Comparative Study to Evaluate the Efficacy of Radiofrequency Ablation versus Trichloroacetic Acid in the Treatment of Xanthelasma Palpebrarum.

BACKGROUND: Xanthelasma palpebrarum (XP) is a metabolic disorder involving the eyelids. Radiofrequency(RF) surgery and trichloroacetic acid (TCA) applications have been listed among the procedures for XP, but comparative studies are not available. AIM: To compare the efficacy of radiofrequency surgery versus trichloroacetic acid application in the treatment of XP. SETTINGS AND
DESIGN: 20 consecutive cases of XP attending dermatology, medicine and endocrinology out-patient departments of M.S. Ramaiah teaching hospital were enrolled for the study. It was an open-label clinical trial conducted in our hospital for a duration of 1 year.
MATERIALS AND METHODS: 20 consecutive patients conforming to inclusion criteria were selected for the study. For each patient, lesions were treated with radiofrequency ablation on one side and TCA application on the other side.
RESULTS: RF ablation was done for 12 patients over right eye lesions and 8 patients over the left eye lesions. TCA applications were done for 8 patients over right eye lesions and 12 patients over left eye lesions. 70% of lesions treated with RF ablation had a score of improvement of 4 and 70% of lesions treated with TCA application had a score of improvement of 4, at 4 weeks of follow-up. At four weeks of follow-up 40% in RF group and 15% in TCA group had scarring and 45% in RF group and 30% in TCA group had pigmentation.
CONCLUSION: RF ablation as compared to TCA application, required fewer sessions for achieving more than 75% clearance of lesions. However, TCA applications were associated with fewer complications comparatively.

INTRODUCTION

Xanthelasma palpebrarum (XP)/xanthelasmata are the xanthomata that develop around the eyes. They most commonly affect the upper eyelids and the area around the medial canthus.[1] It is the most common type of xanthoma.[2] The clinical morphologies of xanthelasma can be categorised into macular, flat plaques and papulonodular types. Although essentially benign, treatment is of cosmetic importance. About 60% of patients have associated hypercholesterolaemia. Radiofrequency (RF) ablation and trichloroacetic acid (TCA) application[2] have been listed among the procedures for XP, but comparative studies are not available. The present study was undertaken to compare the efficacy of RF surgery versus TCA application in the treatment of XP.

SUBJECTS AND METHODS

Twenty consecutive cases of XP attending Dermatology, Medicine and Endocrinology Outpatient Departments (OPDs) of M. S. Ramaiah Medical College and Teaching Hospital (MSRMTH) were enrolled in the study. It was an open-label clinical trial conducted in our hospital for duration of 1 year. Written informed consent was obtained from all the patients enrolled in the study.

The inclusion criteria included male and female patients with XP in the age group, 20–60 years with lesions on both eyelids.

Patients with known allergy to lignocaine, on anticoagulants/pacemakers/with known cardiac illness were excluded fromthe study. Also patients with atopy and periorbital dermatitis, diabetic patients with poor glycaemic control and patients with immunosuppression were excluded.

All patients attending the OPD's of Dermatology, General Medicine and Endocrinology at MSRMTH, were screened for XP, and clinical diagnosis was made by an examining dermatologist. Twenty consecutive patients conforming to inclusion criteria were selected for the study.

For each patient, lesions were treated with RF ablation on the one side and TCA (30%–70%) application on the other side. Patients were allotted randomly, and for a given patient, all the lesions on the one side were treated with radiofrequency and the other side were treated with TCA. Although the number of lesions was unequal on both sides, to maintain uniformity for comparison, all the lesions on one side were treated with either RF ablation or TCA application. The RF equipment used was from Ellman International, Inc., Oceanside, NY, USA., model Dento – Surg 90 F.F.P, Volts AC 220/240, 1.6 amps, frequency 3.8 MHz. The lesions were ablated till they turned brown, and the scab was removed with a saline gauze. The lesions were ablated till the pink tissue was seen. Procedures were repeated at weekly intervals if required based on the individual cases. The maximum duration of treatment was for 4 weeks. TCA was applied on the lesions following multiple puncture made on the lesions with a 26 G needle, 2 mm apart. The end-point of TCA application was frosting of lesions. Following the frosting, the lesions were thoroughly rinsed with normal saline. The lesions treated with RF/TCA were covered with 2% fusidic acid, and the applications were continued for 5 days following procedure. The clinical improvement was assessed on weekly basis with serial photographs. The results were scored on a 0–4 point scale:[4]

