Review

Systematic review of laser therapy in xanthelasma

palpebrarum
Austin H. Nguyen, MS, Adam M. Vaudreuil, BS, and Christopher J. Huerter, MD

Division of Dermatology, Creighton Abstract

University School of Medicine, Omaha, NE,
USA
Correspondence
Christopher J. Huerter, MD
Division of Dermatology, Creighton
University School of Medicine
2500 California Plaza
Omaha, NE
USA
E-mail: christopherhuerter@creighton.edu
Financial support: None.
Conflicts of interest: None to declare.
Xanthelasma palpebrarum is a benign periorbital xanthoma with substantial cosmetic and
psychosocial burden for patients. Treatment modalities should be considered based on
efficacy as well as cosmetic outcome. Laser modalities in the treatment of xanthelasma
palpebrarum have not been comprehensively reviewed and discussed. Accordingly, this
study seeks to systematically and critically review the available literature discussing laser
treatment of xanthelasma palpebrarum. PubMed was systematically reviewed for reports
on laser therapy in the treatment of xanthelasma palpebrarum. A total of 21 studies were
included in this review discussing laser treatment of xanthelasma palpebrarum. Laser types
included carbon dioxide, yttrium aluminum garnet, pulsed dye, argon, and a 1450 nm diode
laser. The carbon dioxide laser was the most commonly reported modality followed by
yttrium aluminum garnet laser. All of the laser modalities offered moderate to excellent
clearance rates with minimal side effect profiles. Further large scale studies comparing
different laser modalities are required to determine the best laser modality. However, laser
modalities as a whole offer a treatment option for xanthelasma palpebrarum, that is,
cosmetically excellent with a reasonable side-effect profile.

application is simple and straightforward but can cause scar for-

Introduction
Xanthelasma palpebrarum is a commonly observed plane
xanthoma of the periorbital region. This condition presents as
flat, yellow to orange, noninflammatory lesions of the eyelids
and surrounding tissue. Although considered benign, they are
cosmetically disfiguring and can cause psychological distress to
patients. In addition, the presence of xanthelasma may be a
cutaneous manifestation of underlying dyslipidemia; about one-
half of patients presenting with xanthelasma will have hyperlipi-
demia.1 Xanthelasma form as a consequence of the intracellular
and dermal deposition of lipid. However, the exact mechanism
of their development is not fully known. It is presumed that the
leakage of plasma lipoproteins through dermal capillaries and
phagocytosis by macrophages, creating lipid-laden foam cells,
1
plays a role in xanthelasma pathogenesis.
Traditional treatment of xanthelasma palpebrarum has been
surgical excision. Surgical excision carries with it the risks of
cosmetically unacceptable or functional scar with possible ectro-
pion. As a result of complications, secondary procedures such
as scar revision or skin flap/graft placement could be required.2
Meanwhile, laser therapy has been described in the treatment
of xanthelasma and seems to be a viable alternative to surgical
excision with fewer side effects and good cosmesis.3 Other
destructive methods such as trichloroacetic acid (TCA) and
cryosurgery have also been tried with mixed results.3,4 TCA
mation and ectropion.3 When compared to TCA, laser therapy
requires fewer sessions and less downtime, also producing bet-
ter cure rates and fewer recurrences.5,6 While cryosurgery has
relatively minimal side effects, its use can be complicated by
high recurrence rates and secondary infection.4 Laser therapy,
on the other hand, has a potentially better side effect profile
and fewer recurrences.
Tissue ablation via laser therapy is achieved when light is
absorbed by tissue chromophores corresponding to the laser’s
specific wavelength of light. Three of the major chromophores in
the skin are melanin, hemoglobin, and cellular water.7 As the
chromophore absorbs light, thermal energy is released and
absorbed by the surrounding tissue, thereby causing tissue
destruction.7 In the case of xanthelasma, it is postulated that the
thermal energy damages the perivascular foam cells leading to
their destruction. In addition, the coagulation of hyperpermeable
vessels within the dermis could theoretically lead to blockage of
further lipid leakage into the tissue and thus prevent recurrence.8
A variety of lasers has been employed in the treatment of
xanthelasma palpebrarum: carbon dioxide (CO2), yttrium alum-
num garnet (YAG), argon, pulsed dye (PDL), and 1450 nm
diode. Argon and pulsed dye lasers use shorter wavelengths of
light preferentially absorbed by hemoglobin. With these physical
characteristics, argon and pulsed dye lasers are used primarily
for vascular lesions.7 In the treatment of xanthelasma, these e47

