Introduction

Xanthelasma palpebrarum (XP), the most common cutaneous xanthoma, presents with yellowish plaques over the medial aspect of upper and lower eyelids. It is a benign skin problem commonly affecting the middle-aged and the older adults and can be very disfiguring.[1] Various modalities of treatments are available ranging from medicines such as probucol, alirocumab, and pingyangmycin to simple excision, cryotherapy, TCA peels, phenol cautery, radio frequency, and lasers.[23] The disadvantages of the procedures include delayed wound healing, chances of scarring, pigmentary alterations, and recurrence. Among the lasers used, pulsed dye laser (PDL) is a promising approach but has not been widely used in India for the treatment of XP. We report the efficacy of PDL in the management of XP.

Materials and Methods

Five cases of XP, aged between 40 and 50 years, were selected for PDL treatment after proper history taking and examination. They had in total 14 lesions, size ranging from 4 to 7mm. Two of them had hypercholesterolemia and one patient had diabetes and was on OHA (oral hypoglycemic agent). They had no absolute contraindications such as active infection at the treatment site or pregnancy. The selected patients were counseled and photo documentation was done before the procedure. Eutectic mixture of lignocaine (2.5% wt/wt) and prilocaine (2.5%) was used as topical anesthetic agent. Intraocular eye shields were used before starting the laser session. The patients were given four sessions of PDL (Vbeam; Candela, USA) treatment at an interval of 2 weeks. The parameters used were wavelength of 595nm, fluence 7–10 mj, pulse duration 1.5–3ms, spot size 5mm, number of passes 2, and DCD settings 30/10ms. After the procedure, the patients were observed for immediate complaints such as erythema, edema, pain, and blister formation. Most of them showed a bluish discoloration immediately at the treated site. All the patients tolerated the procedure well and had no pain or purpura. All of them developed minimal crusting that cleared within 5 days. They were asked to apply a repairing cream containing Rhealba oat and hyaluronic acid (0.2%) for 5 days and were advised to protect the treated area from ultraviolet rays till they completed their treatment. They were asked to visit the clinic after 2 weeks for assessment and for subsequent sessions. Photo documentation was done during each visit. The results were assessed clinically and by comparing photographs. They were followed up for 2 years at an interval of 6 months.

Results

All the patients showed 90%–100% clearance after four sessions [Figure 1–4]. None of them had any complications such as scarring or dyschromia. There was no recurrence in any of the patients at the end of 2 years.

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Figure 1

Xanthelasma palebrarum: before PDL treatment

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Figure 2

Xanthelasma palebrarum: after four sessions of PDL

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Figure 3

Xanthelasma palebrarum: before PDL treatment

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Figure 4

Xanthelasma palebrarum: after four sessions of PDL

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Discussion

XP is commonly treated surgically either by simple excision or by using radio frequency or lasers. Ablative procedures such as radio frequency and carbon dioxide/argon laser require local anesthetic injection; cause pain; and carry risk of infection, scarring, and pigmentation.[45678] These lesions could bleed profusely as the foam cells are intermingled with blood vessels. Moreover these techniques have downtime of 7–10 days. To overcome these issues, nonablative lasers such as PDL have been tried and are found to be effective in the management of XP.[9] But no studies on PDL are reported from India till date.

The exact mechanism of xanthelasma laser surgery is not fully understood. It is presumed that the heat energy, which originates from the coagulation of the vessels within the upper dermis, leads to a damage of the perivascular foam cells. The coagulation of the pathologically hyperpermeable vessels would lead to a block of the leakage of lipids into the tissue and thereby prevent recurrent lesions.

All the patients responded well to the PDL treatments and lesions were removed fully after the fourth session. No local anesthetic was injected and none of them had significant periorbital bruising, which is a major aesthetic advantage over ablative laser treatments. The postprocedure swelling was minimal and was managed with anti-inflammatory creams. There was no scarring as the skin was not cut or ablated during the procedure and none of the patients developed post-inflammatory hyper/hypopigmentation following any of the sessions. The patients were followed for 2 years after complete clearance and none of them had recurrence within that period. This is also a significant advantage over other conventional methods.

Conclusion

Our results prove the efficacy of PDL in the management of XP and this method should be offered for those patients who opt for nonablative laser procedures. Treatment of XP with PDL causes less scarring and the recurrence rate is also low.