Clinical dermatology • Original article CED

Clinical and Experimental Dermatology

Efficacy of trichloroacetic acid (95%) in the management of

xanthelasma palpebrarum
P. S. Cannon, R. Ajit and B. Leatherbarrow
Oculoplastic and Orbital Department, Manchester Royal Eye Hospital, Manchester, UK

doi:10.1111/j.1365-2230.2010.03818.x

Summary Background. Xanthelasma palpebrarum (XP) is a commonly occurring benign

eyelid disorder.
Aim. To determine the efficacy of topical trichloroacetic acid (TCA) 95% in the
management of XP.
Methods. This was a retrospective review of patients treated with TCA between June
2000 and July 2007. We recorded the outcomes of patients who attended the clinic at
least 3 months after their treatment. We also contacted all patients with a minimum
interval of 12 months between treatment and a telephone interview to assess for
recurrence ⁄ persistence of the lesion(s).
Results. In total, 102 patients were enrolled in the study. Of these, 44 were reviewed
in the clinic. There were nine persistent lesions and four recurrences recorded at a
mean follow-up of 14.3 months. Telephone interviews were conducted with 51
patients (146 lesions). Of these 51 patients, 43 had been given bilateral TCA treatment.
The mean number of TCA treatments was 1.68. Mean time from the past TCA treat-
ment to the telephone interview was 31.8 months. Of the 51 patients, 17 patients
reported no recurrence, 22 patients had experienced a recurrence, 9 patients had
persistence of the lesion and 3 patients undergone surgical excision of the lesion since
the last TCA treatment. Overall, the success rate for TCA was 61% at a mean follow-up
of 31.8 months.
Conclusions. XP has a strong history of recurrence. TCA treatment may be effective
in XP and is a short, simple and cheap procedure that can be repeated. Although the
requirement for retreatment is high, patient satisfaction with the procedure is also
high.

commonly in the medial area of the eyelids and may

Introduction
Xanthelasma palpebrarum (XP) is a common benign
lesion. It arises from the invasion of the superficial
dermis by xanthoma cells, which are lipid-laden histio-
cytes, and results in inflammation and fibrosis.1 The
lesion occurs clinically as a yellow plaque most
Correspondence: Dr Paul S. Cannon, Manchester Royal Eye Hospital, Oxford
Road, Manchester M13 9WH, UK
E-mail: pscan05@yahoo.co.uk
Conflict of interest: none declared.
Accepted for publication 12 January 2010
extend laterally, with a higher prevalence for the upper
lids2 (Fig. 1a). Although the lesion is not considered
sight-threatening unless it obstructs the visual axis, it
does cause cosmetic concerns, which may lead the
patient to seek its removal.
There are numerous methods currently available for
the management of XP. These include surgical excision,
laser ablation using a variety of lasers (e.g. argon,
carbon dioxide, Q-switched neodymium:yttrium–
aluminium–garnet, and pulsed dye lasers), and chem-
ical cauterization using trichloroacetic acid (TCA) or
bichloroacetic acid (BCA). However, each method of
treatment is associated with particular limitations and

