Rare and unusual presentation of periorbital xanthelasma Manpreet - - PDF document

Rare and unusual presentation of periorbital xanthelasma

Manpreet Juneja ⇑, Qurratulain Chougle, Suhas Abhyankar

Department of Plastic Surgery, D Y Patil Hospital & Research Centre, Sector 5, Nerul, Navi Mumbai 400 706, Maharashtra, India Received 6 January 2016; accepted 4 May 2016 Available online 7 June 2016

Abstract This report presents a sixty year old female with unusual appearance of bilateral xanthelasma palpebrarum of periorbital region. These lesions were approximately 7 cm 3 cm in dimensions. Patient’s main complaints were aesthetic appearance and hindrance in downward gaze. Considering the size of the lesions surgical excision was planned and the raw area covered with full thickness skin grafts from supra clavicular region. The aesthetic and functional outcome was good. The aim of this case report is to put forward an unusual presentation of xanthelasma, at the same time to keep in mind the surgical excision with full thickness skin grafting as an excellent treat- ment modality for periorbital xanthelasma palpebrarum especially in large lesions where other modalities have their own limitations. 2016 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY- NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Xanthelasma; Skin graft; Hyperlipidemia

• 1. Introduction

Xanthelasma palpebrarum is the most common form of

• xanthoma. The lesions appear as yellowish, flat, and soft

and are located mostly at the medial angle of the eyelid (Shields and Shields, 2008). Although xanthelasma is a benign condition and almost never limits functioning, its appearance is often seen as cosmetically disturbing. Surgi- cal excision has been the treatment of choice for decades (Cohen, 1996). Recently, several case reports have described the successful treatment of xanthelasma with the carbon dioxide laser and Q-switch Nd-YAG (Raulin et al., 1999). Alternatives to this treatment is cauterization with trichloracetic acid, liquid nitrogen, or organic and nonorganic acids. However, all of these methods bear multiple sittings and considerable risks of side effects. The therapeutic effect of chemical measures is often unsat-

• isfactory. The depth of tissue penetration by the chemicals

is hardly controllable, the risk of damage to the conjuncti- vae or the sclerae is high (see Figs. 1–4).

• 2. Case report

A 65-year-old female presented in our outpatient department with chief complaints of yellowish papular lesion in the periorbital region of both the eyes since five

• years. The lesions first appeared as small, slightly elevated

plaques which were well circumscribed on the inner canthi

• f the lower eyelids. The lesions gradually increased in size.

On local examination the size of the right infraorbital lesion was 7 4 cm and left infraorbital lesion was 6 4 cm. Rest of the physical examination was normal with no similar lesions elsewhere on the body. Routine investigations including complete haemogram and urine analysis were normal. Lipid profile was within normal lim-

• its. The differential diagnosis based on the clinical profile

was xanthelasma, scleroderma and neurofibromatosis.

http://dx.doi.org/10.1016/j.jdds.2016.05.001 2352-2410/ 2016 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

⇑ Corresponding author. Mobile: +91 9819359019.

E-mail address: drmanpreetjuneja@gmail.com (M. Juneja). Peer review under responsibility of King Saud University. Production and hosting by Elsevier

Available online at www.sciencedirect.com www.jdds.org

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Journal of Dermatology & Dermatologic Surgery 20 (2016) 149–151

Due to unusual appearance of the lesions, the definitive diagnosis was arrived at by tissue biopsy. The histopathol-

• gy showed localised collection of histiocytes with foamy

vacuolated cytoplasm, a few lymphocytes and neutrophils in the dermis. Touton’s type giant cells were also noted. After thorough counselling of the patient and considering the cosmetic and functional complaints, we planned the surgical excision of the lesions and resurfacing of the defect with full thickness skin graft. The full thickness skin grafts were harvested from supraclavicular region to provide a good colour match. The check dressing was done after a period of 7 days. There was complete graft take. The patient was followed up to eighteen months with satisfac- tory outcome and no complications.

• 3. Discussion

Xanthomas are lesions characterised by accumulation of lipid-laden macrophages. Xanthelasma palpebrarum is the most common of the xanthomas. A xanthelasma may instead be referred to as a xanthoma when it is larger and nodular, assuming tumourous proportions (Shields and Shields, 2008). It presents as an asymptomatic, usually bilaterally symmetric soft, velvety, yellow, flat, and polyg-

• nal papules around the eyelids. They are common in peo-

ple of Asian origin and those from the Mediterranean region. Xanthelasmas are most common in the upper eyelid near the inner canthus. Xanthelasma may be associated with hyperlipidemia in which any type of primary hyper- lipoproteinemia can be present. Some secondary hyper- lipoproteinemias, such as cholestasis, may also be associated with xanthelasma. The colour of the patches and its appearance near the eyelids are enough to diagnose the condition. The diagnosis in a confounding case can be confirmed by tissue biopsy. Histologically, it is charac- terised by a regular epidermis and a dense distribution of the xanthomitized macrophages interspersed by numerous Touton’s type giant cells (Cohen, 1996; Breier et al., 2002). Many people find this form of the condition particularly embarrassing and disfiguring, hence opt for removal of the

Figure 2. Intraoperative photograph after excision of xanthelasma. Figure 3. Intraoperative photograph showing sutured full thickness graft. Figure 4. Post operative photograph at 18 month follow up. Figure 1. Pre operative photograph of patient with bilateral periorbital xanthelasma in frontal view. 150

• M. Juneja et al. / Journal of Dermatology & Dermatologic Surgery 20 (2016) 149–151

• lesion. Due to its delicate location near the eye and the high

recurrence rate, the therapy of xanthelasma palpebrarum is a difficult surgical task (Bergman, 1994; Kaplan et al., 1961). The ‘‘classical” treatment option for xanthelasma palpebrarum is the surgical excision. Alternatives to this treatment are cauterization with trichloracetic acid, liquid nitrogen, or organic and nonorganic acids. However, all

• f these methods bear considerable risks of side effects.

The depth of tissue penetration by the chemicals is hardly controllable; the risk of damage to the conjunctivae or the sclerae is high. Some groups have reported about the treatment of xanthelasmas with the pulsed dye laser or the argon laser. However, recently, several case reports have described the successful treatment of xanthelasma with the carbon dioxide laser (Raulin et al., 1999; Dua et al., 2006). In the current era of lasers, the classical method of sur- gical excision is often overlooked but in certain cases as was in our patient it still serves as a valid treatment option. The surgical treatment modality provides treatment in a single stage, provides aesthetically satisfactory result and at the same time provides tissue for histopathological diag-

• nosis. Zarem and Lorincz’s approach superficially excises

xanthelasma lesions, although they also support light elec- trodessication and topical treatment with trichloroacetic acid (Zarem and Lorincz, 1973). Le Roux advocates a modified blepharoplasty incision approach to address the medial canthal area, where xanthelasma are typically found (Le Roux, 1997). Parkes and Waller advocate serial exci- sions (Parkes and Waller, 1984). Hosokawa et al. have described the use of orbicularis oculi musculocutaneous flaps to provide coverage after excision of large lesions.

• 4. Conclusion

Various modalities exist for the treatment of xanthe- lasma, ranging from simple excision, to laser treatment, to chemical peeling. It is advisable to treat as soon as diag-

• nosed. The surgical excision with resurfacing using full

thickness graft is a clever therapeutic option for the treat- ment of xanthelasma palpebrarum especially for large lesions. References

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