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Cosmetically unappealing eyelid lesions surgically excised
Lipid-filled macrophages coalesce to form xanthoma lesions in the superficial dermis.
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A 40-year-old black male presented with concerns regarding bumps on both upper eyelids. The patient conveyed some itching but no pain associated with these lesions. He was not pleased with their appearance.
Two lesions were visible in the superior medial canthi. They were slightly asymmetric in size, with the right measuring 0.8 cm and the left measuring 1.0 cm. They were minimally elevated but not nodular: soft, smooth and immobile, eliciting no pain on palpation. They appeared to be superficial in depth. The patient reported no use of ocular medications at the time of presentation, but was taking three 500 mg tablets of metformin daily (two in the morning and one in the evening) for type 2 diabetes and one 5 mg tablet of lisinopril daily for hypertension. The reported ocular and family history was unremarkable.
Entering unaided visual acuities were 20/30+2 OD and 20/25-1 OS, with pinhole to 20/20 and 20/25, respectively. Near visual acuity was 20/20 in both eyes. Pupils were round, equal and responsive to light with no afferent pupillary defect. Motilities were full in both eyes, and confrontation fields were full as assessed with finger counting. Cover test revealed orthophoria at distance and near. The patient reported never using any optical correction.
We diagnosed the patient with xanthelasma.
Etiology
Xanthoma is a condition in which lipid-filled macrophages coalesce to form lesions in the superficial dermis. These lesions can be found anywhere on the body, but the most common form is in the eyelids. This form is termed xanthelasma. These eyelid lesions are usually located in the medial upper canthi, as the skin is thinner there. They frequently present bilaterally and symmetrically. The typical age of onset is between 40 and 60 years old, with women more commonly affected than men.
Images: Nash P
Teens and adults presenting with this condition should be referred for a lipid panel to rule out underlying dyslipidemia. Young men presenting with xanthelasma are the most likely to return abnormal serum cholesterol levels; however, only about 50% of patients with xanthelasma have dyslipidemia overall. Those who do have underlying abnormal lipid levels may be at a higher risk for xanthelasma recurrence, necessitating retreatment after initial removal, regardless of the method employed.
Treatment
If xanthelasma lesions are identified during a routine eye exam without patient concern for cosmesis, it is often appropriate to bypass treatment in lieu of patient education and observation on a yearly basis. The lesions should be documented for follow-up at subsequent exams. Even if the patient shows elevated serum lipid levels on laboratory testing, systemic treatment does not reverse the appearance of the xanthelasma lesions themselves.
If cosmesis is a concern for the patient, multiple approaches are available for removal. Surgical excision, laser ablation, chemical cautery and cryodestruction are all potential options for consideration. Which approach is employed will vary depending on the size of the lesions, location of the lesions and patient characteristics such as skin pigmentation and age.
Surgical excision of xanthelasma is performed following local anesthesia. The lesion is excised using a scalpel and surgical scissors. The lipid-filled cells will remain attached to the removed skin.
Laser ablation can be performed using an erbium:yttrium-aluminum-garnet (er:YAG) laser with wavelength 2,960 nm set at 20 Joules/cm for an 8-micron ablation depth. When applied to the skin, this laser vaporizes the epidermis down into the lipid-containing cells that make up the xanthelasma. In some cases, this is combined with surgical removal of the lipid material, as the depth may be greater than what the laser settings are able to manage without risking increased damage of collateral tissue. This procedure is performed using local anesthesia. Antibiotic ointment and sterile dressings are used over the treated area and are applied twice daily until the skin completely re-epithelializes. This generally occurs over the course of a week.
Chemical cautery, also referred to as acid peel, uses dichloroacetic acid to induce controlled damage and subsequent reorganization of the skin structure. Petroleum jelly is applied to surrounding normal skin to protect it from over-treatment. The acid is used at full concentration and applied directly to the skin’s surface using a wooden applicator. Some patients will not tolerate the burning sensation if the treatment area is large, so optional local anesthesia may be used.
Cryodestruction utilizes cold temperature to induce controlled damage similar to the above-described methods. The most commonly used agent for cryodestruction is liquid nitrogen; however, other options such as nitrous oxide and carbon dioxide exist. Aseptic conditions are required, but anesthetic is usually not administered. Different application techniques such as direct application and spray are used, as dictated by the size of the treatment area. The healing process also involves re-epithelialization of the destructed tissue area as described in laser and chemical treatments.
Pros and cons
Each treatment modality has benefits and downfalls. The size of the lesion plays into the decision-making process due to the size of the potential scar or, in the case of surgical excision, the risk of causing lid deformation and retraction. Chemical, laser and cryotherapy use have been shown to cause hypopigmentation, sometimes even in Caucasian patients.
Fitzpatrick skin typing assigns numbers scaled 1 to 6, based on the skin’s tendency to tan with UV light exposure. Types 1 to 3 are considered white skin and generally safe for treatments that have a preponderance to cause hypopigmentation, such as chemicals and lasers. Types 4 to 6 are increasingly dark pigmented skin, with 6 representing skin that does not tan at all in response to UV exposure. Types 5 and 6 are not candidates for treatments any more caustic than salicylic acid or glycolic acid used in dermatologic superficial chemical peels. This demonstrates that chemical and laser cauterization is not ideal in patients with darker pigmented skin – a consideration in the case at hand.
