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Eyelid lesions cause cosmetic concerns
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A 39-year-old woman came to our clinic inquiring about a possible bilateral blepharoplasty. The patient stated she was unhappy with a previous lid surgery performed by a different ophthalmologist.
The surgery was performed to excise several lesions that had been present on both upper eyelids. The patient felt the excision had left her with an irregularly shaped crease of the right upper lid (RUL), as well as lateral sagging of the left upper lid (LUL). The previous surgeon performed a revision of the RUL in an attempt to achieve symmetry, but the patient was still dissatisfied with the results.
The patient also reported the presence of new lesions on both lower eyelids, similar to those that had been previously excised from the upper eyelids. The lesions had been present for several months. They were not painful or tender to the touch, but were easily visualized and, therefore, caused cosmetic concerns.
The patient’s medical history was significant for depression and chronic migraines. These two conditions were well managed with Prozac (fluoxetine HCl, Lilly), 20 mg daily, and sumatriptan, 100 mg daily, respectively. She had no known drug allergies. Previous testing was negative for both dyslipidemia and hypertension
The presurgical appearance of the patient, with extensive lesions present on the right lower eyelid.
Images: Rink C
Visual acuity with spectacle correction was 20/15 -1 in each eye. Pupils were equal, round and reactive to light, with no afferent pupillary defect. Motilities were full and smooth, and confrontation visual fields were full in both eyes. Schrimer’s testing was 22 mm OD and 20 mm OS. Margin reflex distance 1 measured 5 mm OD and OS. Margin reflex distance 2 measured 6 mm OD and OS. Levator function was 19 mm to 20 mm OD and 20 mm OS. Ocular health was normal with no signs of infection or inflammation.
Further examination revealed a ptosis of the right brow with extensive tissue overhang centrally. This ptosis was presumably caused by inferior displacement of the brow secondary to the previous RUL surgeries. The patient was scheduled with a plastic surgeon to address her brow ptosis.
There were also several light yellow plaque-like lesions present on both lower eyelids, with a much larger area affected on the right side than the left. The lesions were slightly raised, soft to the touch and immobile. They caused no symptoms other than cosmetic concerns.
Caleb Rink
Leonid Skorin Jr.
Visualization of these lesions in combination with palpation made this diagnosis an easy one: xanthelasma, the most common type of xanthoma (a cutaneous deposit of fatty materials). The word xanthelasma is descriptive when considering its Greek origin: “xanthos” means “yellow,” while “elasma” means “metal plate.” This leads us to a rather precise description of xanthelasma: a yellow, plate-shaped lesion.
It is slightly raised, plaque-like, and can be soft, semisolid or calcified in texture. The fatty deposits found in xanthelasma are made up of foamy histiocytes containing significant amounts of intracellular lipids (primarily cholesterol). These cells are found in perivascular and periadnexal locations, most often in the middle and superficial dermis. Xanthelasmas are benign and may enlarge or coalesce over time.
Epidemiology
Xanthelasma most often forms bilaterally on the nasal upper eyelids, but may be seen anywhere in the palpebral area. It predominantly occurs in patients middle-aged or older. It has a predilection for women, as well as for those with familial lipoprotein and apolipoprotein disorders. Those with familial lipid disorders may develop xanthelasma as early as their 20s. However, studies have found that only about half of those with xanthelasma also have elevated cholesterol levels (Parkes et al., Lee et al.).
Pandhi and colleagues have shown that normolipemic xanthelasma could be due to abnormal plasma lipid ratios, specifically, decreased apolipoprotein A1 (anti-atherogenic) and increased apolipoprotein B (pro-atherogenic). This may predispose these patients to cutaneous and systemic deposition of lipids, as well as atherosclerosis. The same study found that the carotid intima media thickness (CIMT) was significantly higher in patients with xanthelasma. Considering all these associations with xanthelasma, it is recommended that testing be ordered to rule out elevated cholesterol levels, as well as familial lipid disorders. Assessment of CIMT with ultrasonography may also be beneficial in identifying patients with subclinical atherosclerosis.
