Eruptive Xanthomas

A 38-year-old man who had a previous medical history that included epileptic seizure, bipolar disorder, sleep apnea, and hypertriglyceridemia presented to outpatient clinic as a new patient for a recent rash. The rash had started 1 month prior and began on the dorsum of his hands and wrists before progressing up his arms and onto his truck. The patient describes the rash as having a burning sensation but was not pruritic. He had tried over-the-counter creams, including steroid-based creams, but these did not provide relief in symptoms or clearance of the rash. 

His triglycerides were last checked 3 years earlier and were 761 mg/dL at that time. He was not on any cholesterol lowering medications. He has no other known history of family members with hypertriglyceridemia. His medications included pantoprazole, phenobarbital, levetiracetam, quetiapine, and fluoxetine.

Physical examination. Upon physical exam, the rash consisted of multiple, bright pink papules all consistent in size and symmetrically rounded between 2 mm to 4 mm (Figure).  They were located on the hands, elbow, shoulder, lateral flanks, and upper thighs, and they seemed to have a yellowish content. They were not erythematous and did not blanch. The papules were firm in texture. 

Diagnosis. Differential diagnosis included eruptive xanthomas, fibroblastic rheumatism, rheumatic fever nodules, eruptive syringoma, and pityrosporum folliculitis. A shave biopsy for microscopic examination was performed and was reported as eruptive xanthoma from the pathology department. 

Laboratory tests. The patient had a repeat lipid panel done that showed a triglyceride level of 3159 mg/dL with direct reflex LDL level of 63 mg/dL and HDL level of 22 mg/dL. He had a diabetic screen that revealed a fasting glucose level of 278 mg/dL and his HgbA1c was 12.0%. The patient was not previously diagnosed with diabetes mellitus. 

Discussion. Eruptive xanthomas are virtually pathognomonic for hypertriglyceridemia and usually have quick onset with areas of distribution including extensor surfaces and on the buttocks region. They may be tender or pruritic. A xanthoma is a deposition of lipid-laden macrophages that form foam cells in the dermis. There is a large correlation with newly diagnosed diabetes mellitus and eruptive xanthomas; the thought is that insulin is a stimulating factor for lipoprotein lipase and, with deficient insulin, there is deficient triglyceride rich lipoprotein breakdown. 

Treatment. Treatment for eruptive xanthomas includes a strict glycemic intake, low fat diet, and medication therapies. Avoiding alcohol is important to decrease the rates of acute pancreatitis and to decrease very-LDL synthesis from the liver. Patients usually start to see regression of xanthomas within 4 weeks; complete resolution often can take several more weeks. Recurrence is rare with treatment of diabetes mellitus and hypertriglyceridemia.

There are multiple cases of acute pancreatitis after first presentation of rash, which is later diagnosed as eruptive xanthomas. One benefit of early diagnosis of eruptive xanthomas would be to prevent hospital admission for acute pancreatitis secondary to hypertriglyceridemia, if treated early. Another reason for prompt diagnosis is for diabetic evaluation and possible need of therapy and also possibly preventing hospital admission for hyperglycemic state.

Outcome of the case. The patient was started on high dose statin (atorvastatin 80 mg daily) and a fibric acid agent (fenofibrate 160 mg daily) for his hypertriglyceridemia. He was started on a strict carbohydrate diet with insulin. At 1 month of treatment, his skin lesions had receded but had not completely resolved.

References: 

1. Nayak KR, Daly RG. Eruptive xanthomas associated with hypertriglyceridemia and new-onset diabetes mellitus. N Eng J Med. 2004;350(12):1235.

2. Naik NS. Eruptive xanthomas. Dermatol Online J. 2001;7(2):11.

3. Chang HY, Ridky TW, Kimball AB, et al. Eruptive xanthomas associated with olanzapine use. Arch Dermatol. 2003;139(8):1045-1048.

4. Digby M, Belli R, McGraw T, Lee A. Eruptive xanthomas as a cutaneous manifestation of hypertriglyceridemia: a case report. J Clin Aesthet Dermatol. 2011;4(1):44-46.

5. Parker F. Xanthomas and hyperlipidemias. J Am Acad Dermatol. 1985;13(1):1-30.

6. Romano G, Moretti G, Di Benedetto A, et al. Skin lesions in diabetes mellitus: prevalence and clinical correlations. Diabetes Res Clin Pract. 1998;39(2):101-106.