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e48 Review Laser therapy in xanthelasma palpebrarum
lasers may induce coagulation within the vessels of the upper
dermis, thereby destroying the perivascular, lipid-laden foam
cells and preventing further leakage of lipid into the surrounding
tissue.9,10 The 1450 nm diode, Nd:YAG, Er:YAG, and CO2
lasers all use longer wavelengths of light absorbed best by cel-
lular water. This allows for their use in skin resurfacing and the
removal of epidermal lesions, with additional indications
depending on the mode used (continuous, pulsed, etc.).7 CO2
lasers are considered the gold standard ablative laser. The
beam is primarily absorbed by cellular water causing vaporiza-
tion and ablation of tissue.11 The ultrapulsed variation allows for
vaporization of a thin layer of tissue while allowing time for ther-
mal relaxation of the surrounding tissue between pulses.12 Simi-
lar to the CO2 laser, the Er:YAG is maximally absorbed by
water and causes vaporization of water within cells thereby
ablating skin layer by layer.13 Also with water as its chro-
mophore, the 1450 nm diode laser has been shown to induce
photothermal destruction of sebaceous glands in the mid-dermis
by generating destructive heat at this particular depth.14 This
principle has led to its theoretical use in xanthelasma. Lastly,
results of in vitro studies have shown the Q-switched Nd:YAG
laser (1064 nm) to target subcutaneous fatty tissue containing
predominantly triglycerides.15,16 This ability to target fatty tissue
allows for its possible use in targeting fat within xanthelasma.17
The present review seeks to comprehensively define the role of
lasers in the treatment of xanthelasma palpebrarum. The cur-
rent literature is systematically searched and critically reviewed
to compare the different laser modalities in xanthelasma palpe-
brarum treatment.
Materials and methods
A systematic literature search was conducted in PubMed to
identify articles relevant to the topic of laser therapy in
International Journal of Dermatology 2017, 56, e47–e55
Nguyen, Vaudreuil, and Huerter
xanthelasma palpebrarum published until March 2016 with no
backdate restriction. The search terms included “xanthelasma”,
“palpebrarum”, and “treatment”. Titles and abstracts of search
results were independently screened by two investigators for
relevance. Potentially relevant original studies with available
full-text written in English (reviews and conference abstracts
were excluded) were retrieved for final inclusion review. Dis-
crepancies were resolved by consensus. Reports on patients
with xanthelasma palpebrarum treated using laser modalities
were included.
Results
Initial PubMed search (Fig. 1) returned 52 articles. After screen-
ing of titles and abstracts, 26 studies were retrieved in full-text
to be reviewed for final inclusion. Ultimately, 21 articles were
included in the present review. Study characteristics are sum-
marized in Table 1. The included studies discussed treatment
of xanthelasma palpebrarum using the following lasers: CO2 (9
studies), Er:YAG (5 studies), ND:YAG (3 studies), argon (2
studies), PDL (2 studies), and 1450 nm diode laser (1 study).
Studies included 1–50 patients for a total of 381 patients with
xanthelasma palpebrarum discussed in the present review. Two
studies reported inclusion of treatment naive patients,5,18
whereas another two reported washout periods of 12 weeks
after previous treatments prior to initiating laser therapy.9,17
Otherwise, Most studies did not specify prior treatment history
for the condition of interest.
Carbon dioxide laser therapy
A total of nine studies were included that utilized the CO2 laser
to treat patients with xanthelasma palpebrarum.5,6,11,12,18–22
Study findings are summarized in Table 2. Included studies dis-
cussed a total of 165 patients with ages varying between 26
Figure 1 Systematic search of PubMed
returned 52 total studies. After screening of
titles and abstracts, the full text of 26
studies was reviewed. A final total of 21
studies were included in this review
ª 2017 The International Society of Dermatology
Nguyen, Vaudreuil, and Huerter Laser therapy in xanthelasma palpebrarum Review e49

