Xanthelasma: Symptoms, Types, Causes and Treatment

Xanthelasma is more than just a cosmetic concern—it’s a visible clue to underlying metabolic and cardiovascular health. Most commonly found as soft, yellowish plaques on the eyelids, xanthelasma can be distressing for patients and may signal deeper health issues. In this comprehensive article, we’ll explore the symptoms, types, causes, and treatment options for xanthelasma, synthesizing the latest medical research to offer a clear, patient-centered guide.

Symptoms of Xanthelasma

Xanthelasma's symptoms are often subtle and painless, but their visibility can have a significant psychological impact. Recognizing the typical features is crucial for early identification and intervention. Let’s explore how xanthelasma presents itself and what signs to look out for.

Appearance	Location	Sensation	Source
Yellowish	Eyelids	Asymptomatic	4 5 6 7
Soft, velvety	Inner canthus	No pain	4 5 7
Polygonal	Bilateral	Cosmetic	4 5 6 7
Plaques/papules	Upper/lower lid	Distress	4 5 6

Table 1: Key Symptoms

Typical Manifestations

Xanthelasma usually appears as soft, yellowish plaques or papules on the eyelids. The lesions are often symmetrical, bilateral, and found around the inner corners (canthus) of the upper and lower eyelids. Their texture is described as velvety or slightly raised, and they tend to have a polygonal shape, blending into the surrounding skin 4 5 7.

Sensation and Patient Experience

Most xanthelasma lesions are entirely asymptomatic—there is no pain, itching, or discomfort. However, the cosmetic appearance can cause significant psychological or social distress for patients, especially when the lesions are large or prominent 6.

Progression and Complications

• Growth: Lesions may slowly enlarge over time, sometimes merging together.
• Cosmetic Impact: Although benign, their visibility often motivates patients to seek medical advice 5 6 7.
• Underlying Health: Presence of xanthelasma can hint at underlying lipid abnormalities or metabolic dysfunction, even in patients without symptoms 4.

Types of Xanthelasma

Though xanthelasma often refers to the classic eyelid presentation, it is actually one subset of a broader group called xanthomas. Understanding the different types helps clinicians identify systemic associations and tailor management accordingly.

Type	Features	Associated Disorders	Source
Xanthelasma palpebrarum	Eyelid plaques, soft, yellowish	Dyslipidemia, atherosclerosis	2 3 4 5
Eruptive xanthomas	Sudden, small yellow papules	Severe hypertriglyceridemia	2
Tendinous xanthomas	Firm nodules over tendons	Familial hypercholesterolemia	2
Tuberous xanthomas	Nodular, over joints	Cerebrotendinous xanthomatosis	2
Plane xanthomas	Flat, diffuse patches	Paraproteinemia, lymphoproliferative	2

Table 2: Types of Xanthelasma and Related Xanthomas

Xanthelasma Palpebrarum

This is the most common form, seen as soft, yellowish plaques on the eyelids. It is often bilateral and symmetrical, affecting middle-aged and older adults 2 4 5. While historically considered only cosmetic, recent research links it to cardiovascular risk 2 3.

Other Xanthoma Variants

• Eruptive xanthomas: Rapidly appearing, small yellow papules, usually on the buttocks or extensor surfaces, and strongly associated with severe hypertriglyceridemia 2.
• Tendinous xanthomas: Firm nodules on tendons such as the Achilles and fingers, often marking familial hypercholesterolemia 2.
• Tuberous xanthomas: Nodular lesions over pressure points and joints, seen in rare lipid disorders 2.
• Plane xanthomas: Large, flat yellow patches, often linked to blood protein abnormalities or lymphoproliferative diseases 2.

Clinical Significance

Identifying the specific type of xanthoma is important:

• Cardiovascular risk: Some types, especially tendinous and xanthelasma palpebrarum, are associated with increased risk of atherosclerosis and cardiovascular disease 2 3.
• Metabolic markers: Eruptive xanthomas signal severe lipid disturbances and risk of pancreatitis or diabetes 2.

Causes of Xanthelasma

Understanding what triggers xanthelasma can help guide both treatment and prevention. While the hallmark is lipid deposition, not all patients have abnormal cholesterol.

Cause	Mechanism	Risk Factors	Source
Hyperlipidemia	Lipid deposition in skin	Dyslipidemia, genetics	2 3 4 5
Metabolic dysfunction	Abnormal glucose, inflammation	Diabetes, fatty liver	1
Lipoprotein abnormalities	LDL/HDL imbalance	Atherosclerosis	3 4
Local factors	Perivascular foam cell infiltration	Age, skin changes	5 6 7
Other systemic diseases	Thyroid, liver disorders	Hypothyroidism, hepatic cysts	1 5

Table 3: Key Causes and Risk Factors

Hyperlipidemia and Lipid Disorders

About half of patients with xanthelasma palpebrarum have elevated cholesterol or triglycerides. The classic mechanism is the accumulation of lipid-laden foam cells in the skin, due to excessive uptake and modification of LDL cholesterol 2 3 4 5. However, up to 50% of cases may occur in people with normal lipid profiles 3.

