Eye
Eyelid
Tumors
Xanthelasma
Editorial Board Member: Bethany R. Rohr, M.D.
Last author update: 16 November 2023
Last staff update: 16 November 2023
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PubMed Search: Xanthelasma
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Prognostic factors | Case reports | Treatment | Clinical images | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Negative stains | Videos | Sample pathology report | Differential diagnosis | Additional references | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Patel P, Yeaney G. Xanthelasma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/eyeeyelidxanthelasma.html. Accessed December 14th, 2024.
Definition / general
- Xanthelasma is a soft yellow, lipid laden plaque occurring bilaterally on the medial aspect of eyelid skin
- It may occur in association with primary hypercholesterolemia
Essential features
- Yellow, lipid laden plaques occur symmetrically on bilateral medial upper and lower eyelids
- Typically occurs in middle aged to elderly patients; occurs in women more than men (Plast Reconstr Surg 2002;110:1310)
- About half of patients have hyperlipidemia (Plast Reconstr Surg 2002;110:1310)
- Histopathology reveals foamy histiocytes in the superficial dermis
Terminology
- Xanthelasma palpebrarum
- Cutaneous xanthoma
ICD coding
Epidemiology
- F > M (Plast Reconstr Surg 2002;110:1310)
- Age of onset: 15 - 73 years; peak: 30 - 50 years (Clin Cosmet Investig Dermatol 2017;11:1)
- ~Half of patients with hyperlipidemia (Plast Reconstr Surg 2002;110:1310)
- Increased likelihood of familial hyperlipidemia if presentation occurs at < 40 years of age (Plast Reconstr Surg 2002;110:1310)
- May be associated with atherosclerosis, diabetes mellitus and thyroid disease (Plast Reconstr Surg Glob Open 2023;11:e4982)
Sites
- Symmetric on eyelids
Pathophysiology
- Intracellular cholesterol rich deposition (Clin Cosmet Investig Dermatol 2017;11:1)
Etiology
- Primary hyperlipidemias (especially type 2a) (Plast Reconstr Surg 2002;110:1310)
- Low high density lipoprotein (HDL) levels (Clin Cosmet Investig Dermatol 2017;11:1)
- Secondary hyperlipidemias, such as hypothyroidism, diabetes mellitus, drugs (glucocorticoids, estrogens, etc.) (Plast Reconstr Surg 2002;110:1310)
- Diet rich in saturated fats, cholesterol and alcohol (Clin Cosmet Investig Dermatol 2017;11:1)
Clinical features
- Thin, yellow papules and plaques symmetrically distributed on the medial upper or lower eyelids
- May be associated with cirrhosis, thyroid disorder, nephrotic syndrome
- Periorbital hyperpigmentation noted in > 80% of women with xanthelasma (J Clin Aesthet Dermatol 2016;9:52)
Diagnosis
- Clinical diagnosis based on characteristic appearance
- Biopsy not usually required
Laboratory
- Lipid panel to evaluate for hypercholesterolemia
Prognostic factors
- Increased risk of recurrence with the following (Plast Reconstr Surg 2002;110:1310)
- All 4 eyelids are involved
- Underlying hyperlipidemia
- Prior recurrence
Case reports
- 29 and 40 year old women with xanthelasma palpebrarum arising as a side effect of nilotinib (BMJ Case Rep 2016;2016:bcr2015213511)
- 45 year old White man with a several year history of xanthelasma of the bilateral medial canthal area (Plast Reconstr Surg Glob Open 2023;11:e4982)
- 46 year old Japanese woman with a 1 year history of asymptomatic yellowish papules on the neck and elbow (J Dermatol 2019;46:e362)
- 66 year old man presented with longstanding lesions on the 4 eyelids for several years, recently becoming larger and heavily pigmented (Am J Dermatopathol 2023;45:646)
- 70 year old man with bilateral extensive nodular xanthelasma palpebrarum (Int Ophthalmol 2018;38:803)
Treatment
- Conservative, as nodules often recur
- Excision, laser ablation or topical treatment for cosmesis
- Lipid lowering agent (Ann Intern Med 2020;172:701)
- References: Plast Reconstr Surg Glob Open 2023;11:e4982, Dermatol Surg 2020;46:847
Clinical images
Contributed by Gabrielle Yeaney, M.D.
Bilateral eyelids
Microscopic (histologic) description
- Lipid laden foamy histiocytes in superficial dermis, clustering around blood vessel walls
Microscopic (histologic) images
Contributed by Gabrielle Yeaney, M.D.
Foamy cells superficial dermis
Lipid laden histiocytes
Extension around neurovascular bundle
Touton multinucleated cells
Perivascular clusters
Positive stains
- Additional stains are not required
- Oil red O
- CD68
- CD163
- Reference: Arch Pathol Lab Med 2009;133:1994
Negative stains
- BRAF V600E (wild type)
- CD1a
- Langerin
- Reference: Arch Pathol Lab Med 2009;133:1994
Videos
Xanthelasma (xanthoma of eyelid)
Sample pathology report
- Skin, eyelid, shave biopsy:
- Xanthelasma
Differential diagnosis
- Periorbital Erdheim-Chester disease:
- Similar but more abundant sheets of foamy histiocytes forming mass lesion
- Widespread, mulitfocal disorder involving viscera and bones, BRAF V600E
- Periorbital Langerhans cell histiocytosis:
- Injected foreign material, poly-L lactic acid (tissue filler) paraffinoma (J Cutan Pathol 2008;35:536):
- Paraffinoma features: look for empty pseudocystic spaces
Additional references
Board review style question #1
A 56 year old woman presents with bilateral eyelid lesions. Histopathology is shown. Which of the following is the most likely diagnosis?
- Chalazion
- Erdheim-Chester disease
- Langerhans cell histiocytosis
- Ruptured epidermal inclusion cyst
- Xanthelasma
Board review style answer #1
E. Xanthelasma is correct because there are abundant foamy histiocytes in the superficial dermis. Answer A is incorrect because chalazion typically shows mixed acute and chronic inflammation with extracellular lipid deposits; it is sometimes granulomatous. Answer B is incorrect because Erdheim-Chester is a non-Langerhans histiocytosis with intermixed lymphocytes, which may involve the orbit but also has involvement of other organ systems: bone, CNS, pituitary. Answer C is incorrect because there is not an abundant mixed inflammatory infiltrate with histiocytes showing grooved nuclei. Answer D is incorrect because ruptured epidermal inclusion cyst would show portions of epithelial lines cyst with a surrounding mixed inflammatory infiltrate, often with keratin debris and foreign body giant cells, many of which may contain keratin fragments.
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Board review style question #2
A 50 year old woman presents with bilateral medial upper eyelid yellow plaques. Which systemic medical condition is most likely associated with this pathology?
- Acromegaly
- Atherosclerosis
- Breast cancer
- Colon cancer
Board review style answer #2
B. Atherosclerosis. Xanthelasma characteristically presents with symmetric medial upper eyelid yellow plaques. It may be associated with cirrhosis, atherosclerosis, thyroid disorders, nephrotic syndrome, primary hyperlipidemias (especially type 2a) and diabetes mellitus. Answer A is incorrect because acromegaly is growth hormone overproduction and is not associated with xanthelasma. Answer C is incorrect because breast cancer is not associated with xanthelasma. Metastatic breast cancer can cause enophthalmos but not yellow plaques. Answer D is incorrect because colon cancer is not associated with xanthelasma.
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