Case Study by Divya Sharma ; Sandra Marchese Johnson MD , FAAD
Eruptive Xanthoma
Abstract
A pleasant , 27-year-old white man presented to our clinic for a second opinion about a one-year history of worsening bumps on his skin . He states that he was diagnosed with molluscum contagiosum but is not responding to treatment . He admits to a history of hypertension and type 1 diabetes mellitus but due to financial situation has not been able to afford his medicines . He admits to only taking multivitamins . He denies tobacco and alcohol use . On physical examination , he has too numerous to count multiple yellow grouped umbilicated papules , some coalescing into plaques , scattered on the body . A presumptive diagnosis of eruptive xanthomas was made . A skin biopsy was performed that confirmed the diagnosis . Laboratory evaluation was performed . Pertinent abnormal tests include total cholesterol 444 ( 0-200 mg / dL0 , triglycerides 3176 ( 0-150 mg / dL ), HDL 14 ( 40-60 mg / dL ), glucose 423 ( 70-105 mg / dL ), creatinine 1.30 ( 0.72-1.25 mg / dL ). He was referred to our local free clinic . He now is being treated for his diabetes and hyperlipidemia . The skin lesions started resolving after one month of medications and no cutaneous interventions .
Discussion
Cutaneous manifestations of systemic diseases are paramount for all health
care professionals to know . Xanthomas are cutaneous manifestations of hyperlipidemia . They can present as plaques , papules , or nodules that consist of an accumulation of lipids . Xanthomas occur most commonly in the skin and tendons . 1 The pathogenesis of xanthomas is related to the abnormal accumulation of lipid-laden macrophages in the skin ; this is due
Figure 1 : Multiple yellow , grouped umbilicated papules , some coalescing into plaques , scattered on the right upper arm . violaceous periocular rash .
to primary lipid disorders or secondary causes of hyperlipidemia that include metabolic diseases , hepatic diseases , hematologic disorders , and as side effects of drugs . 2 Xanthomas that occur in normolipemic patients , termed normolipemic xanthomas , are much rarer occurrences .
Eruptive xanthomas are discrete , inflammatory-type papules that usually present in clusters around the buttocks , elbows , lower arms , or knees . 2 The primary lipid disorders most often associated with eruptive xanthomas are primary hyperchylomicronemia and familial hypertriglyceridemia . 2 Obesity , cholestasis , uncontrolled diabetes , and medications such as retinoids , estrogen therapy , and protease inhibitors are the most common secondary causes of hyperlipidemia associated with eruptive xanthomas . Importantly , the most common setting in which eruptive xanthomas occur is with uncontrolled diabetes , which was the case for our patient . 3
On physical examination , eruptive xanthomas appear as dome-shaped , discrete , papules that are initially red , but later become yellow with a surrounding red halo . 2 Notably , eruptive xanthomas display the Koebner phenomenon , in which the lesions can occur secondary to skin trauma . 1 As in our patient , the triglyceride levels in patients with eruptive xanthomas are markedly elevated , frequently being above 1,000 mg / dL . When suspecting eruptive xanthomas , one must also keep in mind the differential diagnoses , which include
230 • The Journal of the Arkansas Medical Society www . ArkMed . org