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Eruptive Xanthoma – A Systemic Sign of Elevated Triglycerides?

A Systemic Sign of Elevated Triglycerides
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Recently a patient walked into the clinic with a concern of acne on the shoulder that has remained unresolved over the course of several months. 

What comes to mind? 

He has a previous diagnosis of hypertriglyceridemia– elevated triglyceride levels in the flood. The rash that this patient mistook as acne is, in fact, eruptive xanthomas. Not all rashes are merely a skin condition. Rashes may be more than skin deep and suggestive of an underlying medical condition that has yet to be addressed. 

The objective of this article is to promote awareness on the possibility of a warning sign of systemic cardiovascular health issues. This is when a person is plagued with a seemingly benign dermatological rash.

xanthoma
Eruptive xanthoma is commonly confused as acne.

What are eruptive xanthomas?

Eruptive xanthomas are small (less than 1cm) yellow-hued papules with a reddish rim that can be seen over the shoulders, upper back, neck, abdomen, face, knees, and the buttock region. They can be slightly tender and/or itchy.

While uncommon, eruptive xanthoma can be noticeable if a person has it. Eruptive xanthomas can be seen in 8.5% of patients with severe hypertriglyceridaemia. The lesions are benign and can resolve over time with treatment and management of the triglyceride level. 

Why is it so important to pick up the findings of eruptive xanthomas?

As mentioned, it is associated with severe hypertriglyceridaemia which is a condition where a person’s blood has abnormally elevated or high concentrations of triglycerides (a type of fat). If this is left unattended, you can be at risk of cardiovascular complications such as a stroke, coronary heart disease, heart attack, or even pancreatitis

If you have an unexplained rash that is yellowish with a red rim and you are concerned that it could be a sign of eruptive xanthomas, do see a doctor to get yourself checked.

triglycerides
You could be at risk of cardiovascular complications with elevated levels of triglycerides.

What are triglycerides?

Triglycerides are lipids (fats) that can be found in your bloodstream. Triglycerides are made up of fatty acids (both saturated and unsaturated) and glycerol (a form of sugar).

They are produced from extra carbohydrate, alcohol, and glucose that we consume and are stored in the fat cells of our body. Our liver also naturally produces triglycerides. Triglycerides are used as a source of energy when required or when you are in between your meals. 

What is the difference between triglycerides and cholesterol?

Triglycerides are stored unused fat cells or calories. These provide your body with energy when required. Cholesterols, on the other hand, are proteins that help to synthesise cells and hormones. 

What is hypertriglyceridaemia?

Hypertriglyceridaemia is a common medical condition that is often encountered when a person performs a blood test for lipid screening as part of a cardiovascular risk workup. It is defined as an abnormal concentration of triglycerides in the blood. A normal triglyceride level is less than 150 mg/dl. 

According to the Ministry of Health (MOH), Singapore, Clinical Practice Guidelines for lipid, the definition of hypertriglyceridaemia is as below:

  • Hypertriglyceridaemia: 150 to 399 mg/dl
  • Severe hypertriglyceridaemia: more than 400 mg/dl

Who is at risk of developing hypertriglyceridaemia in Singapore?

There are several factors that may increase your risk of developing hypertriglyceridaemia, these are:

  • Excessive alcohol intake: also known as alcohol induced hypertriglyceridaemia, individuals with this condition are advised to reduce or stop alcohol consumption.
  • Obesity: hypertriglyceridaemia is commonly associated with obesity.
  • Diabetes: hypertriglyceridaemia is commonly seen in individuals with uncontrolled diabetes.
  • Smoking: smoking has long been associated with a plethora of diseases and health conditions such as hyperglyceridaemia.
  • Family history of cardiovascular disease: studies have shown that cardiovascular disease is linked to hypertriglyceridaemia.   
  • Liver and kidney disease: hypertriglyceridaemia has long been associated with liver and kidney disease.
  • Thyroid disease: thyroid dysfunction has been linked to hypertriglyceridaemia.
  • High carbohydrate diet: diets with levels of carbohydrate higher than normal can lead to hypertriglyceridaemia. 
  • Medications such as use of steroid, diuretics, beta blockers: certain types of medication can lead to hypertriglyceridaemia.
hypertriglyceridemia
Upper abdominal pain could be a sign of hypertriglyceridaemia.

What are the symptoms of hypertriglyceridaemia?

Patients with elevated triglyceride are usually asymptomatic. However, they may have non-specific symptoms when the triglyceride level is greater than 1000 to 2000 mg/dl. 

Clinical symptoms include:

  • Skin rashes or small yellow-red hued papules (xanthomas) on the trunk and limbs
  • Yellow patches (xanthelasma) over the eyelid
  • Feeling bloated
  • Fullness of the abdomen
  • Upper abdominal pain or discomfort
  • Nausea
  • Vomiting
  • Shortness of breath 

You are advised to seek medical attention if you develop any of the above symptoms to evaluate further any underlying medical conditions.

xanthelasma
Xanthelasmas are a common symptom in individuals with elevated triglycerides or hypertriglyceridaemia.