0 - No improvement

1 - Moderate result (<25% clearing)

2 - Satisfactory result (25%–50% clearing)

3 - Good result (50%–75% clearing)

4 - Excellent result (>75% clearing).

Patients were assessed for the presence of any scars, pigmentation, recurrence and Koebner's phenomenon. Final evaluation was done at the end of 4 weeks. Parameters studied included age, sex, duration of the disease, number of lesions, clinical morphology of lesions, associated medical conditions, other associated xanthomas, and lipid profile was ordered for each patient.

Appropriate response to the treatment was documented with serial photographs. Photographs were assessed by two investigators regarding the clinical improvement and associated complications. Final follow-up at 6 months after the last session was done.

Ethics

Ethical clearance was obtained from the ethical review board of our institution.

Method of statistical analysis

The following methods of statistical analysis have been used in this study. The results averaged (mean ± standard deviation) for continuous data, and number and percentage for dichotomous data are presented in tables and figures. Proportions were compared using Chi-square test of significance.

In the above test, P < 0.05 was accepted as indicating statistical significance. Data analysis was carried out using Statistical Package for Social Science package (SPSS Inc. Released 2009. PASW statistics for windows version 18.0).

RESULTS

Twenty patients were enrolled for the study, of them 18 were female and 2 were male. The most common morphology seen was of flat plaque type. RF ablation was done for 12 patients over right eye lesions and 8 patients over the left eye lesions. TCA applications were done for 8 patients over right eye lesions and 12 patients over left eye lesions. At 1st week of follow-up [Table 1], 40% in TCA group had <50% improvement and 65% in RF group had 50%–75% improvement in lesions (score of >3). At 2nd week of follow-up [Table 1], 85% in TCA group had 50%–75% improvement and 25% in RF group had more than 75% improvement in lesions (score of 4). At 3rd week of follow-up [Table 1], 65% in TCA group had 50%–75% improvement and only 35% in TCA group had more than 75% improvement in lesions (score of 4). At 4th week of follow-up [Table 1], 70% in TCA group had 50%–75% improvement (score of 3) and 70% in RF group had more than 75% improvement in lesions (score of 4). At 4 weeks of follow-up [Table 2], 40% in RF group and 15% in TCA group had scarring and 45% in RF group and 30% in TCA group had pigmentation [Table 3].

Table 1

Various treatment groups with their outcome at weekly intervals correlated with percentage of improvement in lesions

Table 2

Scarring as a complication observed at 4 weeks of follow-up

Table 3

Pigmentation as a complication observed at 4 weeks of follow-up

DISCUSSION

XP is the most common type of xanthoma. It most commonly affects the upper eyelids and the area around the medial canthus. XP is most commonly seen in middle-aged and older adults with a peak incidence between 30 and 50 years. Women are more commonly affected than men. They are seen in people with normal circulating lipid levels, as well as familial hypercholestrolaemia, type III hyperlipoprotienaemia and chronic cholestasis.[12] All patients included in our study were normolipaemic.

XP can have various morphological patterns such as macular, papular, plaque type and nodular varieties. They are classified as Grade I if lesions are seen only on the upper eyelid, Grade II if lesions extend to the medial canthus area, Grade III if the lesions are seen on upper and lower eyelids and grade IV if there are diffuse lesions an medial as well as lateral aspects of upper and lower eyelids. Figures 1–3 illustrate three representative cases.