Table 1 Characteristics of included reports of laser treatment in xanthelasma palpebrarum

N of Xanthelasma
cases Mean age Gender Location (# of
Study (lesions) (range) (M:F) Prior treatment Laser Lipid results (# of patients) lesions)

Abdelkader 40 (65) (30–60) 17:23 – Argon and – Bilateral, either in

et al. 201523 Er:YAG the upper or lower
lid (50) Unilateral
(15)
Apfelberg 6 (16) 58 4:2 – CO2 Hyperlipidemia syndrome (2) Eyelids (16)
et al. 198719
Basar et al. 24 (40) 46 (32–59) 10:14 – Argon – Upper eyelid (28)
200429 Lower eyelid (12)
Borelli et al. 15 (33) 52 (37–66) – Excision (n = 2), Er:YAG Hypercholesterolemia and Upper eyelid (16)
200113 argon laser hypertriglyceridemia (4) Lower eyelid (17)
(n = 2)
Corradino 12 ( ) 48.5 (35–65) – – Ultrapulsed Familial dyslipidemia (type IIa) on Average lesion size
et al. 201511 CO2 statin therapy (2) average = 10 cm2, lesions
cholesterol for all patients affected the
221.9 mg/dl superior and
inferior bilateral
eyelids
Delgado et al. 12 (32) 54.6 (35–75) 2:10 Treatment naive Ultrapulsed High cholesterol (2) R superior eyelid (8)
201318 (n = 12) CO2 L superior eyelid (8)
R inferior eyelid (8)
L inferior eyelid (8)
Drnov

sek- 8 (32) – – – Er:YAG – –
Olup et al.
199724
Esmat et al. 20 (48) 46.5 (28–68) 4:16 Surgical excision Superpulsed Hypercholesterolemia and Upper eyelid (34)
201420 (3) or fractional hypertriglyceridemia (18) Lower eyelid (14)
CO2
Fusade 11 (38) 55.8 (42–70) 6:5 – Q-switched Increased > 2 g/l (6) Upper eyelid (2)
200827 Nd:YAG Normal (4) Lower eyelid (4)
Upper and lower
eyelids (32)
Goel et al. 50 ( ) 41.2 (26–69) 13:37 Treatment naive Ultrapulsed Total cholesterol: 201.51  50.22 Upper eyelid (27)
20155 (n = 50) CO2 vs HDL: 44.18  7.25 Lower eyelid (3)
TCA LDL: 110.52  25.93 Bilateral (46)
Triglycerides: 128.20  41.88
Gungor et al. 21 ( ) 42.3 (22–70) 1:20 – Er:YAG – –
201425
Kaliyadan 1( ) 57 0:1 – Q-switched – Bilateral
et al. 201028 Nd:YAG xanthelasma
palpebrarum below
the lower eyelids
Karsai et al. 37 (76) 54.4 (32–75) 11:26 No treatment Q-switched Patients with lower LDL-C L upper eyelid (32)
200917 within 12 weeks Nd:YAG concentrations were consistently R upper eyelid (17)
(n = 37) more likely to have a good L lower eyelid (15)
response than a moderate or R lower eyelid (12)
no response
Karsai et al. 20 (38) 53 (38–68) 0:20 No laser surgery PDL No correlation between systemic L upper eyelid (14)
20109 within 12 weeks lipid concentrations and treatment R upper eyelid (11)
(n = 20) response L lower eyelid (8)
R lower eyelid (5)
Levy et al. 2 61 (59, 63) 0:2 – Er:YAG – Bilateral lower
200326 eyelids (1)
R upper eyelid (1)

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e50 Review Laser therapy in xanthelasma palpebrarum Nguyen, Vaudreuil, and Huerter

Table 1 Continued

N of Xanthelasma
cases Mean age Gender Location (# of
Study (lesions) (range) (M:F) Prior treatment Laser Lipid results (# of patients) lesions)