 2010 The Author(s)

Journal compilation  2010 British Association of Dermatologists • Clinical and Experimental Dermatology, 35, 845–848 845
Efficacy of 95% trichloroacetic acid for XP • P. S. Cannon et al.
(a)
(b)
(c)
Figure 1 Male patient with xanthelasma palpebrarum on all four
lids: (a) before treatment; (b) immediately after the application
of 95% TCA (note the blanching effect on the lesions);
(c) 3 months after treatment, with a good result.
side-effects such as skin loss, scarring, recurrence,
persistence, repeat treatments, expense, hypopigmenta-
tion and hyperpigmentation.3–10 Currently there does
not seem to be a preferred treatment method for this
condition. An evaluation of the efficacy of the various
treatments from the examination of the currently
available literature on the management of this condition
has been limited either by small study cohort numbers
or by short follow-up periods. In this study, we set out to
assess the efficacy of TCA in the management of a large
number of patients with XP over a long follow-up
period.
Methods
This was a retrospective review of all patients treated for
XP using TCA 95% between June 2000 and July 2007.
The patients were identified by the code used in the
846 Journal compilation  2010 British Association of Dermatologists • Clinical and Experimental Dermatology, 35, 845–848
Manchester Royal Eye Hospital coding department for
TCA treatment. Data were obtained on the age of the
patient, side of TCA treatment, number of eyelids
treated, number of TCA treatments, last clinical visit,
and previous surgery. All patients who had been
clinically examined at least 3 months after their last
TCA treatment were identified. An attempt was made to
contact all patients for a telephone interview at least
12 months after the last TCA treatment to inquire
about recurrence or persistence of the lesion, whether
the patient was concerned by this recurrence ⁄ persis-
tence, and if the patient wished to be referred for
discussion of further treatment options. The time
interval between the last treatment and the telephone
interview was recorded. Three attempts were made on
three separate occasions to contact each patient for the
telephone interview.
Excluded from the study were patients who had no
telephone number recorded, those who died before the
telephone interview, those who were unavailable when
telephoned, and those who had a telephone interview
< 12 months after their last TCA treatment.
Using the hospital coding system, 102 patients who
were treated with TCA between June 2000 and July
2007 were identified. Of these, 44 had been reviewed
in the clinic at least 3 months after their last TCA
treatment. During these visits, nine persistent lesions
and four recurrent lesions were recorded, with a
mean follow-up of 14.3 months. A further 25 patients
were excluded because their follow-up visit had
occurred < 3 months after their last treatment, and
33 patients were excluded for failing to attend the
clinic.
For the interview part of the study, we included 51
patients (43 women, 8 men; mean age 48.1 ± 9.6
years, range 24–67) with 146 lesions treated with TCA,
whose telephone interview was at least 12 months after
their last TCA treatment. Of these, 11 patients had also
been clinically examined at least 3 months after the last
TCA treatment. The remaining 51 patients were
excluded: 32 patients were unavailable for the tele-
phone interview, 18 patients had undergone treatment
< 12 months previously, and 1 patient had died.
The patients had undergone treatment according to a
protocol supervised by a team of consultant oculoplastic
surgeons, which ensured a uniform degree of consis-
tency in the technique. The procedure was carried out
in the operating theatre with the patient in the supine
position. The areas to be treated were infiltrated with
lignocaine 2% hydrochloride with epinephrine
1 : 80 · 103 (Lignospan; Septodent, Maidstone, Kent,
UK). A solution of TCA 95% (Preston Pharmaceutical
 2010 The Author(s)

