الفهرس 
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Abstract
Xanthelasma palpebrarum is the most common type of plane cutaneous xanthomas, which occurs on the eyelids with a higher prevalence for the upper lids. It is more frequent in women and its prevalence increases with age with a peak in 4th to 5th decade of life. It clinically presents as asymptomatic, usually symmetrical, yellow, soft, and painless plaques. Histologically, xanthelasma is composed of foam cells, lipid- ladenhistiocytes, with cholesterol deposits, which accumulate around dermal capillaries and cutaneous appendages. It can be classified into 4 grades by clinical manifestation and invasion range of the lesions. Xanthelasma palpebrarum serves as a cutaneous marker for different lipoprotein or apolipororein disorders in approximately 50% of patients, but it can also occur in normolipidaemic patients. Patients with a young age of onset and a positive family history of xanthelasma are at higher risk of having lipid profile abnormalities. Xanthelasma rarely causes functional problems such as obstructed vision, but it can cause significant psychological distress due to its associated cosmetic disfigurement. Patients usually seek treatment due to esthetic compromises of the periorbital area caused by xanthelasma plaques. Many treatment modalities have been proposed to deal with xanthelasma palpebrarum, including cryotherapy, peeling, electric cauterization, laser therapy (e.g., carbon dioxide, argon, Q-switched Nd:YAG, Er: YAG, and pulsed dye lasers), surgical resection and intralesional injection of pingyangmycin. However, it can be recalcitrant to the currently available therapeutic modalities as these therapies revolve around the ablation or resection of the involved tissue, without clear understanding xanthelasma’s pathophysiology. Carbon dioxide laser is the gold standard in ablative lasers and it is superior to other lasers in treatment of xanthelasma. The CO2 laser beam (10,600 nm wavelength) is selectively absorbed by the extracellular fluid of biologic structures. This leads to an unspecific vaporization and photocoagulation of the tissues, as well as the mode of action of the CO2 laser allows a layer-by-layer ablation of xanthelasma, with reported variable incidence of recurrence and adverse events. Heparin sodium is widely used on pre-disseminated intravascular coagulation stage in patients because of the effect of anticoagulation. Heparin sodium also can promote the activity and concentration of the lipoprotein lipase (LPL) enzyme, which plays a role on the activity and concentration of the lipoprotein lipase (LPL), which leads to reduction of blood viscosity, and improvement of local microcirculation, so it was suggested that heparin sodium may have therapeutic effects on xanthelasma histiocytes and promote clearance of xanthelasma plaques. The aim of this work was to evaluate and compare the efficacy, and safety of ablative CO2 laser versus intralesional injection of heparin sodium in the treatment of xanthelasma palpebrarum This study included 15 patients presented with bilateral xanthelasma palpebrarum who were selected from the Outpatient Clinic of Dermatology and Venereology Department, Tanta University Hospitals. Methods: All patients were subjected to: 1- Full history taking. 2- General and dermatological examination. 3- Routine laboratory investigations including evaluation of lipid profile. 4- Treatment in Laser Unit of Dermatology and Venereology Department, Global Tanta Hospital, Tanta University, as follow: -group A: Ablative CO2 laser on one side of the face, 3 sessions at one month interval. -group B: Intralesional injection of heparin sodium on the other side, 10 sessions at one week interval. -The patients were followed up monthly for 3 months after the last session to record any side effects or recurrence of the lesions. Evaluation of the treatment: It was done by: 1- Digital photographs. 2- Clinical and dermoscopic evaluation. 3- Global Aesthetic Improvement Score. 4- Degree of patients’ satisfaction. 5- Assessment of post treatment scarring by objective scar grading scale. Results: Demographic data of the studied patients: • Gender: The patients included in this study were 2 males (13.3%) and 13 females (86.7%). • Age: Their age ranged from 27.0 – 60.0 years with a mean age of 45.93 ± 9.72 • The duration: It was ranged from 1 to 10 years with a mean of 4.27 ± 2.64. • Regarding Fitzpatrick’s skin type: 5 patients (33.3%) were skin type III, and 10 patients (66.7%) were skin type IV. • Regarding family history:13 patients (86.6%) had negative family history, and 2 patients (13.4%) had positive family history of xanthelasma palpebrarum • Regarding the course of lesions: Course: 9 patients had stationary course (60%) and 6 patients had progressive course (40%). • Lipid profile: 8 patients (53.3 %) presented with xanthelasma palpebrarum associated with lipid profile abnormalities (elevated serum cholesterol, triglycerides and/or LDL level ). However, the remaining 7 patients (46.7%) had normal lipid profile, where serum cholesterol, triglycerides, LDL were within normal range. • Clinical grades of xanthelasma palpebrarum: : 6 patients (40%) had grade I xanthelasma palpebrarum, 4 patients (26.7%) had grade II xanthelasma palpebrarum, 3 patients had grade III xanthelasma palpebrarum (20.0%) and 2 patients had grade IV xanthelasma palpebrarum (13.3%). Evaluation of therapeutic efficacy: • Global Aesthetic Improvement Scale: group A (ablative CO2 laser side): 15 patients (100%) showed excellent improvement. group B (intralesional heparin sodium injection side): 10 patients (66.7%) showed excellent improvement, one patient (6.7 %) showed marked improvement, 2 patients (13.3%) showed moderate improvement and 2 patients (13.3%) showed mild improvement • Regarding results of dermoscopic evaluation one month after last treatment session: group A (ablative CO2 laser side): After 2 monthly sessions, all 15 patients (100%) showed complete clearance of xanthelasma plaques. group B (intralesional heparin sodium injection side): After 10 sessions of weekly intalesional injection of heparin sodium, 7 patients (46.7%) showed complete clearance of xanthelasma plaque, 3 patients (20%) showed clearance of xanthelama plaques clinically with dermoscopic remnants of xanthelasma lesions, 5 patients (33.3%) showed clinical reduction in size of xanthelasma lesions with dermoscopic confirmation of remnants of xanthelasma lesions. • Regarding the scoring of clinical and dermoscopic improvement: group A (ablative CO2 laser side): All 15 patients (100%) showed complete response (Score 3), with complete disappearance of all treated xanthelasma lesions both clinically by naked eye and dermoscopically with no dermoscopic xanthelasma plaques remnants. group B (intralesional heparin sodium injection side): 7 patients (46.7%) showed complete response (Score 3), with complete disappearance of all treated xanthelasma lesions, both clinically (by naked eye) and dermoscopically with no dermoscopic xanthelasma plaques remnants. However, 3 patients (20.0%) showed (Score 2) response, with apparent clinical cure (by naked eye), but with presence of residual dermoscopic xanhelasma plaques remnants. Unfortunately, 5 patients (33.3%) showed (Score 1) response with just clinical reduction in size of xanthelasma lesions with dermoscopic confirmation of remnants of xanthelasma lesions. There was statistically significant difference between both treatment side with p. value= 0.007* • Regarding patients’ satisfaction: group A (ablative CO2laser side): 8 patients (53.3%) were very satisfied, 4 patients (26.7%) were satisfied, 2 patients (13.3%) were slightly satisfied and one patient (6.7%) was unsatisfied. group B (intralesional heparin sodium injection side): 10 patients (66.7 %) were very satisfied, one patient (6.7%) was satisfied, 2 patients (13.3%) were slightly satisfied and 2 patients (13.3%) were slightly satisfied. The majority of the patients were satisfied with results in both treatment sides with no statistically significant difference between the 2 treatment areas. p. value= 1.000 • Regarding the post treatment side effects: group A (ablative CO2 laser side): All 15 patients (100 %) showed pain, erythema and superficial crustation, 9 patients (60%) showed edema and 5 patients (33.3%) showed scarring, 6 patients (40.0%) post inflammatory hyperpigmentation or hypopigmentation (PIH) and no patients showed recurrence of the lesions during the follow up period. group B (intralesional heparin sodium injection side): All 15 patients (100%) showed slight periorbital edema accompanied by mild periorbital ecchymosis for few hours after injection that disappeared spontaneously with no other side effects as no patients developed scarring, or post inflammatory hypo or hyperpigmentation (PIH). Moreover, no recurrence reported among the 7 patients with complete clinical and dermoscopic cure during the follow up period. • Regarding objective grading of scars: group A (ablative CO2 laser side): 10 patients (66.7%) showed (Grade 1) invisible scar, 2 patients (13.3%) showed (Grade 2) minimally visible scar, 2 patients (13.3%) showed (Grade 3) moderately visible scar and one patient (6.7%) showed (Grade 4) markedly visible scar. group B (intralesional heparin sodium injection side): All 15 patients (100%) showed (Grade 1) invisible scar (no scar both clinically and dermoscopically). There was also a statistically significant difference between the two treated areas according to the scar grading, with no incidence of scarring among the patients of group B with p. value =0.039*.