This patient’s management
A lipid panel was ordered for our patient. His triglyceride level was found to be 445 mg/dL (normal is less than 150 mg/dL) and total cholesterol was 298 mg/dL (normal is less than 200 mg/dL). His high density lipoprotein was 50 mg/dL (normal range is 40 mg/dL to 60 mg/dL). His primary care physician started him on pravastatin 40 mg tablets once nightly.
The considerations of xanthelasma treatment in this particular case arose from the potential for hypopigmentation with laser or dichloroacetic acid application. The patient had Fitzpatrick skin type 5/6 and was not a candidate for such treatments. The lesions were small and isolated sufficiently that surgical excision was deemed the most appropriate course of action.
The procedure was performed in the minor operating room at the eye clinic. The eye was anesthetized with topical tetracaine applied to the lower cul-de-sac of each eye. Xylocaine 2% with 1:100,000 epinephrine was injected into the right and left medial upper eyelids. The area was sterilely prepped with povidone iodine swabs and sterile drapes. Once it had been confirmed that the patient was anesthetized adequately, excision began with an elliptical incision around the right upper eyelid lesion, including approximately 0.5 mm of normal surrounding tissue. The overlying epidermis and attached lipid-filled lesion was partially separated from the underlying connective tissue. Once the lesion was fully removed, the surrounding skin had to be undermined using curved iris scissors to allow the wound to close. Cauterization was used to achieve hemostasis. The same procedure was performed on the left medial upper eyelid. Both wounds were closed using multiple interrupted 6-0 silk sutures. Care was taken to prevent lid retraction. Because of the small size of these lesions, this did not become a concern. There were no complications accompanying the procedure.
Once the incision was closed, an ophthalmic antibiotic ointment was applied. The patient was educated to apply this ointment twice a day until his scheduled follow up in 1 week.
Histology
Both excised lesions were sent to pathology for confirmation of the diagnosis of xanthelasma. The histology slides confirmed xanthelasma tissue and also provided some additional insight into the physiology behind the contraindication for use with other removal techniques in pigmented individuals. The layer of hyperpigmentation seen at the basal aspect of the epidermis is likely destroyed with laser, chemicals and cryotherapy, which may lend itself to increased hypopigmentation. In patients with increased pigmentation in the basal epidermis, surgical excision causes the least destruction of this layer, resulting in transient hypopigmentation contained to the location of new skin formation between apposed incision edges.
The typical histology of xanthelasma was found in these lesions, which consists of apparently empty space in cells with small purple stained nuclei. This appearance is the result of fatty tissue not fixing during the staining process, allowing for the white to faint purple tint seen in these lipid-filled cells. The strongly stained pink tissue indicates collagen. This particular patient’s skin had a fair amount of collagen, which contributed to the need for undermining of surrounding skin for closure of the wound.
At his 1 week follow-up for suture removal, the patient reported no bleeding or seepage from the incision sites and compliance with the application of antibiotic ointment. The sutures were removed without complication, and the edges of the incision had approximated well, with only the approximation line showing any amount of pigment change, expected to be transient and resolve with complete healing time. The patient was satisfied with the results and educated to continue to apply the antibiotic ointment. He was also educated on the potential for recurrence.
- References:
- Berlin AL, et al. Challenge: Treatment of xanthelasma palpebrum. The Dermatologist. 2009;17(8). http://www.the-dermatologist.com/content/challenge-treatment-of-xanthelasma-palpebrarum.
- Fabbrocini G. Chemical Peels. Medscape Reference. http://emedicine.medscape.com/article/1829120. Updated June 30, 2015. Accessed January 13, 2016.
- Hampton R. Xanthelasma. Medscape Reference. http://emedicine .medscape.com/article/1213423. Updated November 19, 2015. Accessed January 13, 2016.
- Haygood LJ, et al. Dermatol Surg. 1998;24(9):1027-1031. doi:10.1111/j.1524-4725.1998.tb04297.x.
- Kanski K, et al. Chapter 1: Eyelids: Miscellaneous benign tumours. Clinical Ophthalmology. 7th ed. Elsevier Saunders. 2011:10-15.
- Myint S. Eyelid and adnexa lesions. In: Onofrey B, Skorin L, Holdeman, N. eds. Ocular Therapeutics Handbook, A Clinical Manual. 3rd ed. Lippincott, Williams and Wilkins. 2011:609-612.
- Sharma VK, et al. Indian J Dermatol Venerol Leprol. 2009;75(8):90-10.
- For more information:
- Paige Nash, BS, plans to graduate from Pacific University College of Optometry this year. She can be reached at: Nash7538@pacificu.edu.
- Leonid Skorin Jr., OD, DO, MS, FAAO, FAOCO, practices at the Mayo Clinic Health System in Albert Lea, Minn., and is a member of the Primary Care Optometry News Editorial Board. He can be reached at Mayo Clinic Health System; skorin.leonid@mayo.edu.
Disclosures: Nash and Skorin report no relevant financial disclosures.