Figure 1

(a) Plaque type of xanthelasma palpebrarum distributed bilaterally over upper and lower eyelids. (b) Right eye lesions were treated with radiofrequency ablation and left eye lesions were treated with trichloroacetic acid (70%) applications. (c) Follow-up of lesions at 3rd week, lesions of the right eye show an improvement of three with scarring and the lesions of the left eye have healed with hypopigmentation

Figure 3

(a) Macular type of xanthelasma palpebrarum distributed over upper eyelids bilaterally. The right eye lesions were treated with 30% trichloroacetic acid application and left eye lesions were treated with radiofrequency ablation. (b) Score of 4 on right eye at 4 weeks and left eye lesion has healed with hypopigmentation

(a) Plaque type of xanthelasma palpebrarum distributed over upper eyelids on left and right side. (b) The right eye lesions were treated with radiofrequency ablations and left eye lesions with trichloroacetic acid (60%) applications. (c) At 4 weeks of follow-up, right eye lesions show a score of 4 and left eye lesions show a score of 4. The right side shows more hypopigmentation as compared to left eye

Although the classical treatment option remains surgical excision, alternatively, chemical cauterisation, cryosurgery and electrofulguration have all been tried in the past with mixed results.[3] Surgical excision of XP is difficult, especially in cases where the lesions are multiple, close to the eyes and have indistinct borders. There is a risk of ectropion associated with surgical excision of lesions in the lower eyelid. For larger lesions, reconstruction with full thickness grafts or flaps may be necessary. There is also a transient risk of haematomas and infections associated with surgery.

The other modalities of treatment for XP include CO2 laser,[45] Erb: Yag laser, Q-switched Nd: Yag laser,[678] pulse dye laser, potassium-titanyl-potassium laser, argon laser[9] and diode[10] lasers. These lasers have a disadvantage of being expensive.

TCA in varying strengths[81112] is used in treatment of various morphological patterns of XP. TCA is a very cost-effective modality of treatment in XP, and there are few case reports and pilot studies which have demonstrated the efficacy of TCA in treatment of XP. RF cautery unit is also a very cost-effective modality of treatment in XP and is easily available with all practitioners. The TCA applications as well as RF cautery can be performed at multiple sessions until clearance of lesions.

In our study, the most common morphology was plaque type and 30% TCA was used for the same. There was a comparable difference in outcome observed in the percentages of improvement in each group, and the data analysis points out that RF showed a better improvement in score of lesions at 2nd week and TCA required multiple sessions to achieve a score of 4. The scarring and pigmentation were more in the RF group at 4 weeks of follow-up. There was no recurrence of lesions at 6 months of follow-up. The outcomes of other studies[111314] as compared to the present study are summarised in Table 4.

Table 4

Comparison of outcomes of various studies with trichloroacetic acid

This study highlights the use of TCA, which is a very cost-effective modality of treatment for XP, but multiple sessions are required to achieve a score of 4. RF ablation requires fewer sessions for treating XP, and there were few side effects reported such as scarring and pigmentation (however not statistically significant as compared to TCA in our study).

TCA can be effectively used to treat even a plaque type of XP in a primary care setting by a dermatologist who has undergone a basic training in the procedure. This study also highlights the use of multiple puncture technique used in application of TCA. The various lasers as an option mentioned are very expensive and not affordable by common patients and some of them have varied results in treatment of XP.

RF surgery can be done by a dermatologist who has just started practice with a minimum setup and the number of sessions required is fewer and is a very cost-effective modality of treatment. In this era of lasers, the contemporary methods to treat the entity achieving similar results to lasers are highlighted.

The small sample size is a limitation of this study; however, a good number of lesions were treated and the effects were similar in all the lesions. This study was conducted as there are no reported data comparing the efficacy of RF versus TCA as a modality of treatment for XP.

CONCLUSION

RF ablation required fewer sessions to achieve an improvement of more than 75% clearance of lesions compared to TCA applications, but statistically it was not significant. Scarring as a complication was comparatively lesser in TCA applications, with a 25% difference in association, as compared to RF, but even this association was not statistically significant. Our study also highlights the use of multiple puncture technique in application of TCA for XP, which is not reported before. However, with larger sample data, these findings may be confirmed. TCA application is a very cost-effective modality and can be used in routine clinical practice, even in a primary care health centre for the treatment of XP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.