High cholesterol is silent. It does not cause headaches, tiredness, red cheeks or spots, despite what some websites claim. For most people the first sign is the one nobody wants: a heart attack or stroke. That is why it is worth knowing the two real signs that can appear on the face, and why it matters even more to test if you have none of them.
Xanthelasma: yellow patches on the eyelids
Xanthelasma (the full name is xanthelasma palpebrarum) are soft, flat or slightly raised, yellowish plaques that sit on the eyelids, usually at the inner corner nearest the nose. They are painless, often symmetrical, and tend to grow slowly over months or years. They are deposits of cholesterol under the skin.
About half of people with xanthelasma have raised cholesterol or triglycerides on a blood test, and the other half have normal results. That might sound reassuring, but it is not quite: large population studies have found that people with xanthelasma have a higher risk of heart attack and heart disease over the following years whatever their cholesterol level. So xanthelasma is a reason for a lipid profile and a proper cardiovascular risk assessment, not just a cosmetic concern.
They are more common after 40, in women, and in people with familial hypercholesterolaemia, diabetes or an underactive thyroid.
Corneal arcus: a grey ring around the iris
Corneal arcus (arcus senilis in older adults, arcus juvenilis in younger people) is a grey, white or bluish ring around the outer edge of the coloured part of the eye. It is cholesterol deposited in the edge of the cornea. It does not affect vision.
Its meaning depends entirely on age. Over 60 it is extremely common, present in most people by their eighties, and on its own is not a reliable sign of high cholesterol. Under 45 it is a different matter. An arcus in a younger adult is strongly associated with familial hypercholesterolaemia, an inherited condition affecting about 1 in 250 people in the UK in which LDL cholesterol runs very high from birth. Most people with it have never been diagnosed. A young person with an arcus should have a lipid profile and, if LDL is high, a family history taken and a referral considered.
Signs that are not on the face but belong in the same conversation
- Tendon xanthomas: firm lumps in the Achilles tendon or over the knuckles. These are almost specific to familial hypercholesterolaemia and are one of the diagnostic criteria.
- Eruptive xanthomas: crops of small yellow or red bumps on the buttocks, shoulders or elbows that appear suddenly. These mean very high triglycerides, which carry a risk of pancreatitis, and need prompt testing.
- Xanthomas in the palm creases: a rare sign of a specific inherited lipid disorder.
What is not a sign of high cholesterol
Several things are regularly blamed on cholesterol without evidence. A diagonal crease in the earlobe has been studied for decades with inconsistent results and is not used clinically. Red or flushed cheeks, puffiness, dark circles, spots, yellow skin and a yellow tint to the whites of the eyes are not cholesterol signs; the last two point to the liver and need a different test. Headaches, dizziness and tiredness are not caused by cholesterol either. If you have any of these, they deserve attention on their own terms, not as a cholesterol clue.
Cholesterol (lipid profile) test, £49
Total cholesterol, LDL, HDL, triglycerides and non HDL cholesterol from one sample, with a GP's review and your cardiovascular risk explained in plain English. No fasting needed.
Book a cholesterol testIf you have one of these signs
- Have a lipid profile. It measures total cholesterol, LDL, HDL, non HDL cholesterol and triglycerides. Fasting is no longer required for a standard test.
- Check the rest. HbA1c for diabetes, thyroid function and a liver test, because all three can raise cholesterol and all three are common in people with xanthelasma.
- Ask about familial hypercholesterolaemia if your LDL is above 4.9 mmol/L, you have an arcus under 45, tendon xanthomas, or a close relative who had a heart attack before 60 (men) or 65 (women).
- Have your 10 year cardiovascular risk calculated (QRISK in the UK), which combines cholesterol with blood pressure, age, smoking, weight and family history. Treatment decisions are based on this, not on the cholesterol number alone.
What the cholesterol numbers mean
| Marker | Generally healthy (UK) | Note |
|---|---|---|
| Total cholesterol | 5 mmol/L or below | Less useful on its own than the breakdown |
| LDL cholesterol | 3 mmol/L or below | The main driver of artery disease; above 4.9 raises the question of an inherited cause |
| Non HDL cholesterol | 4 mmol/L or below | The figure UK guidance now prefers for risk and treatment targets |
| HDL cholesterol | 1 mmol/L or above (men), 1.2 or above (women) | Protective; very high values are not a reason to ignore a high LDL |
| Triglycerides | Below 1.7 mmol/L (fasting) or 2.3 (non fasting) | Very high levels cause eruptive xanthomas and pancreatitis |
These are population guides. The level that is right for you depends on your overall risk: someone who has already had a heart attack or has diabetes is treated to much lower targets than someone with no other risk factors.
