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A 27-year-old woman presents to your medical clinic with a chief complaint of bilateral lesions along the medial canthus of her eyes as shown in Figure A. She is quite concerned about the cosmetic appearance of these lesions and would like them removed. She has no other complaints nor any significant past medical history. In addressing this patient's chief complaint, what would be the next appropriate step in management?
Refer to a dermatologist for Mohs surgery
Obtain a lipid panel
Obtain anti-topoisomerase antibodies
Obtain anti-transglutaminase antibodies
Provide reassurance and refer to an oculoplastic surgeon for removal of the lesions
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Xanthelasmas in a young patient may be indicative of familial hypercholesterolemia. A lipid panel should be checked.
Xanthelasmas may be associated with primary biliary cirrhosis and familial hypercholesterolemia. Xanthelasmas are yellow plaques on the medial aspects of the eyelids and are commonly bilateral. Each lesion is filled with lipid-laden histiocytes. While xanthomas that appear on the eye are called xanthelasmas, those that appear on the Achilles are called tendinous xanthomas. Another example of physical examination findings that suggest hyperlipidemia are a corneal arcus, or lipid deposited in the cornea. Recall that in familial hypercholesterolemia, patients have elevated LDL due to a defective or absent LDL receptor. Heterozygotes have cholesterol in the range of 300 mg/DL, while homozygotes have levels above 700. These patients are at risk of severe atherosclerosis early in life.
Figure A depicts the classic appearance of a xanthelasma. Illustration A depicts a corneal arcus (arcus senilis).
Answer 1: Mohs surgery would be indicated for basal cell or squamous cell carcinoma, yet these lesions do not have a malignant appearance consistent with these diseases.
Answer 3: Anti-topoisomerase antibodies are associated with diffuse systemic scleroderma. Anti-mitochondrial antibodies may be ordered as they are associated with primary biliary cirrhosis, which may cause xanthelasmas.
Answer 4: Anti-transglutaminase antibodies are associated with Celiac disease. Anti-mitochondrial antibodies may be ordered as they are associated with primary biliary cirrhosis, which may cause xanthelasmas.
Answer 5: Providing reassurance alone and referral for removal is not sufficient as these lesions could represent a serious chronic condition which requires treatment.
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