Abstract and Figures

Periorbital hyperpigmentation is a commonly encountered condition. There is very little scientific data available on the clinical profile and pathogenesis of periorbital hyperpigmentation. Periorbital hyperpigmentation is caused by various exogenous and endogenous factors. The causative factors include genetic or heredity, excessive pigmentation, postinflammatory hyperpigmentation secondary to atopic and allergic contact dermatitis, periorbital edema, excessive vascularity, shadowing due to skin laxity and tear trough associated with aging. There are a number of treatment options available for periorbital hyperpigmentation. Among the available alternatives to treat dark circles are topical depigmenting agents, such as hydroquinone, kojic acid, azelaic acid, and topical retinoic acid, and physical therapies, such as chemical peels, surgical corrections, and laser therapy, most of which are tried scientifically for melasma, another common condition of hyperpigmentation that occurs on the face. The aim of treatment should be to identify and treat the primary cause of hyperpigmentation as well as its contributing factors.
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[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ] 49
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SKIN OF COLOR
Abstract
Periorbital hyperpigmentation is a
commonly encountered condition.
There is very little scientific data
available on the clinical profile and
pathogenesis of periorbital
hyperpigmentation. Periorbital
hyperpigmentation is caused by
various exogenous and endogenous
factors. The causative factors include
genetic or heredity, excessive
pigmentation, postinflammatory
hyperpigmentation secondary to
atopic and allergic contact dermatitis,
periorbital edema, excessive
vascularity, shadowing due to skin
laxity and tear trough associated with
aging. There are a number of
treatment options available for
periorbital hyperpigmentation. Among
the available alternatives to treat dark
circles are topical depigmenting
agents, such as hydroquinone, kojic
acid, azelaic acid, and topical retinoic
acid, and physical therapies, such as
chemical peels, surgical corrections,
and laser therapy, most of which are
tried scientifically for melasma,
another common condition of
hyperpigmentation that occurs on the
face. The aim of treatment should be
to identify and treat the primary cause
of hyperpigmentation as well as its
contributing factors.
Introduction
Periorbital hyperpigmentation
(POH), also known as periocular
hyperpigmentation, periorbital
melanosis, dark circles, infraorbital
darkening, infraorbital discoloration, or
idiopathic cutaneous hyperchromia of
the orbital region, is a common
condition encountered in dermatology
practice.1–4 It is an ill-defined entity
that presents as bilateral round or
semicircular homogenous brown or
dark brown pigmented macules in the
periocular region.1,2 It can affect an
individual’s emotional well-being and
influence quality of life.
There is scarcity of data regarding
the incidence and prevalence of POH
due to its transitory nature and lack
of reasonable etiological explanation.
In an Indian study, it was found that
POH was most prevalent in the age
group of 16 to 25 years (i.e., 95 out of
200 patients [47.50%]). Among the
200 patients studied, it was more
prevalent in women (162 [81%]) than
men and the majority of the affected
women were housewives (91
45.50%]).5
Classification
Recently, Huang et al6performed a
clinical analysis and proposed
classification on the basis of clinical
pattern of pigmentation and
vasculature.6Periorbital
hyperpigmentation was classified into
pigmented (brown color), vascular
(blue/pink/purple color), structural
(skin color), and mixed type based on
the clinical appearance assessed by
the physician. The mixed type of dark
eye circle included the following four
subtypes: as pigmented-vascular (PV),
pigmented-structural (PS), vascular-
structural (VS), and a combination of
the three.
Pigmented type (P) appears as
infraorbital brown hue. Vascular (V)
type appears as infraorbital blue, pink,
or purple hue with or without
periorbital puffiness. Structural type
(S) appears as structural shadows
formed by facial anatomic surface
contours. It can be associated with
infraorbital palpebral bags,
blepharoptosis, and loss of fat with
bony prominence. Mixed type (M)
combines two or three of the above
appearances. This classification can
help in introducing the therapeutic
modalities on the basis of POH type, as
different types of POH respond to
different types of treatment.
