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The FP suspected xanthomas secondary to hyperlipidemia. Blood work revealed a random blood sugar of 203 mg/dL, a fasting triglyceride level >7000 mg/dL, and total cholesterol >700 mg/dL. High-density lipoproteins were 32 mg/dL, and there were no chylomicrons present. The FP diagnosed xanthomas, poorly controlled diabetes mellitus, and hyperlipidemia.
Xanthomas are usually a consequence of primary or secondary hyperlipidemia. There are 5 basic types:
- Eruptive xanthomas—the source of this patient’s discomfort—are the most common. They appear as crops of yellow or hyperpigmented papules with erythematous halos in Caucasian patients.
- Tendon xanthomas are frequently seen on the Achilles and extensor finger tendons.
- Plane xanthomas are flat and commonly found on the palmar creases, face, upper trunk, and on scars.
- Tuberous xanthomas are found most frequently on the hands or over large joints.
- Xanthelasma are yellow papules located on the eyelids.
Initial treatment should target the underlying hyperlipidemia (when present) because hypolipidemic drug treatment often results in regression of the lesions. When standard therapy fails, low-density lipoprotein apheresis can be effective for tendon xanthomas.
Recognizing the importance of treating the patient’s diabetes, as well as hyperlipidemia, the FP in this case started the patient on metformin, gemfibrozil, and an HMG-CoA-reductase inhibitor.
The patient was lost to follow-up.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith M. Xanthomas. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:951-953.
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