Can xanthelasma be removed?
Yes. Options include surgical excision, laser, chemical peels with trichloroacetic acid and cryotherapy. Treatment is cosmetic, is usually not funded by the NHS, and the plaques can return, particularly if cholesterol stays high. Lowering cholesterol with diet and, where indicated, a statin does not reliably make existing xanthelasma disappear but it does reduce recurrence after removal, and it is the part that protects your heart. Removing the plaque without testing the cholesterol treats the sign and misses the point.
Lowering cholesterol
For most people the first steps are the familiar ones: replacing saturated fat with unsaturated fat, more fibre from oats, pulses, fruit and vegetables, more oily fish, less processed meat and fewer sugary drinks, regular exercise, not smoking and losing weight if needed. Plant sterol spreads and drinks lower LDL by about 7 to 10%. A statin lowers LDL by 30 to 50% and is recommended when 10 year cardiovascular risk is 10% or more, or straight away in familial hypercholesterolaemia regardless of risk score. Newer options exist for people who cannot tolerate statins or need a larger reduction.
When to see a doctor
Make an appointment if you notice yellow patches on your eyelids, a grey ring around the iris and you are under 45, lumps in your Achilles tendons or knuckles, or a sudden crop of small yellow bumps anywhere on the skin. See a doctor urgently if any of these comes with chest pain, breathlessness on exertion, or pain in the calves when walking, which can mean the cholesterol has already affected your arteries.
Questions people ask
What are the signs of high cholesterol on the face?
Only two are real: xanthelasma, which are yellow patches on or around the eyelids, and corneal arcus, a grey or white ring around the edge of the iris. Both are cholesterol deposits. Neither is present in most people with high cholesterol, so a blood test is the only reliable way to know your level.
Does xanthelasma always mean high cholesterol?
No. Around half of people with xanthelasma have a normal cholesterol test. Even so, having xanthelasma is linked to a higher risk of heart disease regardless of the cholesterol level, so everyone with it should have a lipid profile and a cardiovascular risk assessment, and the plaques themselves can be removed if they bother you.
Is a grey ring around the iris a sign of high cholesterol?
It depends on your age. A corneal arcus in someone under 45 is a strong pointer to high cholesterol, and in particular to familial hypercholesterolaemia, and needs a blood test. Over 60 it is so common that on its own it means very little, although a cholesterol check is still sensible if you have never had one.
Can you see high cholesterol in your eyes?
Sometimes. The arcus ring and eyelid xanthelasma are visible from the outside. An optician can also see the effects of high cholesterol on the small blood vessels at the back of the eye during a routine eye test, which is one reason regular eye tests are worthwhile.
What does high cholesterol feel like?
Nothing. High cholesterol has no symptoms. Tiredness, headaches, dizziness and flushed cheeks are not caused by it. The first symptom is usually a complication such as angina, a heart attack or a stroke, which is why testing is recommended for all adults over 40 and earlier if there is a family history.
What cholesterol level needs treatment?
There is no single cut off. Treatment decisions in the UK are based on your 10 year risk of a heart attack or stroke, calculated from your cholesterol together with age, blood pressure, smoking, weight, diabetes and family history. A statin is generally recommended when that risk is 10% or more. An LDL above 4.9 mmol/L, or any LDL with tendon xanthomas or arcus under 45, raises the question of familial hypercholesterolaemia, which is treated regardless of the risk score.
Should I see a cardiologist about xanthelasma?
Start with a GP and a lipid profile. If your cholesterol is very high, familial hypercholesterolaemia is suspected, or you have symptoms such as chest pain or breathlessness, a cardiology review with further heart tests is the right next step. At OneMedicine that can be arranged with Professor Jawad Khan, our consultant cardiologist, in the same clinic.
Cholesterol test, £49, reviewed by a GP
Lipid profile with a GP review of your cardiovascular risk, and a consultant cardiologist on site if you need more. Book online with OneMedicine, CQC registered clinic in Kings Heath, Birmingham. Results usually within 24 hours.
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Specialist interest: Cardiovascular Medicine · OneMedicine, CQC registered clinic