Service, Royal Preston Hospital, Preston, UK) was used.
Exceptional care was taken when applying the TCA, by
painting very thin layers onto the XP with the pointed
tip of a wooden applicator stick, thus avoiding contact
with the normal skin tissue around the lesion and the
eyes. No form of physical barrier to the surrounding skin
was used. The application was repeated until the lesion
blanched and appeared frosted white (Fig. 1b). Follow-
ing the treatment, chloramphenicol ointment (Aventis
Pharma, West Malling, Kent, UK) was applied to the
lesions four times a day for 2 weeks. Patients were
informed that they might experience mild discomfort in
the initial 24–48 h, and that the treated areas would
appear red and might ulcerate for up to 2 weeks after
the treatment.
Results
Of the 51 patients who had a telephone interview,
43 patients had received bilateral TCA treatment;
another 4 patients had received treatment to the left
eye, and 4 had received treatment to the right eye. TCA
treatment had been given to a single eyelid in 7 patients,
to 2 eyelids in 15 patients, to 3 eyelids in 7 patients, and
to all 4 eyelids in 22 patients. Only two patients had
received prior treatment for their lesions: one had
undergone a previous surgical excision and the second
had received a previous TCA 50% treatment. In total,
31 patients had received a single TCA treatment, 12
patients had received 2 treatments, 5 patients had
received 3 treatments, and 3 had received 4 TCA
treatments; the mean number of TCA treatments
recorded was 1.68.
The mean time from the last TCA treatment to the
telephone interview was 31.8 months (range 12–65).
At the time of their telephone interview, 17 patients
reported no recurrence, 22 patients had experienced a
recurrence, 9 patients had persistence of the lesion and
3 patients had undergone surgical excision of the lesion
since their last TCA treatment. Overall, the complete
success rate (no recurrence ⁄ persistence) for TCA was
33.33% at a mean follow-up of 31.8 months. In the
recurrent ⁄ persistent group, 17 patients were sufficiently
concerned by the appearance of their lesions to seek
further treatment options. The remaining 14 patients
were satisfied that the TCA treatment had either
reduced the colour or the size of the lesions. Therefore,
TCA had a limited success rate of 61% in this study. We
found no association between the number of eyelids
involved (P > 0.56) or number of TCA treatments
(P = 0.44) and the rate of recurrence or persistence of
the lesions.
 2010 The Author(s)
Journal compilation  2010 British Association of Dermatologists • Clinical and Experimental Dermatology, 35, 845–848
Efficacy of 95% trichloroacetic acid for XP • P. S. Cannon et al.
Discussion
Mono-, di- and trichloroacetic acid are examples of
chlorinated acetic acids, which have been widely used
in high concentrations as tissue cauterants.11 Their
mode of action involves precipitating and coagulating
proteins, in addition to dissolving lipids.10 The desired
reaction on the skin during a chemical peel is related to
the concentration of the acid, the technique used,
pressure of the application, and the skin preparation.12
The main complications associated with this form of
treatment include hypopigmentation, hyperpigmenta-
tion, scarring, ectropion and the potential inadvertent
application to the conjunctiva or cornea with resultant
inflammation and scarring.
TCA in the management of XP has been previously
described. Haque and Ramesh9 recommended TCA for
the treatment of lesions < 3 mm in diameter. They
achieved better results on papulonodular and flat plaque
lesions at higher concentrations, although the duration
of follow-up was not cited and only 18 patients were
treated with TCA 100%. Hypopigmentation was a
common complication in their Indian-based patient
group, followed by hyperpigmentation and scarring. We
had two non-white patients who reported hypopigmen-
tation after TCA treatment. Haygood et al.10 investi-
gated the use of BCA 100% in 25 lesions (13 white
patients). They had complete initial clearance in 18
lesions (10 patients) after a single treatment. Five
lesions recurred over a mean period of 64 months,
which were retreated using BCA 100% with a good
result.
Recurrence is a common problem with XP, irrespec-
tive of the mode of treatment used. Mendelson and
Masson3 found that 40% of patients had recurrence
after primary surgical excision, 60% after secondary
excision and 80% when all four eyelids were involved.
Argon laser photocoagulation treatment was found by
Hintschich13 to have a high recurrence rate (12 of 32
treated lesions) at 12–16 months.
In the group of patients in our study who were
reviewed in the clinic at least 3 months after their last
TCA treatment, we found a complete success rate of
70% at a mean follow-up of 14.3 months. This rate
dropped to 33% at a mean follow-up of 31.8 months
as ascertained by telephone interview. Although
the recurrence ⁄ persistence rates were high, only 17
patients in this group were concerned by the appear-
ance of their lesions and requested referral for further
discussion of possible treatment options. Another 14
patients felt that the TCA treatment had achieved
limited success in either reducing the colour or the size
847
Efficacy of 95% trichloroacetic acid for XP • P. S. Cannon et al.
of the lesions, and these patients were not concerned by
their appearance. Such a group of patients has not been
previously reported in the literature. The study may be
limited by the fact that the patients interviewed were
not clinically assessed at this time; however, the findings
are valid as the subjective cosmetic concern of the
patient is the main indication for treatment of this
benign condition.
In applying the TCA there is the potential problem of
not applying a sufficient quantity of the TCA in order to
safeguard against excessive scarring and damage to the
surrounding normal skin. However, the use of a wooden
applicator with a pointed tip allows thin layers of TCA to
be painted onto the lesion, which reduces dripping of the
TCA and inadvertent application to normal skin or the
eyes. One of the advantages with TCA is preservation of
skin tissue (Fig. 1c).
We found no association between the number of
eyelids involved or number of TCA treatments and the
rate of recurrence or persistence of the lesions. In the
recurrent group we had 17 patients who had 2 TCA
treatments and 11 patients who had only a single
treatment. A similar trend was noted in the patients
with persistent lesions: 5 ⁄ 9 patients had only a single
treatment.
In conclusion, we found that XP is a difficult
condition to manage, and has a strong likelihood of
recurrence. We found that TCA 95% has an overall
success rate of 61% judged by patient satisfaction with
the treatment. The treatment is simple to apply with a
very low cost, but requires multiple applications to
achieve satisfactory results. Although we did not have a
control group in this study, the results presented seem
to show a favourable outcome with TCA treatment,
therefore we would recommend a larger controlled
study to confirm this.
848 Journal compilation  2010 British Association of Dermatologists • Clinical and Experimental Dermatology, 35, 845–848
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