A 47-year-old man with eruptions on his trunk
Differential diagnosis
Neurofibromas may have an appearance similar to eruptive xanthomas, but would usually be less numerous and less symptomatic. Prurigo nodularis would be another condition to be considered; however, this patient did not have any excoriations. Primary milia can also appear as keratinfilled cysts; however, these are much smaller and usually located on the face.
TREATMENT: Control the lipids and triglycerides
Patients may be prescribed HMG-CoA reductase inhibitors (statins) and fibric acid derivatives for control of lipid and triglyceride abnormalities. Further, counseling should involve diet modification, exercise, smoking cessation, and stringent control of diabetes.5 As a general rule, high doses of statins should not be given to patients who are taking fibrates.6 The combination of a statin and fibric acid derivative is not without risks: it may increase the risk of myopathy and rhabdomyolysis.
We started this patient on fenofibrate (Tricor) along with rosuvastatin (Crestor). When given in combination with any statin medication, fenofibrate resulted in fewer reports of rhabdomyolysis and myopathy than the older fibrate gemfibrozil (Lopid). It is believed that fenofibrate undergoes a different pathway of glucuronidation than gemfibrozil. Most statins undergo glucuronidation in the same family of enzymes as gemfibrozil, which could cause competition in converting the statin to a form that undergoes liver metabolism. Thus, metabolism of the statin is decreased and adverse effects such as rhabdomyolysis and myopathy occurs.7
