What is Xanthelasma?
Also known as xanthelasma palpebrum, these planar, yellow-to-gray plaques can be found on the eyelids and periorbital skin area. They are the most frequent and least specific of most xanthomas. They will not normally cause pain to the sufferer, but they can be cosmetically disfiguring and thus cause embarrassment and depression, due to their visual nature.
Xanthelasma can take many forms, and they may be soft, semisolid, or calcareous. They often form in symmetrical patches, and the upper eyelids are more frequently affected than the lower lids. In many cases, all 4 lids are involved. They often range in size from 2 – 30mm and are flat surfaced and have distinct borders, and they will often grow in size and in number over time. They are ‘foamy’ in nature and classed as a cutaneous necro-biotic disorder.
When observed in isolation, xanthelasma can present a diagnostic problem because one-half of patients with it have normal lipid levels. However, their existence, especially in a young patient, justifies an extensive history, physical examination, and investigation of your fasting plasma lipid levels. So, what is the xanthelasma definition?
Xanthelasma are the cutaneous manifestations of lipidosis, a condition in which lipids (molecules that naturally occur in the body, lipids include sterols fat-soluble vitamins A, D, E, and K, fats, waxes, monoglycerides, diglycerides, triglycerides and phospholipids) cluster in skin cells and become visible on the surface.
Basically, xanthelasma is the deposit of cholesterol in the white blood cells of the skin, resulting in the formation of yellow plaques on the surface. There are a number of types of xanthelasma based on different pathologies. However, the original xanthelasma definition stays the same. Here we describe the many types as well as the clinical presentation of this disease.
Tests for Xanthelasma
Characteristic appearance on physical examination
As the Xanthelasma definition states, these lesions appear as planar, yellow-to-gray plaques present on the eyelids and the periorbital epidermis
Carrying out a fasting lipid level test can readily determine whether a patient’s xanthelasma was a consequence of hyperlipidemia in the first place. Clinicians should test patients with xanthelasma, particularly if they are young or have multiple family histories with early on atherosclerotic disease.
The positioning of xanthelasma creates a confusion. One significant differential diagnosis is an appendageal tumor. It is important to rule out any malignancy and this is best done by examining the tissue under a microscope.
Who is vulnerable to this Disease?
As the Xanthelasma definition implies, it can happen in a number of hereditary disorders of lipoprotein metabolism including homozygous and heterozygous familial hypercholesterolemia, familial dysbetalipoproteinemia (type III), and in systemic disease.
What is the reason for the Disease?
Many times it is the lipid that is at the root of this disorder, as is evident by the xanthelasma definition. There may be good proof that the lipid found within xanthomas is the same lipid circulating in high concentrations in the plasma of patients. However, the precise mechanisms that result in xanthoma development are less clear. It’s been proven that scavenger receptors for low-density lipoprotein (LDL), present on macrophages can take-up lipid. This converts them into foam skin cells. It has additionally been proven that extravasated lipid can produce foam skin cells by inducing vascular endothelial receptors.
Furthermore, oxidized low-density lipoprotein has been proven to be involved in the creation and infiltration of foam skin cells within the dermis. Local factors like temperature, activity, and friction may increase LDL leakage from capillaries. This further aggravates the condition.
Systemic Implications and Complications
The basic xanthelasma definition should allow the clinician to check for complications of hyperlipidemia. These patients should be screened for lipid abnormalities and also have vigilant treatment of their lipid derangement to decrease the development of atherosclerotic disease. This is necessary to reduce the vascular and in turn heart, thrombotic, clotting and organ complications of deranged lipid levels.
Different kinds of Xanthoma
- Lesions occur symmetrically on higher and lower eyelids
- Lesions are delicate, yellow papules or plaques
- Lesions start as small bump and slowly but surely grow greater over almost a year. as demonstrated in the image, left to thier own devices, xanthelasma on the cheek and xanthelasma on the nose, can be a possible outcome.
