A 44-year-old white female presented with a yellow-orange plaque under her left eye. The lesion had been present for approximately 1 year and was slowly enlarging. The patient had no other medical problems and no history of dyslipidemia. Her cholesterol level was 170.
Physical examination revealed a yellow orange plaque under her left eye measuring approximately 1.1 x 0.6 cm. (Figure 1) Hyperpigmentation and crinkling of the skin was present over both lower lids. Because of the distinctive color and distribution of the plaque, a diagnosis of unilateral xanthelasma was made.
Figure 1. Yellow-orange plaque under the patient’s left eye with crinkling of the eyelid skin and mild undereye hyperpigmentation.
Trichloroacetic acid, surgical excision, and laser skin resurfacing are the favored modalities for the treatment of xanthelasma. Laser skin resurfacing was thought to be the best choice in this case because it would remove the xanthelasma and at the same time improve the dark circles and crinkling of the lower lid skin. All four treatments have a risk of incomplete clearing the xanthelasma and a chance of recurrence.
The patient was anesthetized using a 1% lidocaine with epinephrine infraorbital block and local infiltration. Both sides of her face were treated so that there was not a disparity between the improved lower eyelid texture and color. Prophylaxis with dicloxacillin 500 mg orally twice a day for 2 weeks and valacyclovir 500 mg orally twice a day for 10 days was started the day before surgery. Metal eye shields were put into place. The patient’s entire lower lids were then treated with the CO2 laser (Ultrapulse; Coherent Inc., Santa Clara, CA) in four passes as follows: one pass at 350 mJ with the 3-mm handpiece, one pass at 250 mJ with the 3-mm handpiece, and two passes at 250 mJ/50W with the computer pattern generator handpiece (pattern 2, size 7, density 5). The xanthelasma was then treated with nine passes at 250 mJ/50 W with the computer pattern generator handpiece (pattern 2, size 7, density 5). (Figure 2A, B)
Figure 2A. Immediately postprocedure with the CO2 laser.
Figure 2B. Immediately postprocedure with the CO2 laser.
The patient tolerated the procedure well and was instructed to liberally apply a bland ointment and perform soaks at home every 2 hours. During the healing process, the xanthelasma remained visible until complete reepithelialization occurred. At 3 days, the lesion was 75% covered by normal epidermis. Healing was complete at 10 days.
The patient was photographed at 6 months’ postprocedure with significant improvement in lower eyelid texture and dark circles. (Figure 3) She remains free of recurrence at 4 years.
Figure 3. Six months’ postprocedure with good clearance of the xanthelasma and improvement in crinkling and dark circles in the undereye area.
Melissa A. Bogle, MD, Laser and Cosmetic Surgery Center of Houston, Houston, Texas
Jeffrey S. Dover, MD, FRCPC, SkinCare Physicians, Chestnut Hill, Massachusetts; Section of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Department of Dermatology, Dartmouth Medical School, Hanover, New Hampshire
Kenneth A. Arndt, MD, SkinCare Physicians, Chestnut Hill, Massachusetts; Section of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut; Department of Dermatology, Dartmouth Medical School, Hanover, New Hampshire; Department of Dermatology, Harvard Medical School, Boston, Massachusetts