Xanthelasma: causes, cholesterol link and treatment options

Patient.info says the lesions are typically asymptomatic and treatment is sought for cosmetic purposes, and that they can be left alone unless removal is wanted for appearance, which is not usually available on the NHS. Options it lists include surgical excision (with or without a skin graft for large lesions), chemical treatment such as topical trichloroacetic acid, laser treatment and cryocautery or liquid nitrogen. Surgical excision and cryocautery may be available in some primary care settings, while the other options are likely to need referral to secondary care.

PCDS says physical treatments such as curettage, laser and trichloroacetic acid chemical peels can all help, but lesions often recur. Patient.info likewise warns that xanthelasmas may recur after any of these interventions. Because the patches sit on the eyelids, treatment is best discussed with a GP, dermatologist or eyelid surgeon rather than attempted with home products.

The cause is lipid (fat) building up in the skin. Patient.info's professional article describes the plaques as areas of lipid-containing macrophages, and says the exact pathophysiology is not known. The Primary Care Dermatology Society (PCDS) describes xanthomata as skin lesions caused by the accumulation of fat in macrophages in the skin.

The link with blood fats is inconsistent. Patient.info says xanthelasma may be a localised skin condition without any abnormality of lipoprotein metabolism, or may be associated with an increase in cholesterol-rich LDL. PCDS says xanthelasma may or may not be associated with hyperlipidaemia (raised blood fats), while most types of xanthoma are indicative of disorders of lipid metabolism and may also be associated with other conditions such as diabetes mellitus or renal failure.

The NHS says high cholesterol does not usually cause symptoms and that you can only find out if you have it from a blood test.

Xanthelasma is a skin finding rather than a disease in its own right. Patient.info's professional article describes the typical appearance as yellow, flat plaques on the upper or lower eyelids, most often near the inner corner of the eye, which represent areas of lipid-containing macrophages. It says the exact pathophysiology is not known. PCDS describes them as soft and velvety, with yellow flat-topped papules or plaques that arise symmetrically on the upper and lower eyelids.

Both sources place xanthelasma in the wider family of xanthomata, the lipid-rich skin lesions that can appear in different places on the body. PCDS names tendon, tuberous, eruptive, plane and palmar types alongside xanthelasma, and says xanthelasma is the most common of them.

Patient.info says xanthelasma may be a localised skin condition without any systemic abnormality of lipoprotein metabolism, or may be associated with an increase in cholesterol-rich LDL. It says some patients with xanthelasma have normal lipid levels, which is less common in younger patients, and that although these people are not at increased risk of carotid atherosclerosis they are more commonly found to have other cardiovascular risk factors, such as a higher BMI, waist circumference and LDL cholesterol.

PCDS makes a broader point about xanthomata: most types are indicative of disorders of lipid metabolism and may also be associated with other conditions such as diabetes mellitus or renal failure. For this reason Patient.info recommends fasting lipid levels be checked, and a formal cardiovascular risk assessment if hyperlipidaemia is found, with prevention measures as indicated. In practice that means asking your GP for a blood test and a discussion about heart health, whether or not you want the patches treated.

The two sources are not identical on this point. PCDS says that if LDL cholesterol levels are raised, treatment to reduce the levels may improve the size of the lesions, and that many xanthomata improve with lipid lowering. Patient.info says that lipid-lowering medication and diet modification have a limited, if any, effect on these particular lesions. The practical message is that cholesterol treatment is advised for your heart and circulation if the blood test shows it is needed, and that any effect on the patches should be seen as a possible bonus rather than the aim.

Patient.info says xanthelasma occurs a little more often in women than in men, with a peak incidence in the fourth to fifth decades. Once a plaque has formed, it tends to stay the same size or grow slowly and does not go away by itself. The same source says eyelid function generally remains unimpaired and drooping of the eyelid (ptosis) is rare.

Because the diagnosis is usually obvious from colour and site, a doctor can often recognise xanthelasma by looking. Patient.info notes that syringomas, which are small skin-coloured papules on the lower eyelids, and milia, which are white spherical cysts, are sometimes mistaken for it.

Patient.info recommends that fasting lipid levels are checked in a person with xanthelasma, with a formal cardiovascular risk assessment if raised blood fats are found. The NHS says high cholesterol can only be found out from a blood test, and that too much cholesterol can block your blood vessels and make you more likely to have heart problems or a stroke.

Asking a GP about yellow patches is reasonable even if you do not want them treated. PCDS also describes other types of xanthoma that are more closely tied to lipid disorders and diabetes, and says that eruptive xanthomata appear as crops of small yellow papules that may be itchy or tender. New yellow lumps elsewhere, or lesions that appear quickly, are worth a prompt GP appointment.

PCDS describes tendon xanthomata as slowly enlarging nodules over the tendons, commonly on the backs of the fingers, the feet and the Achilles tendon, associated with severe raised cholesterol. Eruptive xanthomata appear as crops of small yellow papules, are usually itchy or tender, and are associated with high triglycerides, which may be secondary to diabetes. If you notice new yellow lumps elsewhere, or lesions that appear quickly, arrange a prompt GP appointment, because these types are more closely tied to lipid disorders and diabetes.

Patient.info says treatment is usually sought for cosmetic purposes and is not usually available on the NHS, while the lipid blood test and any cardiovascular risk assessment that follows would be part of routine NHS care. It says surgical excision and cryocautery may be available in some primary care settings, while other options are likely to need referral to secondary care.

Because the patches sit on the eyelids, treatment is best discussed with a GP, dermatologist or eyelid surgeon rather than attempted with home products. Ask about the chance of recurrence, which both sources describe as common, before deciding.