Ultrapulse carbon dioxide laser ablation of xanthelasma palpebrarum: a case series

Tissue Ablation: Applications and Perspectives

Tissue ablation techniques have emerged as a critical component of modern medical practice and biomedical research, offering versatile solutions for treating various diseases and disorders. Percutaneous ablation is minimally invasive and offers numerous advantages over traditional surgery, such as shorter recovery times, reduced hospital stays, and decreased healthcare costs. Intra-procedural imaging during ablation also allows precise visualization of the treated tissue while minimizing injury to the surrounding normal tissues, reducing the risk of complications. Here, the mechanisms of tissue ablation and innovative energy delivery systems are explored, highlighting recent advancements that have reshaped the landscape of clinical practice. Current clinical challenges related to tissue ablation are also discussed, underlining unmet clinical needs for more advanced material-based approaches to improve the delivery of energy and pharmacology-based therapeutics.

Examining treatment strategies for xanthelasma palpebrarum: a comprehensive literature review of contemporary modalities

Xanthelasma palpebrarum (XP) is the predominant form of cutaneous xanthoma, as it accounts for greater than 95% of cases. It is characterized by the presence of foam cell clusters containing a large amount of low-density lipoprotein (LDL), which are located in the connective tissue of skin, tendons, and fascia. XP lesions commonly present as distinctive yellow-orange macules, papules, or nodules, and are primarily on the upper eyelids as well as the inner canthus. Women are affected twice as often as men, with lesions typically emerging between the ages of 35 and 55. The pathophysiology of XP involves abnormal lipid metabolism and is often associated with hyperlipidemic states like Type II and IV hyperlipidemia, hypothyroidism, weight gain, and fatty diet. Despite the availability of various treatment methods, current XP management lacks standardization, particularly due to limited comparative research. To address this gap, we conducted an extensive literature review of 45 studies published between 2012 to 2023, which provides an updated overview of current XP treatment modalities. This comprehensive analysis will inform researchers and clinicians on the evolving landscape of XP management.

Clinical and dermoscopic assessment of ablative carbon dioxide laser versus intradermal heparin sodium in xanthelasma

BACKGROUND

Ablative carbon dioxide (CO2 ) laser is still a cornerstone in the management of xanthelasma. However, post-laser complications such as post-inflammatory hyperpigmentation or scarring have to be considered. Heparin sodium was recently suggested as an effective therapeutic modality for xanthelasma.

OBJECTIVE

The aim of this work was to compare the therapeutic value of ablative CO2 laser versus intradermal heparin sodium in xanthelasma.

METHODS

This study was piloted on 30 xanthelasma patients, whose lesions were randomly categorized into two groups. Group A was managed with CO2 laser ablation (2 sessions scheduled every 4 weeks), whereas Group B was managed with intradermal heparin sodium injections (10 sessions scheduled every week). Pre- and post-treatments evaluations were done both clinically and dermoscopically.

RESULTS

Significant reduction of xanthelasma lesions was reported in response to both therapeutic interventions. However, the ablative CO2 laser was more significantly effective than intradermal heparin sodium. Interestingly, intradermal injection of heparin sodium was nearly as effective as ablative CO2 laser in early (<2 years duration) grade I and II xanthelasma, with a lower incidence of post-therapy side effects.

CONCLUSIONS

Intradermal injection of heparin sodium could be suggested as a safe and cost-effective therapeutic technique for early mild grade I and II xanthelasma. Moreover, it could be recommended as a pre-operative management of grade III and IV xanthelasma to reduce the lesions to be easily ablated with CO2 laser.

A Practical Review of the Management of Xanthelasma palpebrarum

Xanthelasma palpebrarum is the most common type of xanthomatous lesion. Various methods for treating Xanthelasma palpebrarum have been reported. We conducted a systematic review to evaluate the efficacy and associated complications of different treatment methods, and we summarized these findings as a practical review designed to be clinically useful, accessible, and impactful.

Methods

The PubMed and Embase databases were searched to identify clinical studies that reported on outcomes and complications of different methods of Xanthelasma treatment. The electronic databases were searched from January 1990 to October 2022. Data on study characteristics, lesion clearance, complications, and recurrences were collected.

Results

Forty-nine articles (including 1329 patients) were reviewed. The studies reported on surgical excision, laser modalities, electrosurgical techniques, chemical peeling, cryotherapy, and intralesional injection. The majority of studies were retrospective (69%) and single-arm (84%). Surgical excision combined with blepharoplasty and skin grafts showed excellent outcomes for large Xanthelasma. CO₂ and erbium yttrium aluminum garnet (Er:YAG) were the most commonly studied lasers and showed more than 75% improvement in over 90% and 80% of patients, respectively. Comparative studies reported better efficacy for CO₂ laser than both Er:YAG laser and 30%-50% trichloroacetic acid. Dyspigmentation was the most encountered complication.