Mourad et al. 30 – – – CO2 vs. TCA Total cholesterol: Normal/<200 (16) –

20156 High/>200 (14)
LDL: Normal/<129 (17)
High/130–189 (9)
Very high/>190 (4)
Triglycerides: Normal (30)
HDL: Normal (30)
Park et al. 16 ( ) 49.7 (24–69) 6:10 – 1450 nm Normal cholesterol (6) –
201130 diode laser Hypercholesterolemia (5)
Not checked (5)
Pathania 10 (20) 58.3 (42–65) 4:6 Electrofulguration Ultrapulse Serum cholesterol and triglycerides Upper eyelid (1)
et al. 2015 (n = 1), TCA CO2 elevated in 2 patients with Lower eyelid (2)
(n = 3) recurrence (226/200 and 308/265) Upper and lower
(full data presented in Table 1 of eyelids (7)
referenced article) Bilateral eyes (10)
Average cholesterol: 180
Average triglycerides: 158
Raulin et al. 23 (52) 45 (32–70) 7:16 Surgical excision Ultrapulse Normal (8) Upper eyelid (35)
199921 (n = 1), PDL CO2 Abnormal (8) Lower eyelid (17)
(n = 5) Not tested (7)
Mixed hyperlipidemia (2)
Hypercholesterolemia type IIa (6)
Low HDL (11)
High lipoprotein (4)
Scho€nermark 1 (1) 45 0:1 – PDL Normolipidemic (1) R upper eyelid (1)
et al. 19968
Ullmann et al. 22 (52) (36–63) 6:16 – CO2 Hyperlipidemia (2) One eyelid
199322 involved (2)
Two eyelids (14)
Three eyelids (2)
Four eyelids (4)

CO2, carbon dioxide; Er:YAG, erbium-doped yttrium aluminum garnet; F, female; L, left; M, male; Nd:YAG, neodymium-doped yttrium alu-
minum garnet; PDL, pulsed dye laser; R, right; TCA, trichloroacetic acid.

and 75 years. Overall, the outcome was excellent, with com-
plete initial resolution achieved in all studies save one,6 in which
outcome was graded on a qualitative “good” to “excellent” scale.
Recurrence occurred in 13 patients (7.8%).5,11,12,21,22 In most
cases, the outcome was achieved with 1–3 treatment sessions
at 2-week intervals, when specified.
Esmat and colleagues20 prospectively compared efficacy of
the superpulsed and fractional CO2 lasers. Forty-eight lesions
on 20 included patients were randomly assigned to 1 session of
total lesion ablation with superpulsed CO2 laser or 3–5 sessions
of fractional CO2 laser therapy at 4–6 week intervals. Both
modalities successfully removed lesions. However, the super-
pulsed CO2 laser demonstrated significantly better scores of
improvement in lesion color and thickness, when compared with
those treated by fractional CO2 laser. For those patients treated
with fractional CO2 laser, downtime was significantly shorter
(average 5.8 d vs. superpulsed 12.3 d, P = 0.001). In addition,
patient satisfaction was significantly improved with use of the
fractional laser, particularly those with lesions of large surface
area. Scarring (n = 11) and recurrence (n = 3) rate were found
to be higher in the superpulsed-treated group, whereas no evi-
dence of scarring and recurrence were observed in the patients
treated with fractional CO2 laser.
Another study6 compared CO2 laser efficacy with that of topi-
cal trichloroacetic acid (TCA) in 30 patients with xanthelasma
palpebrarum. Patients receiving TCA were randomly assigned
to concentrations of 35, 50, and 70% TCA peeling every
2 weeks for a maximum of six sessions or until clinical cure. Six
patients received CO2 laser therapy. Increasing TCA concentra-
tion reduced the number of sessions required. However, no
significant differences were found in efficacy between 70% TCA
and CO2 laser. Two patients with lipid abnormalities developed
recurrent lesions after 35% TCA and CO2 therapy, respectively.
Goel et al.5 also compared efficacy of monthly ultrapulsed CO2
laser therapy with weekly 30% TCA in xanthelasma palpe-
brarum treatment. The complete cure rate was higher in the