Clinical Features
Clinically, POH is characterized by
light- to dark-colored, brownish-black
pigmentation surrounding the eyelids.
It gives a tired look to the patient.
Diagnosis is mainly based on clinical
examination. It is important to
differentiate the dark eyelid skin with
shadowing due to tear trough. Manual
stretching of the lower eyelid skin can
help to differentiate between true
pigmentation and shadowing effect.
Although the former retains its
appearance with stretching, the latter
improves or resolves entirely. An
S K I N O F C O L O R
Section Editors: Seemal R. Desai, MD, FAAD; Andrew Alexis, MD, FAAD
Periorbital Hyperpigmentation:
A Comprehensive Review
Rashmi Sarkar, MD, MNAMS; Rashmi Ranjan, MD;
Shilpa Garg, DNB; Vijay K. Garg, MD, MNAMS;
Sidharth Sonthalia, MD, DNB;
Shivani Bansal, MD, DNB
(J Clin Aesthet Dermatol. 2016;9(1):49–55.)
[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ]
50
increase in violaceous discoloration on
manual stretching of the lower eyelids
is due to thin eyelid skin or
hypervascularity of lower eyelid.7
Wood’s lamp examination can be
done to differentiate between the
epidermal and dermal pigmentation.8
The variations in epidermal
pigmentation become more apparent
under Wood’s light. For dermal
pigmentation, this contrast is less
pronounced. Ultrasonographic
evaluation can help to differentiate the
vascular cause from the periorbital
puffiness.
Histopathology
Histological characteristics of
periorbital hyperpigmentation suggest
that it can be both epidermal and
dermal in nature. Biopsy specimen
must be stained with routine
hematoxylin and eosin. Special stains
can also be used. Fontana-Masson
silver stain can be used to stain
melanin. Hemosiderin deposits seen in
few cases (resulting from
extravasation and superficial location
of vasculature) can be stained with
Perl’s potassium ferrcyanide.9,10
Etiology
There are very little scientific data
available on the clinical profile and
pathogenesis of POH. Various
exogenous and endogenous factors are
possibly implicated in its pathogenesis.
The causative factors include genetic
or heredity, excessive pigmentation,
postinflammatory hyperpigmentation
secondary to atopic and allergic
contact dermatitis, periorbital edema,
excessive vascularity, and shadowing
due to skin laxity and tear trough
associated with aging.
Genetics
Periorbital hyperpigmentation is
considered to have a genetic basis.
Goodman and Belcher11 reported many
families with pigmentation around the
periorbital area in several members of
the family. Some were mildly affected
and some severely affected. Many of
them recognized the pigmentation
early in childhood and stated that
pigmentation increased with age. They
were also aware that stress made
pigmentary changes more intense,
while rest and good health seems to
produce lessening of color.11 Gellin et
al reported a familial case in which 22
members were affected in six
generations that had a genetically
determined form of hyperpigmentation
involving the periorbital area.11
Periorbital pigmentation due to
dermal melanocytosis. Dermal
melanocytosis is characterized by the
presence of melanocytes in the dermis.
Clinically, these lesions are
recognizable by their distinctive grey
or blue-grey appearance. Dermal
melanocytosis causing periocular
hyperperpigmentation can be due to
congenital or acquired causes.9,12,13
Dermal melanocytosis can be placed
into the pigmentary class of Huang et
al’s classification.
Nevus of Ota, also known as
oculodermal melanocytosis or nevus
fuscocaeruleus ophthalmomaxillaris, is
a type of congenital dermal
melanocytosis that involves the areas
innervated by the first and second
divisions of the trigeminal nerve. It
appears as speckled or mottled brown-
grey to blue-black patches that may
involve the skin, conjunctiva, sclera,
tympanic membrane, or oral and nasal
mucosa of the affected dermatomes. If
it is located infraorbitally, it can be a
cause of periorbital
hyperpigmentation.
