Treatment of Xanthelasma
Palpebrarum with the Carbon
Dioxide Laser
DAVID 8. APFELBERG, M.D.
MORTON R. MASER, M.D.
HARVEY LASH, M.D.
DAVID N. WHITE, M.D.
Abstract. Six patients with xanthelasma palpebrarum of
the eyelids have been treated with the CO, laser and fol-
lowed for periods varying up to 4 years. Satisfactory cos-
metic results were achieved in all patients without sig-
nificant scarring, and no recurrence has been discovered
thus far.
INTRODUCTION
Xanthelasma palpebrarum is a benign collection of
bright-yellow, lipomatous plaques that appear in
the upper and lower eyelids. Although the condi-
tion does not cause a functional visual loss nor is it
malignant, the removal of the plaques has been
fraught with numerous surgical problems. In ad-
dition to the limitation of surgical or nonsurgical
removal of relatively large amounts of eyelid skin,
the frequent recurrence of such lesions has been a
serious problem. This report describes a simple, ef-
fective, nontraumatic, and apparently permanent
removal of xanthelasma palpebrarum of the eyelids
utilizing the unique photovaporization capacity of
the CO, laser.
David 8. Apfelberg, M.D.; Morton R. Maser, M.D.; Harvey
Lash, M.D.; and David N. White are Staff Physicians,
Department of Plastic and Reconstructive Surgery and
Comprehensive Laser Center, Palo Alto Medical Foun-
dation, Palo Alto, California.
Address reprint requests to David B. Apfelberg, M.D.,
Department of Plastic and Reconstructive Surgery and
Comprehensive Laser Center, Palo Alto Medical Foun-
dation, 300 Homer Ave., Palo Alto, CA 94301.
1. Dermatol. Surg. Oncol. 13:2 February 1987
ARTICLE
MATERIALS AND METHODS
Treatment of xanthelasma palpebrarum of the eye-
lids is aided by magnification through an operating
microscope (5-10 x ) or by the wearing of 4.5 loupe
glasses. The CO, laser (Cooper Lasersonics 250 Z)
is hand held perpendicular to the skin with a 1-mm
spot size. Our laser was set for 10 watts of power.
This was delivered in a pulse repetition rate of 50,
a pulse width of 5, and an irradiation time of 25.
Total joules or watts per centimeter squared deliv-
ered to each tissue area was between 400 and 500
joules. Superpulse capability aids in the rapid va-
porization and mechanical disruption of pigment.
Initial focused beam vaporizes the overlying skin
and superficial portions of the xanthelasma depo-
sition. Subsequent defocused treatment followed by
gentle curettage with a small skin curette removes
residual pigment down to the upper dermis and
occasionally fascia overlying the orbicularis muscle.
No attempt is made to close such wounds and heal-
ing is by epithelialization or second intention.
Post-treatment recommendations include ice
compresses, ophthalmic ointment, elevation, and
rest for the 5-7 days required for healing. Initial
skin discoloration fades and blends in 3-6 months.
All were treated as outpatients under local anes-
thesia. Treatments are usually staged such that only
one eye (upper and lower) is done at a time.
PATIENT AND TREATMENT DATA
Six patients have been treated since June 1982 in-
cluding 16 separate eyelids. There were four males
and two females, with an average age of 58. Two
patients had associated hyperlipidemia syndrome
149
CO, LASER TREATMENT OF XANTHELASMA
FIGURE 1. Xanthelasma palpebrarum of the eyelids prior
to treatment.
FIGURE 3. Xanthelasma palpebrarum of eyelids prior to
treatment .
FIGURE 5. Pretreatment biopsy demonstrating collection
of foam cells and inflammatory cells in the superficial
dermis with overlying normal epidermis (H&E, original
magnification x 6).
150
FIGURE 2. Results of treatment demonstrating eradica-
tion of lesions with satisfactory cosmetic result and no
recurrence 18 months post-treatment.
FIGURE 4. Satisfactory removal of lesions without recur-
rence with good cosmetic results after 2 years.
FIGURE 6. Biopsy 6 months following laser treatment
demonstrating normal, well-differentiated epidermis and
dermal fibrosis with increased numbers of fibroblasts and
dilated capillaries and no residual cholesterol deposit.
(H&E, original magnification x 6).
1. Dermatol. Surg. Oncol. 13:2 February 1987

and the age of onset of appearance averaged 35-48
years. An average of three treatments (including
initial test patch) was required to eradicate pigment
in involved eyelids. The average power setting var-
ied between 4 and 9 watts. Longest follow-up has
been 4 years and shortest, 14 months. All patients
have had satisfactory resolution of xanthelasma
palpebrarum with excellent cosmetic effect, and thus
far, no recurrences have been noted (Figs. 1-4). Pre-
and post-treatment biopsies have demonstrated that
the foam cells of cholesterol present initially are
eradicated and that a normal epidermis over a
fibrotic dermis replaces the initial lesion (Figs. 5
and 6).