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Nguyen, Vaudreuil, and Huerter Laser therapy in xanthelasma palpebrarum Review e51

Table 2 Treatment of xanthelasma palpebrarum with CO2 laser

Mean number
of sessions Follow-
(range), up
Study Specifications Outcome Adverse effects interval (months)

Apfelberg 1 mm spot, 10 W, 100% CR, excellent cosmetic effect, – 3 14–48

et al. 400–500 J/cm2 no recurrence
198719
Corradino 20 Hz, 75 mJ, 100% CR, recurrence (n = 2) – 2.9 (2–4), 15 d 2, 6, 12
et al. 1.5 W
201511
Delgado 20 W, 100 mJ 100% CR Palpebral edema (n = 1), erythema 1 (3: n = 1, 2: 12
et al. 91 month (n = 1), hypopigmentation n = 2)
201318 (n = 1)
Esmat Superpulsed: 100% CR. Superpulsed: more Superpulsed: transient hypopigmentation Superpulsed: 1 3
et al. 0.5–1.5 W improved color and thickness. (n = 3), atrophic scars (n = 11), upper Fractional:
201420 Fractional: 20 W Fractional: shorter downtime, higher eyelid retraction (n = 2), recurrence 3–5,
patient satisfaction. (n = 3). 4–6 weeks
Fractional: transient hyperpigmentation
(n = 2)
Goel et al. 7–10 W, 250– 100% CR, recurrence (n = 4) Erythema (n = 19), hypopigmentation 1–3, monthly 1, 3, 6
20155 350 mJ, <300 µs, (n = 3), hyperpigmentation (n = 2)
1 mm spot, 0–
100 Hz
Mourad 7–12 J/cm2, 4– Excellent response, recurrence Erythema (n = 5, 55.6%), edema (n = 5), 2, 2 weeks –
et al. 8 mm spot, 0.4 s (n = 1), no significant difference hyperpigmentation (n = 2),
20156 between 70% TCA and CO2 laser hypopigmentation (n = 3)
efficacy
Pathania 10 600 nm, 100% CR, recurrence (n = 2) Postinflammatory hyperpigmentation (n = 2) 1 9
et al. 100–200 Hz;
201512 200–400 ls,
1–2 mm spot
Raulin 10 600 nm; 100% CR, recurrence (n = 3) Erythema 92–4 months (n = 5), 1 10
et al. 250–500 mJ; hyperpigmentation 97 months (n = 1),
199921 600–900 ms, hypopigmentation (n = 3)
1.5–2.5 mm spot
Ullmann 3–5 W, 1 mm spot, Perfect healing (n = 13), slight scar/ Hypopigmentation (n = 4), 1–2 (2: n = 4) 15–54
et al. continuous mode pigmentation (n = 9), recurrence hyperpigmentation (n = 1) (mean
199322 (n = 2) 26)

CR, complete resolution; TCA, trichloroacetic acid.

group receiving CO2 laser therapy (25 of 25), when compared
to those receiving TCA (14 of 25). Additionally, mean number of
sessions was lowered in the laser group, except in those with
mild disease. However, no significant differences were detected
in scarring and recurrence rates.
Reported adverse events typically included transient dyspig-
mentation, erythema, and scarring. Transient dyspigmentation
was the most consistently reported adverse outcome, with
hypopigmentation reported in 17 patients6,18,20–22 and hyperpig-
mentation reported in 10 patients.6,12,20–22 Mild erythema and
edema were additional common complaints. Esmat et al.20
reported atrophic scarring (n = 11) and upper eyelid retraction
(n = 2) with use of the superpulsed laser. These effects were
not reported in the remaining studies, which generally used
ultrapulsed lasers or did not report CO2 laser type.
Erbium:YAG lasers
Five studies13,23–26 (n = 66) reported the use of erbium-doped
lasers. These studies administered 1–2 sessions of therapy and
reported a follow-up ranging from 1 to 12 months. Reepithelial-
ization was generally within 5–10 d posttherapy, with no major
side effects reported. Mild to marked dyspigmentation was the
most common side effect. Additionally, a minority of cases
reported minor bleeding and transient edema and erythema. No
cases reported recurrence of the treated lesions.
Comparison of Er:YAG laser efficacy to other treatment
modalities was performed in two studies. Abdelkader and col-
leagues23 compared the argon laser with Er:YAG in the treat-
ment of a total of 40 patients with xanthelasma palpebrarum.
Regardless of laser type, the majority of patients achieved com-
plete resolution (n = 45, 69.2%) or significant decrease in lesion