Metabolic and Systemic Contributors

Recent population studies have linked xanthelasma to:

• Diabetes and impaired fasting glucose: Patients often have higher fasting glucose, with increased risk for metabolic syndrome 1.
• Fatty liver and hepatic cysts: These occur more frequently in xanthelasma patients 1.
• Inflammatory markers: Elevated neutrophil counts and neutrophil-to-lymphocyte ratio suggest an inflammatory component 1.

Lipoprotein and Apolipoprotein Abnormalities

Even in normolipidemic patients, subtle changes such as low HDL cholesterol or specific apolipoprotein imbalances may increase the risk of both xanthelasma and atherosclerosis 3 4.

Local Pathophysiology

Xanthelasma results from perivascular infiltration of foam cells within the superficial reticular dermis. Age, skin integrity, and local microcirculation may play a role in lesion development 5 6 7.

Other Causes

• Thyroid dysfunction: Hypothyroidism is sometimes associated 5.
• Helicobacter pylori infection: Higher rates observed in some populations 1.
• Genetic predisposition: Family history can increase susceptibility 2.

Treatment of Xanthelasma

Treatment for xanthelasma aims to address both the cosmetic impact and underlying health risks. While the lesions themselves are benign, the approach must balance effectiveness, safety, and cosmetic outcome.

Treatment Modality	Pros	Cons/Complications	Source
Surgical excision	Definitive removal	Scarring, ectropion	6 7 8
Laser therapy (CO2, Er:YAG, etc.)	Excellent cosmetic result	Recurrence, cost	7 8 9
Chemical peeling (TCA)	Noninvasive, office-based	Hyperpigmentation, recurrence	5 6 7 8
Cryotherapy	Simple, cost-effective	Dyspigmentation, scarring	6 8
Intralesional injections (e.g., Pingyangmycin, deoxycholic acid)	Minimally invasive	Limited data, recurrence	6 10
Medical management (lipids)	Addresses cause	Lesions rarely regress	6 7

Table 4: Treatment Options and Considerations

First Steps: Assessing Underlying Health

Before cosmetic treatment, it’s crucial to:

• Evaluate lipid profile: Identify and treat underlying dyslipidemia or metabolic disorders 4 5 6 7.
• Screen for diabetes or thyroid dysfunction: Address systemic issues that may contribute to recurrence 1 5.

Surgical Excision

• Traditional approach: Full-thickness excision was once the standard, often paired with blepharoplasty for eyelid lesions.
• Benefits: Offers complete removal and immediate results 6 7.
• Drawbacks: Scarring, eyelid malposition (ectropion), and risk for complications, especially if skin redundancy is limited 6.

Laser Therapy

• Types used: Carbon dioxide (CO2), Er:YAG, Q-switched Nd:YAG, and pulsed dye lasers.
• Advantages: Minimal scarring, good cosmetic results, especially for smaller lesions.
• Considerations: Cost, access to equipment, and potential for recurrence 8 9.

Chemical Peeling

• Trichloroacetic acid (TCA): Applied topically to destroy superficial lesions.
• Pros: Office-based, noninvasive, cost-effective.
• Cons: Risk of hyperpigmentation, especially in darker skin types; may require multiple treatments 5 6 7 8.

Cryotherapy

• Method: Application of liquid nitrogen to freeze lesions.
• Benefits: Simple and effective for small papules.
• Downsides: Risk of scarring or pigment changes 6 8.

Intralesional Injections

• Pingyangmycin or deoxycholic acid: Emerging as minimally invasive options; induce lesion regression via direct injection.
• Efficacy: Early results are promising, with high patient satisfaction and low recurrence rates 6 10.
• Limitations: Limited long-term data and experience.

Medical Management

• Lipid-lowering therapy: Statins or other agents may stabilize lipid profile and prevent recurrence.
• Reality: Lesions themselves rarely regress with medication alone 6 7.

Recurrence and Follow-Up

• Recurrence is common: Especially if underlying lipid abnormalities are untreated or if lesions are incompletely removed 7.
• Patient counseling: Essential to discuss risks, expectations, and preventive strategies.

Conclusion

Xanthelasma is not just a cosmetic issue—it can be a visible sign of underlying metabolic and cardiovascular disease. Recognizing and appropriately managing xanthelasma can improve both appearance and long-term health outcomes.

Summary of Main Points:

• Xanthelasma typically presents as soft, yellowish plaques on the eyelids, causing cosmetic distress but no physical symptoms 4 5 6 7.
• It is the most common type of xanthoma, but other variants exist that can signal different underlying diseases 2.
• Causes include hyperlipidemia, metabolic dysfunction, local skin changes, and sometimes systemic conditions like diabetes or thyroid disease 1 2 3 4 5.
• Treatment options include surgical excision, laser therapy, chemical peeling, cryotherapy, and intralesional injections; each has unique advantages and drawbacks 5 6 7 8 9 10.
• Addressing underlying lipid abnormalities and systemic health is crucial to reduce recurrence and improve overall well-being 3 4 5 6 7.

By understanding the symptoms, types, causes, and treatments of xanthelasma, both patients and clinicians can make informed decisions for better health and quality of life.