This protocol applies to patients presenting with a soft xanthelasma lesion smaller than 3 mm in the absence of an identifiable underlying medical disorder, or in whom conservative management has not produced satisfactory results. Lesion consistency, size, and precise anatomical location guide the treatment selection.
The treatment strategy is determined primarily by whether the lesion falls within or outside a blepharoplasty incision line. Depending on that location, options involve either a surgical excision approach or a minimally invasive ablative intervention — the specific method and technique are detailed in the full protocol.
Based on the above discussion of the literature, we have developed an algorithmic approach to the treatment of xanthelasma lesions (Fig. 1) that takes into account the consistency, size, and location of the lesions.
Parkes and Waller advocate using the classic blepharoplasty incision to excise xanthelasma and warn against extending the incision to include those lesions not included in the standard flap design.
Le Roux advocates a modified blepharoplasty incision approach with the upper incision curving upward on the lateral aspect and the lower incision taking a more inferolateral course than the classic incision.
For isolated xanthelasma, they promote en toto excision of soft or immature lesions in an elliptical fashion but support a different approach for long-standing, hard xanthelasma.
The use of carbon dioxide, argon, erbium: yttrium-argon-garnet, and pulsed dye lasers has been described in the treatment of xanthelasma.
The use of full-strength dichloroacetic and trichloroacetic acid has been described in the dermatology literature.