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e52 Review Laser therapy in xanthelasma palpebrarum Nguyen, Vaudreuil, and Huerter

size. The authors of the study suggested argon laser to be easy
and effective in lesions of small size, whereas the Er:YAG may
be better in larger lesions. In a separate study25 of 21 patients
with xanthelasama palpebrarum, Er:YAG was compared to 70%
TCA therapy. Comparison of pretreatment and posttreatment
scoring of cases found no significant differences between the
two modalities. Additionally, no significant differences in compli-
cation rates were detected.
Neodymium:YAG lasers
Three studies (n = 49) reported the use of neodymium-doped
lasers.17,27,28 These studies administered 1–2 sessions of ther-
apy with a follow-up of 2 weeks to 2 months. Re-epithelializa-
tion occurred in 6–10 d. Reported side effects included hypo/
dyspigmentation, pin-point bleeding and crusting, and swelling.
One study17 found no difference in outcome when comparing
the efficacy of 532 and 1064 nm for the wavelength setting.
Overall, the primary advantage of both YAG laser types
(summarized in Table 3) appeared to be the lower number of
sessions required for therapy (generally 1–2 sessions). While
there was a marked variability in the manner of reporting the
outcome, use of the Er:YAG laser appeared to have better out-
comes than the Nd:YAG laser. Most studies reported complete
resolution in treated patients,13,24,26 while two other studies23,25
reported approximately 1/3 of patients having the “best”
outcome on a relative scale (excellent or >75% clearance,
respectively). The use of Nd:YAG laser appeared to have
unsatisfactory improvement in two studies17,28 but >75% clear-
ance in over half of the lesions treated in another study.27
Additional laser modalities
Five studies used other lasers in the treatment of patients with
xanthelasma palpebrarum, summarized in Table 4. Laser types
included argon,23,29 PDL,8,9 and a 1450 nm diode laser.30
Abdelkader and colleagues23 compared argon laser therapy
to the Er:YAG laser, as described above. The majority of
patients treated with argon laser achieved “excellent” results
(25, 71.4%) on a scale from satisfactory to excellent. The only
reported side effects were dyspigmentation in two patients.
Basar et al.29 used the argon laser to treat 24 patients with xan-
thelasma palpebrarum. Complete initial removal of lesions was
achieved in all cases, with 6 ultimately recurring. Cosmetic out-
come in 85% of cases was considered to be good. Side effects
included erythema, dyspigmentation, and visible scarring or
dyschromia.
PDL was utilized in two studies covering a total of 21
patients. A single case report8 achieved complete clearance of
the lesion after 5 sessions at 2-week intervals. Cosmetically
excellent results were attained, with no scarring or dyspigmen-
tation after the last session. A larger study of 20 patients with

Table 3 Treatment of xanthelasma palpebrarum with YAG lasers

Sessions, Follow-up
Study Specifications Outcome Adverse effects interval (months)

Abdelkader Er:YAG, 1.6 mm spot, Excellent (n = 20), very good (n = 5), good Dyspigmentation (n = 2) 1 6
et al. 300 mJ, 1–5 Hz (n = 2), satisfactory (n = 2)
201523
Borelli et al. Er:YAG, 300–12 mJ, 100% CR, reepithelialization 5–7 d, Minor bleeding, erythema 1 7–12
200113 2–6 Hz no recurrence avg 92 weeks, edema
(n = 1)
Drnov

