Efficacy and safety of surgical excision versus 70% tricholoroacetic acid (TCA) topical application in xanthelasma palpebrarum: a split face randomized trial

Background Despite its frequency, there is lack of comparative evidence evaluating available treatment modalities for xanthelasma palpebrarum (XP). Although surgical excision and trichloroacetic acid (TCA) are commonly used interventions for XP, no study has compared these two modalities. Objective To compare the efficacy and safety of surgical excision versus 70% trichloroacetic acid (TCA) in the management of limited XP. Methods Prospective, split-face, single-blinded single-centre randomized clinical trial conducted from November 2024 to August 2025 with 12-week follow-up. Adults aged ≥18 years with bilateral XP limited to ≤1/3 of the palpebral area were included. Key exclusion criteria were lesions larger than one-third of eyelid height or area and lesions within 2 mm of the canthi. These criteria ensured safe and comparable use of both treatments. Each participant contributed two XP units (XPUs-- defined as all XP lesions in one eye). One eye XPU in each patient was randomized to surgical excision and the contralateral eye XPU to TCA application (up to three sessions, 4 weeks apart). The primary outcome was complete clearance (100% reduction in XPU surface area) at week 12. Secondary outcomes included cosmetic outcome, patient satisfaction, percentage reduction in size, and adverse effects. Results All excision-treated XPUs (36/36; 100%) achieved complete clearance compared with 8/36 XPUs (22.2%) treated with TCA (McNemar test, P< 0.001). Median percentage reduction was 100% for excision and 69.2% for TCA (P< 0.001,Wilcoxon signed-rank test). Excellent cosmetic outcomes occurred in 21/36 (58.3%) excised XPUs versus 1/8 (12.5%) TCA-treated XPUs who achieved complete remission. Dyschromia was more common after TCA (27/36, 75.0%) than excision (15/36, 41.7%). Older age independently predicted excellent cosmetic outcomes after surgical excision with ROC analysis identifying 51 years as the optimal cutoff. Papulonodular morphology was associated with TCA treatment failure. Conclusion Surgical excision was more effective than 70% TCA for limited XP, providing predictable single-session clearance, superior cosmetic outcomes, fewer pigmentary changes and higher patient satisfaction. Excision can be considered the preferred first-line therapy for localized XP.