Refining Xanthelasma Palpebrum Treatment: A Scar Minimising Dual Technique Approach

INTRODUCTION

Xanthelasma pauperum (XP) is the most common type of cutaneous xanthoma, presenting with soft, bilaterally symmetrical, yellowish papules and plaques that occur due to localised periorbital lipid deposition.^[1] Overall, the prevalence is approximately 4%, with a peak seen at the fourth and fifth decades of life, occurring more commonly in women.^[2] Although XP is benign and asymptomatic in nature, these lesions can often be aesthetically unappealing, prompting the need for effective and cosmetically acceptable treatment options.

There is a large range of therapeutic modalities available for treating XP, including surgical excision, laser ablation, chemical cauterisation, cryotherapy, and electrosurgical techniques such as radiofrequency cautery.^[3] Each treatment modality has its own complication profile and limitations. Among these procedures, radiofrequency (RF) cautery has become popular among dermatologists due to its ease of use, relatively lower cost, and ability to precisely target and ablate superficial lesions with minimal bleeding.^[4]

Despite its advantages, RF cautery has its limitations. A key challenge lies in balancing effective lesion clearance with the minimal risk of post inflammatory hyperpigmentation (PIH) and scarring, especially in those with darker skin types. These adverse effects often occur due to excessive thermal damage to surrounding tissues. On the contrary, recurrence can be a common issue when incomplete or superficial removal of the lipid-laden macrophages is done, usually to prevent complications such as PIH or scarring.

This article aims at highlighting a novel dual modality approach to help in effective clearance of the lesion while simultaneously reducing the risk of PIH or scarring.

Surgical innovation

To minimise the risk of scarring and recurrence, a hybrid approach is suggested. After the initial superficial RF cautery to debulk the lesion as seen in Figure 1, a sterile needle of 26 gauge is used to manually extract the remaining xanthelasma deposits [Figure 2]. This technique is analogous to the removal of milia and allows for targeted extraction of deeper lipid material without the need for aggressive cauterisation. The controlled use of RF cautery limits thermal injury, reducing the chances of scarring, while the needle extraction ensures thorough clearance, thereby reducing the risk of recurrence [Figure 3].

Close

Figure 1: Superficial electrocautery done first to debulk the xanthelasma.

Export to PPT

Close

Figure 2: 26G needle used to manually extract xanthelasma deposits.

Export to PPT

Close

Figure 3: Postoperative clinical picture after 3 months, showing complete clearance without any scarring.

Export to PPT

This method offers several advantages, such as enhanced precision, reduced risk of dermal injury, and improved cosmetic outcomes. Patients treated with this approach demonstrate faster healing and minimal post-procedure pigmentation or scarring. This simple modification can be a valuable addition to the surgical toolkit for dermatologists treating XP, especially in patients with darker skin types.

DISCUSSION

A systematic review by Malekzadeh H noted that among 80 cases treated with RF-based techniques, lesion clearance was excellent (98.8%), but dyspigmentation occurred in 20-50% of cases, with scarring occurring in 40% in one study.^[5] Similarly, a direct comparison of RF cautery with trichloroacetic acid (TCA) peels found that both showed comparative clearance; RF cautery had much higher rates of dyspigmentation and scarring (45% and 40%, respectively).^[6]

In contrast to this, the authors propose a dual modality technique combining superficial RF debulking with precise needle extraction, which minimises thermal injury and offers deeper lesion clearance without aggressive cauterisation, thereby potentially reducing risks of post-inflammatory hyperpigmentation, scarring, and recurrence while providing better cosmetic outcomes.

CONCLUSION

The proposed dual modality approach of combining superficial RF cautery with manual needle extraction offers a safe and effective cosmetically superior alternative for treating xanthelasma palpebrum. By minimising the thermal damage and ensuring better lesion clearance, this technique addresses the key limitations of conventional RF treatment, i.e. post-inflammatory hyperpigmentation, scarring, and recurrence. This simple, low-cost modification can significantly enhance outcomes, particularly in patients with darker skin types and serve as a valuable addition to daily dermatologic practice.