Treatment
There are many possible treatments for xanthelasma, and opinions on the best treatment vary widely. Primary surgical excision, blepharoplasty, di- or trichloroacetic acid application, cryotherapy, electrodesiccation, carbon dioxide laser therapy and several other laser therapies have all been explored for their efficacy in treating xanthelasma. While all therapies have shown some benefit, the most common treatments are surgical excision, di- or trichloroacetic acid application and carbon dioxide laser therapy.
Lowering elevated cholesterol levels may help prevent formation of new xanthelasmas, but most sources agree that it will not cause regression of existing xanthelasmas (Parkes et al.). Shields and colleagues reported on one patient whose xanthelasma completely resolved after several years’ use of Zocor (simvastatin, Merck Sharp & Dohme).
Application of dichloroacetic acid with blanching as it cauterizes the skin’s surface.
Surgical excision has been found to be effective, particularly in lesions involving the deep dermis or muscle. However, this procedure poses a risk of ectropian when used to remove xanthelasma from the lower eyelids, as well as other cosmetic issues.
This patient’s management
In the case of our patient, surgical excision of her xanthelasmas initially left her with noticeable asymmetry of her upper eyelids and a secondary brow ptosis. Some reports indicate a high recurrence rate with surgical excision, but one study found a low recurrence rate (3.1%) if the excision is sufficiently deep (Lee et al.). Carbon dioxide laser can also be effective, but as with surgical excision, cost can be an issue.
Application of di- or trichloroacetic acid has been used successfully to treat xanthelasma lesions, with results similar to carbon dioxide laser and surgical excision, but with fewer risks and minimal expense. It can also be repeated, as tissue is not being permanently removed. The most significant risks include recurrence (as with any treatment) and hypopigmentation, which occurs more often in darker pigmented individuals.
One-week follow-up showing eschar formation.
Given our patient’s history of dissatisfaction with surgical excision, it was decided to try application of dichloroacetic acid (DCA) because it is a repeatable, but affordable, procedure. It was decided to first treat a small area of xanthelasma on the left lower lid to ensure hypopigmentation would not occur after healing.
The procedure
The first treatment area was cleaned only with an alcohol wipe. Sterilization with povidone iodine was not necessary, as DCA kills any bacteria on the skin surface. Petroleum jelly was applied with a cotton swab to the lesion borders, preventing unintentional contact of DCA with normal skin. The wooden applicator was then used to apply DCA directly onto the affected area. Immediate whitening of the skin is seen, and a sharp, but transient, burning sensation noted by the patient.
Once the skin had scabbed over and completely healed, no issues of hypopigmentation were found. The patient tolerated the treatment well and was pleased with the result.
Based on this favorable outcome, we decided to proceed with DCA treatment of the remaining xanthelasma present on both lower eyelids. However, the patient was apprehensive about the associated burning sensation, particularly when considering the large area affected on the right lower eyelid. It was agreed that local anesthesia would be a better alternative.
We injected 2% lidocaine with 1:100,000 epinephrine into the right lower lid only. This put the patient at ease going into DCA treatment and minimized discomfort. Application of DCA was performed in the same manner as before, and a follow-up appointment was scheduled for 1 week.
Postoperative presentation of the patient at 2 weeks, with new pink skin being exposed after the eschar had fallen off.
Outcomes
At follow-up, the patient had concerns that the large eschar forming on the right lower lid was pulling her skin and felt tight. There was no sign of infection, but erythromycin ophthalmic ointment was given for application twice a day to the skin surface to prevent infection and improve lubrication.
At the next appointment, the patient reported the ointment helped relieve the “tight” sensation she felt previously. The overlying eschar had completely fallen off and new healthy skin tissue appeared. With time, more uniform skin pigmentation should occur.
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Disclosures: Rink and Skorin have no relevant financial interests to disclose.