The medical term xanthelasma palpebrarum is composed of two words. Xanthelasma, derived from ancient Greece where "xanthos" means yellow and "elesma" means plate. Palpebrarum is a Latin word that means "near or related to the eyelid." It is a lipid-rich deposition, mainly cholesterol. It is mostly semisolid yellowish deposits that are commonly found on the medial aspect of the eyes. It is often seen along the corners of the upper and lower eyelids. Xanthelasma palpebrarum is the commonest coetaneous presentation of xanthoma which occurs over the eyelids, even with the absence of any other cutaneous or mucosal lesions. It is characterized by soft, yellowish papules and plaques that occur more commonly near the inner canthus of the eyelid more often at the upper eyelid. Lesions are usually symmetrical. There might be one or multiples. 
Xanthelasma palpebrarum is a benign condition that never leads to serious consequences, but it is cosmetically bothersome, and most of the patients are unhappy about their image, and they seek medical advice. The patients visit dermatology offices, Reconstructive surgery clinics, and ophthalmology clinics looking for permanent solutions.
About 50% of patients who develop xanthelasma have lipid disorder. It is commonly seen in patients with:
Xanthelasma palpebrarum are observed also in patients who had previous erythroderma, generalized cutaneous inflammatory dermatosis, and in cases who had previous contact dermatitis. It may be a predictor of ischemic heart disease, myocardial infarction, or systemic atherosclerosis.
Xanthelasmas are the most widely recognized type of xanthoma. They are yellowish deposits composed of a cholesterol-filled substance that appear mostly over the medial aspects of the eyelids. Several medical conditions associated with the appearance of xanthelasma including hyperlipidemia, Diabetes and thyroid dysfunctions. It might appear in patients with normal lipid profile namely, cholesterol and triglyceride levels.
In xanthelasma palpebrarum, the epidermis is spared and the papillary dermis as well. In the reticular dermis, the inflammatory infiltrate is perivascular, and it is composed of mixed cells including mono and multi-nucleated foam cells within the lipid-laden cytoplasmic vacuoles in the superficial reticular dermis. The subcutaneous fatty layer is usually spared.
These lesions are often seen in the fourth and fifth decade of life. Once xanthelasma has developed, it will not spontaneously disappear but will remain the same or increase in size. The majority of people come to attention because of cosmetic concerns. Typically, xanthelasma palpebrarum patient presents with soft, yellowish papules and plaques over the medial canthus of the upper lid. Sometimes it might be solid, semi-solid or firm. These papules cannot be squeezed. These deposits usually will not go away on their own and typically will grow up with the time.
Since a high number of individuals with xanthelasma have a lipid disorder, measurement of serum lipid profile is recommended. Also, liver panel, thyroid function test, fasting blood glucose can be done, or if the patient is diabetic, the glycosylated hemoglobin level measures the blood sugar control over the last 3 months. In most of the cases, cholesterol and triglyceride levels are elevated, and the high-density lipoprotein (HDL) level is reduced. To measure the lipid profile accurately, the patients should fast for at least 12 hours.
The treatment of xanthelasma involves changes in lifestyle and taking medications to lower serum lipids. Even though a low-fat diet and statins are often recommended, they have a limited effect on xanthelasmas once they have developed. If the lesions are a cosmetic concern, they can be excised by simple surgical procedure, cauterized, or removed with liquid nitrogen sessions. Surgery around the eyelids is fraught with complications and can result in ectropion, eyelid retraction, and injury to the eye itself. Use of cryotherapy and chemical cauterization can lead to severe scarring and skin discoloration.
Other methods include chemical peels utilizing trichloroacetic acid (TCA) in a high percentage of 50% or above to reach to the optimum depth for the cholesterol deposits in the reticular dermis; similar substances like salicylic acid might be used as well. Deep peels may be complicated by hyperpigmentation, especially in dark-skin individuals, so the treating physician should pay attention to this point very well.
Lasers can be used to treat selected cases of xanthelasma palpebrarum using carbon dioxide, erbium, pulsed dye, argon, and Nd:YAG lasers. Most of the patients might accept laser treatments since they are not associated with tissue destructions or loss, and its better alternative for surgery. Complications of laser therapy include pain, erythema, pigmentations, scars, and eyes injuries. Fractionated Er:YAG and/ or fractionated CO2 lasers are the most commonly used machines to treat xanthelasmas.
Radiofrequency machines can be used to treat some cases of xanthelasma because it is a very safe method compared to other modalities but it is less effective, and it might be expensive.
Even after removal, recurrence of xanthelasma is common especially due to genetics and high cholesterol levels. Lipid-lowering medications can be used in patients with high cholesterol and triglyceride levels to prevent ischemic attacks and further deposits.
A treatment plan for any patient with xanthelasma should be interprofessional involving a dietician, internist, dermatologist, and oculoplastic surgeon. Always remember to start with changing the dietary lifestyle of the patient, and if he or she requires lipid-lowering drugs, refer them to an internist before establishing treatment sessions. Simple and safe treatment methods should be tried first. Invasive procedures should be the last option. Liquid nitrogen sessions are the first to be offered for the patients.
Unfortunately, the recurrence rate of xanthelasma is high despite the treatment mode. Furthermore, it is important to treat the underlying medical conditions like hyperlipidemia, liver diseases, diabetes, and thyroid disorders.
Assessment of any patients with xanthelasma palpebrarum starts with taking a full, detailed history and doing a proper physical examination. A family history of ischemic heart diseases is important, and it might give a clue for the depth of hyperlipidemia in the family. Dietary lifestyle modifications like reducing carbohydrate and fat intake and replacing these with vegetables and fruits will help in reducing the cholesterol and triglyceride levels. Physical exercise is very important to lower the lipid level. Treatment of the underlying causes such as diabetes, thyroid problems, and obesity will improve the overall result of the treatment sessions.
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