sek- Er:YAG, 450–550 mJ, 100% CR, reepithelialization 7–10 d Erythema 93 weeks 1 1–10 (mean, 3)
Olup et al. 3–5 mm spot diameter,
199724 5–7 J/cm2
Fusade Nd:YAG, 2 mm spot, >75% clearance (n = 6, 20 lesions), 50–70% Hypopigmentation (n = 2) 1 2
200827 10 Hz, 5–7 ns, (n = 2, 6 lesions), 25–50% (n = 3, 12 lesions),
1064 nm, 4–8 J/cm2 reeptihelialization 6–10 d
Gungor Er:YAG, 2940 nm, >75% clearance (n = 7), 50–75% (n = 6), Mild dyspigmentation 1–2 1
et al. 200–300 mJ, 4 Hz, 25–50 (n = 7), <25% (n = 1) (n = 12), marked
201425 3 mm spot dyspigmentation (n = 7)
Kaliyadan Nd:YAG, 1064 nm, Left: >50% clearance; Right: no significant Dyspigmentation 2, 2 weeks 2 weeks
et al. 5 J/cm2 improvement
201028
Karsai Nd:YAG, 532 or No improvement (75–90%), 1 degree of Pin-point bleeding and 2, 4 weeks 4 weeks
et al. 1064 nm, 2 or 6 J/cm2, clearance (10–25%), No efficacy difference crusting 97–10 d,
200917 5 Hz, 6 ns, 4 mm spot with wavelength swelling 92–5 d
Levy et al. Er:YAG, 500 mJ, 10 Hz, 100% CR, no recurrence – 1 12
200326 350 µs, 3 mm spot

Avg, average; CR, complete resolution; Er:YAG, erbium-doped yttrium aluminum garnet; Nd:YAG, neodymium-doped yttrium aluminum garnet.

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Nguyen, Vaudreuil, and Huerter Laser therapy in xanthelasma palpebrarum Review e53

Table 4 Other lasers used in xanthelasma palpebrarum treatment

Follow-
Sessions, up
Study Specifications Outcome Adverse effects interval (months)

Abdelkader Argon, 1000 µm spot, 0.8– Excellent (n = 25), very good Dyspigmentation (n = 2) – 6
et al. 201523 0.9 s, 600–800 mW, (n = 7), good (n = 2),
continuous satisfactory (n = 1)
Basar et al. Argon, 514 nm, 500 µm 100% CR, recurrence (n = 6) Erythema (8 lesions), hyperpigmentation 1–4, 2– 8–16
200429 spot, 0.1–0.2 s, 900 mW (n = 1), hypopigmentation (n = 2), visible 3 weeks (mean
scar/dyschromia (n = 1) 10.2)
Karsai et al. PDL, 585 nm, 7 J/cm2, >50% clearance (~66%), Purpura (38 lesions, 910–12 d), swelling Avg 3.9, 2 4 weeks
20109 0.5 ms, 10 mm spot, 2 >75% (~25%) (38 lesions, 92–5 d), hyperpigmentation –3 weeks
passes (3 lesions)
Park et al. 1450 nm diode laser, 6–mm <20% clearance (n = 2), 20– Hyperpigmentation (n = 5), swelling 93– 1–4, 4– 4–
201130 spot, 12 J/cm2, cryogen 40% (n = 2), 40–60% 4d 6 weeks 6 weeks
cooling: 20–30 ms (n = 8), 60–80% (n = 4)
Scho€nermark PDL, 585 nm, 5 mm spot, CR – 5, 2 weeks –
et al. 19968 7 J/cm2

CR, complete resolution; PDL, pulsed dye laser.

Table 5 Comparison of different laser modalities in xanthelasma palpebrarum treatment

Percent
Laser Number of Mean number clearance Percent recurrence
type studies of sessions (%)a (follow-up range, months) Side effects

CO2 9 1.9 100 8.5% (1–54) Palpebral edema, erythema, hypopigmentation,

hyperpigmentation, atrophic scars, upper eyelid retraction
Er:YAG 5 1.1 86.5 0% (1–12) Dyspigmentation, minor bleeding, erythema, edema
Nd:YAG 3 1.6 55.5 0% (0.5–2) Dyspigmentation, hypopigmentation, pin-point bleeding/
crusting, edema
Argon 2 2.5 100 9.4% (6–16) Dyspigmentation, hyperpigmentation, hypopigmentation,
scar, erythema
PDL 2 4.5 100 0% (0–1) Purpura, edema, hyperpigmentation
1450 nm 1 2.5 47.5 0% (1–1.5) Hyperpigmentation, edema
diode

CO2, carbon dioxide; Er:YAG, erbium-doped yttrium aluminum garnet; Nd:YAG, neodymium-doped yttrium aluminum garnet; PDL, pulsed dye
laser.
a
Excludes studies evaluating response on a relative graded scale.