What is the cause of hypertriglyceridaemia?

Hypertriglyceridaemia can be subcategorised into primary and secondary causes: 

  • Primary causes: due to genetic reasons leading to metabolic disorder of triglyceride levels.
  • Secondary causes: associated with lifestyle factors such as excessive carbohydrate intake and fatty dietary intake further coupled with a sedentary lifestyle. Other secondary causes include underlying medical conditions such as diabetes, hypothyroidism, obesity, or even certain long-term medications. 

You are advised to discuss with your doctor with regards to your family history and general lifestyle patterns. Your doctor will be able to identify any modifiable causes of hypertriglyceridaemia and work out a feasible health care plan to improve and monitor your triglyceride level, simply make an appointment with us. 

Should I be worried if my triglyceride levels are high?

When triglyceride levels are elevated, a person can be at risk of pancreatitis. The risk for pancreatitis is elevated when the triglyceride level is more than 1000 mg/dl.

As elevated triglyceride is often associated with other abnormal lipid readings such as low high-density lipoprotein (HDL), high low-density lipoprotein (LDL) hypertension, diabetes, obesity, and metabolic syndrome, it can hence also be associated with a higher risk of cardiovascular issues such as coronary heart disease and stroke accidents. 

How often should I screen for my triglyceride/lipid level?

If you are in adulthood, you may consider screening your cholesterol (including triglyceride levels) at least once every 2-3 years, as cholesterol levels tend to increase as we age. You are advised to speak to your health care provider, as you may be offered the tests more frequently depending on your previous results and underlying medical risk factors.

general health
Regular general health screenings can help identify underlying medical conditions.

What should I expect when I see my doctor to check my triglyceride/lipid levels?

Your doctor will obtain a medical and social history to understand your general health status and background lifestyle. Your doctor may also obtain a family history for cardiovascular risk factor assessment. A physical examination covering the cardiovascular system will be offered. Depending on your individual risk factors, your doctor may advise for blood tests to screen for cholesterol profile, diabetes screening, and other vital organs screening.

What are the treatments available for hypertriglyceridaemia?

The aim of treating hypertriglyceridaemia is to prevent and reduce risk of pancreatitis and cardiovascular disease. 

Your doctor will advise you on lifestyle modifications, such as:

  • Smoking cessation.
  • Encouraging regular aerobic activities (at least 150 minutes per week of moderate intensity activity or 75 minutes per week of vigorous intensity activity).
  • Aiming for a weight loss of 5 to 10% of body weight.
  • Reducing or minimising alcohol consumption (less than 14 units per day, no more than 2 drinks per day for men, and no more than 1 drink per day for women). 

If lifestyle changes are inadequate to control the triglyceride level, your doctor may prescribe you with oral medications to manage the levels. The risks and benefits of individual pharmacological options will be discussed prior to prescribing. Medication options include omega-3 fatty acids, fibrate, niacin, or statin

Take home message

While hypertriglyceridaemia is a medical condition that is generally asymptomatic, our body may signal us with vague symptoms such as rash or gastrointestinal symptoms to warn us of an underlying brewing medical condition. Take care of your cholesterol and triglyceride level with early screening and testing with us!

References

  1. Yuan G, Al-Shali KZ, Hegele RA. Hypertriglyceridemia: its etiology, effects and treatment. CMAJ. 2007 Apr 10;176(8):1113-20. doi: 10.1503/cmaj.060963. PMID: 17420495; PMCID: PMC1839776.
  2. Eruptive xanthoma associated with hypertriglyeridaemia and diabetes. (n.d.). Retrieved from https://www1.racgp.org.au/ajgp/2023/june/eruptive-xanthoma-associated-with-hypertriglyerida#:~:text=Severe%20hypertriglyceridaemia%20is%20considered%20the,like%20lipoprotein%20lipase%20deficiency%2C%20familial 
  3. Pradhan A, Bhandari M, Vishwakarma P, Sethi R. Triglycerides and Cardiovascular Outcomes-Can We REDUCE-IT ? Int J Angiol. 2020 Mar;29(1):2-11. doi: 10.1055/s-0040-1701639. Epub 2020 Feb 25. PMID: 32132810; PMCID: PMC7054063.
  4. Sandhu S, Al-Sarraf A, Taraboanta C, Frohlich J, Francis GA. Incidence of pancreatitis, secondary causes, and treatment of patients referred to a specialty lipid clinic with severe hypertriglyceridemia: a retrospective cohort study. Lipids Health Dis 2011; 10:157
  5. Al Aboud AM, Shah SS, Al Aboud DM. Xanthelasma Palpebrarum. [Updated 2022 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531501/
  6. Krupa K, Fritz K, Parmar M. Omega-3 Fatty Acids. [Updated 2023 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564314/
  7. Singh G, Correa R. Fibrate Medications. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547756/
  8. Djadjo S, Bajaj T. Niacin. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from:
    https://www.ncbi.nlm.nih.gov/books/NBK541036/
  9. Sizar O, Khare S, Jamil RT, et al. Statin Medications. [Updated 2023 Feb 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430940/ 

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