CO₂ laser excision a novel treatment approach for large xanthelasma lesions

A study has shown that carbon dioxide (CO₂) laser excision may be an innovative approach for treating xanthelasma palpebrarum (XP), particularly for large lesions.

“Before our study, laser ablation was commonly employed for treating XP; however, it had shortcomings, especially when dealing with extensive grade IV lesions,” said the researchers. “Although surgical excision was effective for larger lesions, it frequently necessitated complex reconstructive procedures, which increased the risk of complications and prolonged recovery time.”

The current study reveals a high clearance rate, a low recurrence rate, and minimal complications, they said.

The researchers retrospectively evaluated 295 participants (average age 41.7 years, 77 percent women). Most lesions were grade I (n=246), while the rest were grade II–IV. All participants underwent CO₂ laser excision and were followed for 12 months. Patients sought treatment primarily for cosmetic reasons or to address the discomfort brought about by the lesions. [Br J Ophthalmol 2024;doi:10.1136/bjo-2024-325581]

A total of 185 patients had bilateral lesions, 42 had theirs on the right eye, and 68 had lesions on the left. Most participants (n=254) had lesions on the upper eyelid, six on the lower, and 35 on both. Most patients (n=278) had lesions with heights less than 2 mm, 277 were treatment-naïve, and 18 sought treatment for recurrent lesions.

Efficacy outcomes

Grade I–III lesions demonstrated a high clearance rate, exceeding 99 percent post-treatment. Grade IV lesions, particularly those with a height greater than 2 mm, had a slightly lower clearance rate (95 percent).

A total of 171 participants achieved clearance only after a single session, while 109 needed 2–3 sessions. Only 15 patients required over three sessions.

Twenty patients (6.8 percent) had a recurrence. A significant association existed between larger lesion heights and increased recurrence rates (odds ratio, 2.964; p<0.001).

Postop complications

The most common complications following the procedure were redness, swelling, and a slight burning sensation around the operation area. However, these were transient and generally subsided within 3 days.

During follow-up, the main complications were hypopigmentation (8.5 percent) and hyperpigmentation (8.1 percent), followed by hypertrophic scarring (4.4 percent). No severe complications (eg, infections or damage to the lacrimal punctum) were reported.

An aesthetic matter

XP lesions pose no medical threat but become a cosmetic challenge when they grow and become noticeable. Large lesions may warrant a combination of surgical removal, eyelid reconstruction, and skin grafting. [Orbit 2009;28:16-19]

Lower laser energies lead to smoother treatment surfaces but require longer treatment time. Conversely, higher laser energies reduce vaporization time but may lead to uneven treatment areas. Laser ablation is mostly used for smaller lesions, but recurrence is a concern, especially for lesions deep into the dermis. [Plast Reconstr Surg Glob Open 2023;11:e4982; Arch Plast Surg 2013;40:380-386; J Cutan Aesthet Surg 2018;11:1-6]

“To address these limitations, this study explores the use of CO₂ laser excision for XP, a method that cuts and removes the lesion entirely from its base rather than vaporizing it layer by layer,” the researchers explained. “This approach aims to provide a more efficient and effective treatment for large lesions, with improved outcomes and reduced treatment times.”

An edge over conventional approaches

“Our investigation [shows that] CO₂ laser excision for large XP lesions [is] effective, with a high rate of lesion clearance and manageable number of treatment sessions required for satisfactory outcomes. Postop complications were infrequent and generally mild,” they said.

This approach also avoids invasive reconstructive surgery, thus leading to quicker recovery and excellent cosmetic outcomes. “The procedure time is notably reduced, minimizing damage to surrounding tissues and enhancing patient comfort,” they added.

Taken together, the study suggests that CO₂ laser excision may be a precise, minimally invasive, and effective treatment modality for large XP lesions. But while it has a substantial edge over conventional surgical and laser ablation approaches, the researchers called for further investigation to support the results and fine-tune treatment protocols.