38 xanthelasma palpebrarum lesions9 achieved promising

results with PDL treatment. One quarter of the treated lesions
had excellent results (>75% clearance), whereas two-thirds of
the lesions showed clearance greater than 50%. Patient satis-
faction was generally high. Side effects included purpura, swel-
ling, and hyperpigmentation.
Lastly, a single study used a 1450 nm diode laser with a
cryogen cooling spray to treat sixteen patients with xanthelasma
palpebrarum.30 Most patients (n = 12, 75%) demonstrated mod-
erate to marked improvement (40–80% clearance). Side effects
were minimal, including mild, transient hyperpigmentation
(n = 5), and local swelling lasting 3–4 d.
Discussion
Carbon dioxide lasers were by far the most commonly reported
laser modality for the treatment of xanthelasma palpebrarum.
These lasers offer excellent cosmetic results with a range of 1–
3 sessions of therapy. While requiring more sessions, fractional
CO2 lasers may be particularly attractive because of their low
down time and excellent cosmetic results. Recurrence rates
were reported in these studies. However, reporting bias must
be considered, and large comparative trials are required to
determine true efficacy. The Er:YAG laser appears to also be a
promising modality. Notably, the lower number of sessions

ª 2017 The International Society of Dermatology International Journal of Dermatology 2017, 56, e47–e55
e54 Review Laser therapy in xanthelasma palpebrarum
Figure 2 Rates of clearance and side effects in the different laser
modalities used to treat xanthelasma palpebrarum. Side effects
include edema, erythema, dyspigmentation, visible/atrophic
scarring, eyelid retraction, bleeding, and purpura
required may offer an advantage for treatment. In the few stud-
ies reporting use of the Nd:YAG laser, outcome was highly vari-
able and appears to be less efficacious than Er:YAG.
Comparative studies were a minority of the included reports
in this review. One study23 compared Er:YAG laser to argon,
finding the efficacy and side effect profiles to be comparable.
The remaining multi-arm studies compared a laser modality to
TCA. At higher doses of TCA, efficacy was comparable to that
of the CO2 laser,6 with lower concentrations demonstrating a
lower complete cure rate.5 To offer some comparison, Table 5
demonstrates summary statistics of the discussed laser modali-
ties, with clearance rate and side effect profiles depicted in
Fig. 2.
Surgical excision in skilled hands can achieve cosmetically
excellent results. However, laser treatment offers an alternative
approach.2,3 This may be particularly applicable in patients who
are not good candidates for excision, such as anticoagulated
patients or elderly patients with lax periorbital skin who pose
greater risk for ectropion as a surgical complication.
Conclusions
Overall, reports on laser therapy for xanthelasma palpebrarum
suffer from small cohort size, short follow-up, and single-arm
design. Bearing in mind the limitations of the available and pre-
sently reviewed literature, CO2 and Er:YAG lasers demonstrate
the most potential in treatment of xanthelasma palpebrarum.
CO2 lasers exhibited a promising clearance rate in 1–3 sessions
of treatment. Er:YAG lasers generally required 1–2 sessions,
though it is unclear whether the efficacy matches that of CO2
lasers. Further larger-sized randomized trials comparing these
laser modalities would be helpful. The optimal treatment modal-
ity demonstrating efficacy and low number of sessions need to
International Journal of Dermatology 2017, 56, e47–e55
Nguyen, Vaudreuil, and Huerter
be determined. However, sufficient evidence is available to sug-
gest laser therapies to be a cosmetically excellent treatment
option for xanthelasma palpebrarum.
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