Dermatology Online Journal

Koebner phenomenon in xanthelasma after treatment with trichloroacetic acid
Maryam Akhyani MD¹, Maryam daneshpazhooh MD¹, Alireza K Jafari MD², Zahra S Naraghi MD³, Farzaneh Farahani MD¹, and Siavash Toosi MD¹
Dermatology Online Journal 12 (2): 12

1. Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences. stoosi@razi.tums.ac.ir
2. Department of Ophthalmology, Farabi Hospital, Tehran University of Medical Sciences
3. Department of Pathology, Razi Hospital, Tehran University of Medical Sciences

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Abstract

A 47-year-old woman presented with a history of yellow plaques on her eyelids. These lesions had been diagnosed clinically as xanthelasma and treated five times with topical applications of trichloroacetic acid (TCA) 33 percent. Despite flattening of the original lesions, the patient noticed extension of the lesions on the site of treatment following each session. Skin biopsy showed characteristic findings of xanthelasma. It appears that, in rare instances, xanthelasma palpebrarum may progress following TCA application by a Koebner-like phenomenon.

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Clinical synopsis

A 47-year-old woman presented with a 3-year history of discrete yellow plaques on her eyelids. Her upper eyelids were more extensively involved than the lower ones. With a clinical diagnosis of xanthelasma, during the last year she had been treated with five monthly topical applications of trichloroacetic acid 33 percent (TCA).

Figure 1	Figure 2
Xanthelasma palpebrarum extending after application of five courses of topical trichloroacetic acid 33 percent, a Koebner-like phenomenon

After the last course of treatment, attributed to inadvertent dripping of TCA, there was erythema and crusting beyond the borders of the original lesions. One month after stopping the treatment, despite flattening of the primary lesions, there were new lesions corresponding to the erythematous areas where TCA was applied.

Figure 3	Figure 4
Histopathological analysis showing lipid-laden histiocytes in the superficial dermis and around blood vessels and skin appendages. (H&E, original magnification × 40)

A biopsy was done on one of the new sites. Histopathological examination of the specimen stained with hematoxylin-eosin showed lipid-laden histiocytes in the superficial dermis and around blood vessels and skin appendages.

The clinical and histological findings were compatible with a diagnosis of xanthelasma palpebrarum. There were no associated symptoms. Physical examination was otherwise unremarkable. The full blood cell count, liver and renal function tests, serum immunoglobulin levels, and lipid profiles were all within normal limits.

Discussion

Xanthelasma palpebrarum is the most common form of xanthoma. It appears as yellowish, flat, soft plaques located most commonly on the medial portion of the eyelid. About 60 percent of patients have an associated hypercholesterolemia [1]. The mechanism that initiates macrophage accumulation, cholesterol uptake and foam-cell formation in a normolipemic patient following an inflammatory skin disorder is not clearly understood [2]. It has been suggested that increased plasma lipid peroxidation (derived from oxidized low-density lipoprotein) may lead to accumulation of cholesterol in macrophages and formation of foam cells [3]. Xanthelasma has been reported following erythroderma [4], inflammatory skin disorders, and allergic contact dermatitis in spite of normal lipid profiles [5].

Topically applied dichloroacetic and trichloroacetic acid are described in the literature for the treatment of xanthelasma. Typically, the technique involves painting the lesions using a cotton-tipped applicator in a circular fashion with the greatest amount of acid applied at the margin of the lesions [6]. Recurrence of xanthelasma is common, regardless of the mode of treatment. Mendelson and Masson described a 40 percent recurrence rate after primary excision and a 60 percent recurrence rate after secondary excision. The highest incidence of recurrence was within the first year (26 %) [7].

After the final application of TCA in our patient, we observed erythema and crusting in some areas at a distance from the original lesions; this was attributed to inadvertent dripping of TCA. The crusting was followed by development of xanthelasma exactly on the areas were TCA was applied. The original areas showed improvement and flattening. Even though the original xanthelasma improved with this treatment, the appearance of new lesions on TCA-treated normal skin appears to be the result of induction of xanthelasma by TCA in our patient. Despite this assumption, xanthelasma can be a progressive disease and extension of the lesions could be considered to be a result of the natural history of this process. The progression of xanthelasma to involve previously normal skin, following TCA application, may be considered as a Koebner-like phenomenon. We find no report of Koebner phenomenon in xanthelasma palpebrarum in the English literature, but there are a few case reports of Koebner phenomenon in eruptive xanthoma [8, 9] and in diffuse palmar xanthoma [10]. We suggest that, although topical application of TCA has been used for the treatment of xanthelasma palpebrarum, in rare instances it may induce development of new lesions by a Koebner-like phenomenon.

References

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2. James MP, Warin AP. Plane xanthoma developing in photosensitive eczema: A report of three cases and a discussion of a possible mechanism for lipid accumulation in plane xanthomas. Clin Exp Dermatol 1978: 3; 307-314.

3. Bergman R, Kasif Y, Aviram M, et al. Normolipidaemic xanthelasma palpebrarum: lipid composition, cholesterol metabolism in monocyte-derived macrophages, and plasma lipid peroxidation. Acta Derm Venereol 1996: 76; 107-110.

4. Walker AE, Sneddon IB. Skin xanthelasma following erythroderma. Br J Dermatol 1968: 80; 580-587

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6. Haygood, LJ, Bennett JD, Brodell RT. Treatment of xanthelasma palpebrarum with bichloracetic acid. Dermatol Surg1998: 24: 1027

7. Mendelson BC, Masson JK. Xanthelasma: Follow-up on results after surgical excision. Plast Reconstr Surg1976: 58; 535

8. Miwa N, Kanzaki T. The Koebner phenomenon in eruptive xanthoma. J Dermatol. 1992 Jan;19(1):48-50.

9. Goldstein GD. The Koebner response with eruptive xanthomas. J Am Acad Dermatol. 1984 Jun;10(6):1064-5.

10. Bragg J. Diffuse plane xanthomata. Dermatol Online J. 2005 Dec 30;11(4):4.

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