Correlation between Cholesterol Serum Level and Xanthelasma from Januari 2014 until Desember 2018 in Dermato-Venereology Outpatient Clinic of Dr . M . Djamil Hospital

Xanthelasma is common in middle-aged and older adults. Diagnosis can often be made on clinical based alone. Xanthelasma may be an important marker of underlying disease. Hyperlipidemia is reported occur in approximately 50% of patients. There is no data of xanthelasma in Dermato-Venereologi Outpatient clinic during from Januari in 2014 until Desember in 2018. The objective of this study was to determine the correlation between cholesterol level and xantelasma in Dermato-Venereology outpatient clinic of Dr. M. Djamil Hospital from Januari in 2014 until Desember in 2018. This retrospective study was performed by analyzed medical record of the new patient xanthelasma that visited Dermato-Venereology outpatient clinic of Dr. M. Djamil Hospital from Januari 2014 until Desember 2018. The results showed twenty eight patients xanthelasma and twenty eight controls, eight patients (28,57%) were male and twenty patients (71,43%) were female. Most dominant age is 36-45years, fifteen patients (53,57%). Duration of xanthelasma in this study were 50% patients in more than two years. The most common laboratory finding which was hipercholesterolemia in twenty one cases (75%). In this study, 14,28% patients had assosiated with systemic diseases as diabetes mellitus and hypertension. There were correlation between cholesterol level and xanthelasma statisticaly significant with p<0,05. The conclusion is a correlation between xanthelasma and lipid profile an clinical classificarion of xanthelasma. Xanthelasma is a marker of hyperlipidemia that requiring a complete lipid profile to detect patients potentially to severe it.


Introduction
Xanthomas are plaques or nodules consisting of abnormal lipid deposition and foam cells in skin or in tendons, the most common of which is xanthelasma palpebrum, which usually appears in middle-aged females, with an incidence of 1.1%, and an incidence of only 0.3% in males. 1 The term "xanthelasma" is derived from the Greek word xanthos (yellow) and elasma (beat-en-metal plate).It is characterized by yellowish plaques occurring most commonly near the inner canthus of the eyelid, more often on the upper, rather than the lower lid.Lesions are symmetrically distributed, and may be singular or multiple, nodular or flat and soft, and semisolid or calcareous.

2 , 3 7 Picture 1 .
Classification of xanthelasma are mention in Picture 1, (a) grade I: the lesions involve only the upper eyelids, (b) grade II: the lesions extend to the medial canthal area, (c) grade III: the lesions involve the medial side of the upper and lower eyelids, (d) grade IV: the lesions diffusely involve the medial and lateral side of the upper and lower eyelids.4Theterms dyslipidemia and hyperlipidemia are used interchangeably, but dyslipidemia is preferable as the lipids may not only be raised but may be present in altered proportions.Xanthelasma is a marker of dyslipidemia, requiring a complete lipid profile to detect patients potentially at increased risk of cardiovascular disease.However, only about half of the patients with xanthelasma are hyperlipidemia.The most frequent Fredrickson hyperlipidemic phenotype in hyperlipidemic patients with xanthelasma is type IIa.Lesss frequently found are types IIb,III, and IV.The prevalence of type IIa phenotype with xanthelasma is two to three times greater than the prevalence of this phenotype in a matched gruop of patient with dyslipoproteinemia but without xanthelasmas.5 Xanthelasmas can be found in patients with elevated LDL cholesterol levels, but most often occur in patients with relatively normal lipid levels.6,Classification of xanthelasma 4 Lipids are transported in the blood as small spherical particles, the lipoproteins.The function of the protein coating is to confer water solubility to the lipids and to provide cellular receptors and enzymes essential for lipid metabolism.Proteins in the coating with special functions are called apoproteins.The lipoproteins are derived from 2 sources-diet (exogenous) and liver (endogenous).They consists mainly of cholesterol, phospholipid and triglyceride.High-density lipoproteins (HDL) are composed mostly of phospolipids and esterified cholesterol.They are beneficial because they clean up molecules released into the circulation during the transport of triglyceriderich lipoprotein particles.Low-density lipoproteins (LDL) are consist mainly of cholesterol.LDL is the major atherogenic lipoprotein and raised serum levels are associatede with coronary heart diseases.7 Hyperlipidemias may be primary or secondary.Primary hyperlipidemias are due to severe genetic defects in lipid metabolism or less severe defects plus aggravating factors.Secondary hyperlipidemias are resultr of other diseases and drugs.The hyperlipidemias are associated with characteristics skin lessions.The main lipid that is stored in both hyperlipidemic and normolipidemic xanthelasmas is cholesterol.Some investigators have observed that xanthelasmas in normolipidemic patients do not differ ultrastructurally from hyperlipidemic xanthelasmas or other types of hypercholesterolemic xanthomas.

6 , 7 5 A 7 For
However, xanthelasmas do not develop in most patients with hypercholesterolemia and these lesions can also develop in normolipidemic patients.http://jurnal.fk.unand.ac.idJurnal Kesehatan Andalas.2019; 8(2) Histologically, xanthelasma resemble other xanthomas, that are associated with hypercholesterolemia, they are composed af foamy histiocytes with occasional Touton giant cells.They differ from other types of xanthomas by the superficial location of the foam cells and the nearly complete absence of fibrosis.Ultrastructurally, xanthelasmas resemble other types of hypecholesterolemic xanthomas.The eyelids are exposed to constant movement and friction, and this might be the reason why xanthelasmas develop in these areas.There might also be an intrinsic sensitivity in this patients to this proposed capillary leakage.benign condition which never limits function, xanthelasma palpebrarum is cosmetically disturbing, therefore, patients consult dermatologists, ophthalmologists, or surgeons for lesion removal.Several methods are used to treat xanthelasma palpebrarum and these include simple surgical excision, cryotherapy, chemical peeling with trichloroacetic acid (TCA), radiofrequency (RF), and laser treatment.Each modality has its own advantages and disadvantages.dermatologists seeking to evaluate the causes of xanthelasmas, the standard approach is to order a serum or plasma lipid profile, performed after the patient fasts overnight.These studies permit consideration of secondary causes of lipid abnormalities, particularly if the patient has elevations of LDL cholesterol (>150 mg/ dL) or triglycerides (>150 mg/dL), or decreased levels of HDL cholesterol (<55 mg/dL). 1 The aim of this study is to know the correlation of lipid profile and xantelasma clinical classification in Dermato-Venereology outpatient clinic from Januari 2014 until July 2018.Methods Retrospective study was performed by analyzed medical record of the new patient that visited Dermato-Venereology Outpatientclinic of Dr. M. Djamil Hospital from Januari 2014 until Desember 2018.Variables studied were age, sex and lipid profile dan clinical classification of the patients.

Table 2 .
Distribution of plasma lipid profile of xanthelasma

Table 3 .
Distribution of clinical classification of xantelasma

Table 4 .
Correlation between cholesterol level and xantelasma

Table 4
In this study, the most affected age groups was >36-< 45 years old (53,57%), which was similar to the data published in many literature that xanthelasma can be encountered at middle-aged and older adults.
6As well as study byBergman R (Israel,1994)who said that xanthelasma are more common in women and tend to increase in prevalence with age. 5 hypothyroidsm, obesity, liver disturbance, nephrotic syndrome, biliary tract obstruction.The early diagnosis of the underlying disease can significantly affect future health.11,12