Conclusions

Different methods for the treatment of Xanthelasma palpebrarum have been reported in the literature, with moderate to excellent efficacy and safety profiles depending on the size and location of the lesion. Surgery is more appropriate for larger and deeper lesions, whereas laser and electrosurgical techniques can be used in smaller and more superficial contexts. Only a limited number of comparative studies have been conducted, and novel clinical trials are necessary to further augment appropriate treatment selection.

An overview on the role of CO2 laser in general dermatology

Among different laser types, the carbon dioxide (CO₂ ) laser remains one of the most used by dermatologists. Its usefulness has been demonstrated both for therapeutic and cosmetic purposes. This review aims to provide an overview of the applications of CO₂ laser in dermatology, focusing on the treatment of infective, neoplastic, and antiaesthetic lesions.

A Comparison of Efficacy and Safety of Fractional Carbon Dioxide Laser and Fractional Er:YAG Laser for the Treatment of Xanthelasma Palpebrarum: A Two-Center Randomized Split-Face Controlled Trial

Background: Xanthelasma palpebrarum (XP) is a form of cutaneous xanthoma that presents as collections of yellowish papules or plaques around the eyelids or canthus, affecting patients cosmetically. Objective: This study aimed to compare the efficacy and safety of fractional carbon dioxide (CO₂) laser to that of fractional Er:YAG laser for the treatment of XP. Methods: Two centers recruited patients diagnosed with XP of bilaterally symmetrical lesions. The lesion on one side was randomly assigned to be treated with fractional CO₂ laser while the lesion on the other side was treated with fractional Er:YAG laser. All subjects received up to five treatments, with a 4-week interval between each treatment. Results: Thirty-nine patients completed the study and a total of 82 lesions were available for final assessment. The percentage of "Excellent Improvement" on third and fourth visit was 60.98% versus 39.02% and 90.24% versus 63.41%, respectively, p < 0.05. In a follow-up for 12 to 25 months, the number of lesions recurred on the side treated with fractional CO₂ laser and fractional Er:YAG laser are 9 (22%) and 10 (24%), respectively. Conclusions: In this study, fractional CO₂ laser therapy appears superior since a fewer treatments are required for patients to show significant clinical improvement.

Fractional CO2 laser versus trichloroacetic acid 50% for xanthelasma palpebrarum therapy

BACKGROUND

Although being a benign lesion, xanthelasma palpebrarum (XP) causes cosmetic concerns. There are numerous therapeutic methods for XP with adverse events for each method.

AIMS

Evaluate the safety, efficacy, and downtime of fractional CO₂ laser (10 600 nm) versus 50% trichloroacetic acid (TCA) in XP therapy.

PATIENTS/METHODS

Comparative interventional prospective study involved 20 adult patients with XP. Each patient received a split-face therapy where xanthelasma lesions treated with fractional CO₂ laser on the one side and TCA 50% on the other side for maximum 5 sessions with 2-week intervals in between.

RESULTS

Statistically significant improvement in lesion color, thickness, and size by both fractional CO₂ and TCA 50%, with nonstatistically significant difference between both therapeutic modalities after treatment, although downtime, number of sessions, and patient's satisfaction were significantly better for fractional CO₂ laser.

CONCLUSION

Fractional CO₂ laser (10 600 nm) is ideal for treatment of xanthelasma because it is safe and effective with short downtime, more patient satisfaction, less sessions, and less complications compared with chemical peeling using TCA (50%).

Xanthelasma Palpebrarum: More than Meets the Eye

Xanthelasma palpebrarum (XP) is the most common form of cutaneous xanthomata, and is important aesthetically, because of its close relation to the eyes, as well as medically for its association with cardiovascular disease (CVD). To provide avant-garde review discussing the various aspects of XP, including its aetio-pathogenesis and various treatment modalities. A structured Pubmed and Medline were searched for relevant articles. The finding of recent research has strongly espoused the link between XP and CVD, and mechanisms have been suggested for its formation. The new technologies have led to a multitude of treatment options for XP. XP is a multi-faceted entity; other than simple treatment of the cosmetic aspect of the disease, one must be cognizant of its cardiovascular implications.

Treatment of Xanthelasma Palpebrarum using Pulsed Dye Laser: Original Report on 14 Cases

Xanthelasma palpebrarum, a benign xanthoma occurring around the eyes, are treated using lasers like carbon dioxide, argon, pulsed dye, YAG, and diode(1450) laser .Several studies on PDL for xanthelasma palpebrarum (XP) have been reported from abroad but as per our knowledge there are no Indian studies in this regard. We report the efficacy of pulsed dye laser in the management of xanthelasma palpebrarum in Indian patients.