- May or may not be associated with hyperlipidemia
- Firm, uncomplicated, red-yellow nodules that develop about the pressure areas including the knees, elbows, and buttocks. These are a little different than the typical xanthelasma definition but follow the same pattern.
- Lesions can accumulate together to create multilobulated masses
- Usually associated with hypercholesterolemia (increased cholesterol levels in blood vessels) and increased LDL levels.
- These xanthomas are firm swellings that lie deep in the subcutaneous layer of the skin.
- Appear as gradually enlarging subcutaneous nodules related to the tendons or ligaments
- The yellow plaques as stated in the xanthelasma definition occur most commonly in the hands, feet, and Calf muscles.
- Connected with severe hypercholesterolemia and enhanced LDL levels.
- They are primarily attached to tendons and are commonly found at the Achilles tendon at the ankle and the extension tendons of the fingers.
Diffuse plane xanthomatosis
- An exceptional form of histiocytosis that is different from the typical xanthelasma definition.
- Caused due to an unusual antibody in the bloodstream called a paraprotein.
- Lipid levels are normal.
- About 50% will have a malignancy of the blood vessels; usually multiple myeloma or leukemia.
- Presents with large level reddish-yellow plaques over the facial skin, neck, breasts, and buttocks and in skin folds (like the armpits and groin).
- Lesions typically erupt in groups of small, red-yellow papules
- Most commonly come up on the buttocks, shoulders, legs, and arms but might occur all around the body
- Rarely the facial skin and the mouth area may be affected
- Lesions may be sensitive and usually itchy
- Strong link with hypertriglyceridemia (increased triglyceride levels in bloodstream) often in patients with diabetes mellitus.
- Lesions are flat papules or areas that may appear anywhere on your body
- Lesions on the creases of the hands are indicative of consistent levels of increased lipids in blood vessels called type III dysbetalipoproteinemia
- Could be associated with hyperlipidemia and hypertriglyceridemia.
- Combined with tuberous xanthomas is indicative of type 3 dysbetalipoproteinemia.
- Xanthoma-like lesions anticipated to an uncommon form of histiocytosis.
- Lipid metabolism is normal.
- The skin lesions are a huge selection of small yellowish-brown or reddish-brown bumps, which can be cover the facial skin and trunk. They could particularly have painful consequences on the armpits and groins.
- The tiny bumps can link with one another and form sheets of thickened pores and skin.
All of these different types of xanthomas signify that the disease can present in a variety of ways. However, usually, the primary xanthelasma definition remains true for all. Although the condition itself doesn’t have consequences other than cosmetic problems, you do need to consider the lipid manifestations. The disease requires proper work up to prevent the lipid complications. Plus, the plaque itself can be removed easily. However, unless the lipid levels are controlled there is a high risk of recurrence.
Xanthelasma under the microscope.
The hallmark histopathologic feature of most xanthomas is the occurrence of foam skin cells within the dermis. These skin cells represent macrophages that have accumulated lipid. These skin cells will stain positive for lipid with special staining (Oil-red-O). According to the location of the plaque and the specific location of the foam cells, a histologic specimen of Xanthelasma can contain striated muscle, hairs or just epidermis.
Skin samples showing the Xanthoma cells.
One of the most common causes of Xanthelasma on the eyelids is in people suffering with both primary and secondary hyperlipidemia (elevated levels of any or all lipids and/or lipoproteins found in the blood).
If you have been diagnosed with altered lipoprotein composition or structure, such as lowered high-density lipoprotein (HDL) levels or type II hyperlipidemia in the type IV phenotype, you are more likely to suffer from Xanthelasma.
Are Xanthelasma dangerous?
While the Xanthelasma patches are not harmful themselves, they can be indicative of more serious problems, such as heart disease and high levels of cholesterol. If you do not have a family history of Xanthelasma, they can be an indication of high cholesterol. They might be correlated with a risk of heart disease, and so it is always a good idea to have them examined by your GP to rule out any further problems.
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