the scar. Proper sun protection can prevent the scar from turning too dark or too light as it heals.

Combining Xanthelasma with Blepharoplasty:

Xanthelasma removal can be combined with upper or lower eyelid blepharoplasty or laser resurfacing to optimize cosmetic outcomes. Learn more about Dr. Satterfield’s results with Upper Eyelid Blepharoplasty and Customized Lower Eyelid Blepharoplasty.

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