DISCUSSION
Xanthelasma palpebrarum is a benign condition
characterized by bright-yellow pigment plaques de-
posited in the upper and lower eyelids mainly in
adults in the 4th and 5th decades. Although xan-
thelasma palpebrarum is associated with other xan-
thomas or hyperlipidemia syndromes in only 5% of
patients, fully one-third of all patients examined for
this condition serologically have an elevated cho-
lesterol level. Approximately one-third of patients
have a positive family history with at least one, and
often multiple, family members affected with the
same condition. Many surgical and nonsurgical
methods of treatment have been described in the
treatment of xanthelasma palpebrarum, however,
no single modality has emerged as the dominant
single most effective. Simple excision and closure
may be readily accomplished for small single or even
multiple lesions.2 However, repeat excisions or re-
moval of larger areas risk ectropion or more com-
plicated coverage with grafts. Nonsurgical tech-
niques include topical agents such as liquid nitrogen
or trichloroacetic acid.3 Cautery can destroy the
plaques but topical treatment and cautery often
cannot accomplish complete removal, thus neces-
sitating further treatment.
Recurrence after treatment is one of the most dif-
ficult aspects about treatment of xanthelasma pal-
pebrarum, the other problem area being the limi-
tation in the amount of involved skin which can be
safely removed without causing ectropion. Men-
delson and Masson in 1976*completed a very com-
prehensive evaluation of recurrence after xanthe-
lasma palpebrarum excision. Approximately 40% of
their 92 patients evaluated had a recurrence after
the first excision and 60% had further recurrence
after secondary excisions. Most recurred (26%) in
the first year after excision and this rate steadily
declined each year up to 10 years. Younger patients
1. Dermatol. Surg. Oncol. 13:2 February 1987
APFELBERG ET AL
tended to suffer earlier recurrences, as did those
with a positive family history. Recurrence rate ap-
proached 80% when four lids were involved as op-
posed to approximately 40% when only one, two,
or three lids were involved and recurrence was rel-
atively independent of serum lipid values.
The mechanism of action of the C 0 2 laser is a
controlled layer-by-layer photovaporization of all
pigment often down to the deep dermis or even the
superficial orbicularis muscle fascia with healing by
either epithelialization from adjacent skin or pilo-
sebaceous apparati or by second intention with
granulation and contraction. Resultant scars and
discoloration of skin is minimally apparent and
readily accepted by the patient. Microscopic control
(4-5x) is beneficial to define the lowest layer of
pigment removal without unnecessary vaporization
of normal dermal structures. There has been no re-
currence in 6 patients followed for an average of 2
years (longest 4 years, shortest 14 months). It is
possible that some benefit can be ascribed to the
powerful laser light or its thermal effect which al-
ters the mechanism of lipid production but this the-
ory is, as yet, unproven. C 0 2 laser usage for xan-
thelasma palpebrarum is not original to our service
and has been previously reported by Giler and
Ka~lan.~
SUMMARY
Six patients with 16 eyelids affected with xanthe-
lasma palpebrarum have been treated by photova-
porizarion with the C 0 2laser. All patients have had
a satisfactory cosmetic result and no recurrence has
been noted over a 4-year period of observation. Ini-
tial photoablation with microscopic control fol-
lowed by re-epithelialization has produced excel-
lent cosmetic results without recurrence. This
modality is recommended for patients with multi-
ple coalescent lesions who are not suitable candi-
dates for simple excision and closure and may also
be indicated for isolated and solitary lesions.
REFERENCES
Mendelson BC, Masson JK. Xanthelasma: Follow-up on re-
sults after surgical excision. Plast Reconstr Surg 58:535-538,
1976.
Le Roux P. Modified blepharoplasty incisions: Their use in
xanthelasma. Br J Plast Surg 30:81-83, 1977.
Stegman SJ,Tromovitch TA. Cosmetic Dermatologic Surgery.
Arch Dermatol 118:1013-1016, 1982.
Giler S, Kaplan 1. The use of the CO, laser for the treatment
of cutaneous lesions in an outpatient clinic. In: K Atsumi, N.
Nimsakal (eds), Laser Tokyo '81 (Proceedings 4th Congress
International Society for Laser Surgery). Tokyo, Intergroup
Corp, 1983 p 1-1 to 1-5.
151
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