CO2 Laser Treatment of Xanthelasma Palpebrarum in Skin Types III-IV: Efficacy and Complications After 9-Month Follow-Up

Objective: Ultrapulse CO₂ laser has been used for several decades for removal of xanthelasma lesions. However, most studies to date have focused on Caucasian patients (skin types I-II). We sought to assess the efficacy and complications of CO₂ laser therapy for xanthelasma palpebrarum (XP) in Chinese patients (skin types III-IV). Methods: Data of 38 patients with xanthelasma who received CO₂ laser treatment between December 2013 and January 2016 at our hospital were retrospectively analyzed. Patients were followed up for 9 months. Results: Recurrence occurred in 19/38 (50%) patients. Recurrence was significantly more common in patients with multiple lesions (15/24; 62.5%) than in patients with single lesions (4/14; 28.6%). At 3 months after treatment, the complication rate was 63.16%. The complications included hypopigmentation (23/24; 95.8%) and scarring (1/24; 4.2%). In all patients, the hypopigmentation had disappeared by end of the 9-month follow-up. Conclusions: Ultrapulse CO₂ laser appears to be capable of completely removing XP in patients with medium skin type III-IV. The most common complication is hypopigmentation, but this resolves with time.

Xanthelasma: An Update on Treatment Modalities

Xanthelasmas are localized accumulation of lipid deposits on the eyelids. Lesions are typically asymptomatic and treatment is often sought for cosmetic purposes. Unfortunately, there is paucity of strong evidence in the literature for the effective treatment of normolipidemic xanthelasmas. A literature search using the term “xanthelasma” was carried out in PubMed and Medline databases. Only articles related to treatment were considered and analyzed for their data. Commonly cited treatments include topical trichloroacetic acid, liquid nitrogen cryotherapy, and various lasers including carbon dioxide, Er:YAG, Q-switched Nd:YAG, and pulse dye laser. However, traditional surgical excision has also been used. This article reviews these currently accepted modalities of treatment.

Xanthelasma palpebrarum - a brief review

Xanthelasma palpebrarum is the most common cutaneous xanthoma, characterized by yellowish plaques over eyelids – most commonly, over the inner canthus of the upper lid. It is triggered by hyperlipidemia, thyroid dysfunction, and diabetes mellitus. Xanthelasma results from perivascular infiltration of mono- and multinucleated foam cells within lipid-laden cytoplasmic vacuoles in the superficial reticular dermis. Different modalities of treatment, such as simple surgical excision, cryotherapy, chemical peeling with trichloroacetic acid, radiofrequency, and laser, are used in the treatment of xanthelasma palpebrarum. A brief review of current treatment strategies is presented here.

Treatment of xanthelasma palpebrarum with a 1064-nm, Q-switched Nd:YAG laser

BACKGROUND

Xanthelasma palpebrarum is the most common cutaneous xanthoma characterized by soft, yellow papules or plaques that arise on the periorbital skin. As these lesions can be cosmetically disfiguring, many patients seek medical help to remove these lesions.

OBJECTIVE

To determine the effectiveness and minimum number of treatment sessions with a 1064-nm, Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for the treatment of xanthelasma.

METHODS

A retrospective review of patients with xanthelasma consecutively treated with Q-switched Nd:YAG laser was conducted. Forty-six patients with 103 lesions were identified from January 2012 through August 2015. Photographs taken of patients immediately before treatment and 4-8 weeks after treatment were independently evaluated by 2 dermatologists.

RESULTS

After a single treatment session, 93.2% of lesions had some degree of clearance. All lesions had excellent-to-complete clearance after at least 4 treatment sessions. Patients usually required 4 treatment sessions for optimal results.

LIMITATIONS

This was a retrospective study. Treatment parameters varied, follow-up periods were not uniform, and response was not assessed with a validated scale.

CONCLUSION

The Q-switched Nd:YAG laser is effective and well tolerated in the treatment of xanthelasma in our study population.

Comparative Study to Evaluate the Efficacy of Radiofrequency Ablation versus Trichloroacetic Acid in the Treatment of Xanthelasma Palpebrarum

Background:

Xanthelasma palpebrarum (XP) is a metabolic disorder involving the eyelids. Radiofrequency(RF) surgery and trichloroacetic acid (TCA) applications have been listed among the procedures for XP, but comparative studies are not available.

Aim:

To compare the efficacy of radiofrequency surgery versus trichloroacetic acid application in the treatment of XP.

Settings and Design:

20 consecutive cases of XP attending dermatology, medicine and endocrinology out-patient departments of M.S. Ramaiah teaching hospital were enrolled for the study. It was an open-label clinical trial conducted in our hospital for a duration of 1 year.

Materials and Methods:

20 consecutive patients conforming to inclusion criteria were selected for the study. For each patient, lesions were treated with radiofrequency ablation on one side and TCA application on the other side.

Results:

RF ablation was done for 12 patients over right eye lesions and 8 patients over the left eye lesions. TCA applications were done for 8 patients over right eye lesions and 12 patients over left eye lesions. 70% of lesions treated with RF ablation had a score of improvement of 4 and 70% of lesions treated with TCA application had a score of improvement of 4, at 4 weeks of follow-up. At four weeks of follow-up 40% in RF group and 15% in TCA group had scarring and 45% in RF group and 30% in TCA group had pigmentation.

Conclusion:

RF ablation as compared to TCA application, required fewer sessions for achieving more than 75% clearance of lesions. However, TCA applications were associated with fewer complications comparatively.