Nevus of Hori was first described in
1984 by Hori et al and is defined as
acquired, bilateral nevus of Ota-like
macules. Clinically, it presents with
blue-brown to slate-grey mottled
hyperpigmentation with a predilection
for the malar region, which may
extend to involve the periocular area
causing dark circles. A distinct lack of
ocular or mucosal involvement
differentiates the nevus of Hori from
other forms of dermal melanocytosis.
Reports have linked sun exposure,
hormonal changes in pregnancy, and
chronic atopic dermatitis to
occurrence of nevi of Hori.12,13
Postinflammatory
hyperpigmentation. Excessive
pigmentation can also be due to
postinflammatory hyperpigmentation
secondary to atopic and allergic
contact dermatitis and other
dermatological conditions (e.g., lichen
planus pigmentosus) and can be drug
induced, such as in the case of fixed
drug eruptions and erythema
dyschromium perstans (Figure 1).14,15
Periorbital hyperpigmentation can be
caused by rubbing and scratching of
skin around the eyes and by
accumulation of fluid due to allergy as
in atopic dermatitis and allergic
contact dermatitis.
Superficial location of
vasculature. Superficial location of
vasculature and thin skin overlying the
orbicularis oculi muscle is another
common cause of periorbital
hyperpigmentation.1–3 This condition
usually involves the entire lower
eyelids with a violaceous appearance
due to prominent blood vessels
covered by a thin layer of skin, more in
the inner aspect of the eyelid, and is
usually accentuated during
menstruation. When the lower eyelid is
manually stretched, the area of
darkness spreads out without
blanching or significant lightening and
results in deepening of violaceous
color, which could be used as a
diagnostic test to confirm the
vascularity.2
Tear trough depression. Tear
troughs represent an anatomical
location that becomes depressed with
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[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ] 51
age, centered over the inferio-medial
orbital rim. It is an age-related change.
It occurs mainly because of loss of
subcutaneous fat and thinning of
overlying skin of the orbital rim
ligaments, combined with cheek
descent, conferring hollowness to the
orbital rim area. A combination of the
hollowness and the overlying
pseudoherniation of the infraorbital fat
accentuate the shadowing in the tear
trough causing dark circles, depending
on the lighting condition (Figure 2).1–3
Periorbital edema. The eyelid
region has a spongy property, which
can lead to fluid accumulation due to
systemic and local causes. Diagnostic
features that suggest edema includes
worsening in morning or after eating
salty meals. The history of variability in
intensity and extension is important to
determine the influence of edema on
periorbital hyperpigmentation.16When
compared with normal orbital fat,
edema is still present in downward
gaze and does not change much in
upward gaze.1,2
Extension of pigmentary
demarcation lines of face.
Pigmentary demarcation lines (PDL)
are borders of abrupt transition
between hyperpigmented skin and
lighter areas. According to the site,
they have been labeled A to H lines. F
and G types are present over the
lateral side of orbit and present as V-
shaped and W-shaped patches,
respectively (Figure 3).10,17 In a study
by Malakar et al, 100 Indian patients
with a diagnosis of POH were
evaluated. Their results showed that in
92 percent of study patients,
periorbital melanosis was an extension
of the pigmentary demarcation line
over the face.10
Other Causes
Ocular hypotensive drugs.
Prostaglandin analogues, such as
latanoprost and bimatoprost, which
are used as ocular hypotensive eye
drops in patients with glaucoma, can
also cause periorbital
hyperpigmentation.18,19 Patients
develop periocular hyperpigmentation
most frequently between 3 to 6
months of initiating bimatoprost
therapy. Complete reversal of
pigmentation occurs after
discontinuation of bimatoprost.19 It was
reported that the increased
melanogenesis in dermal melanocytes
and increased transfer of melanin
granules to basal epidermis is the
likely mechanism of bimatoprost-
induced hyperpigmentation.
Environmental Causes
Ultraviolet radiation aggravates
POH,20 and some lifestyle factors may
contribute to developing POH,
including lack of sleep, stress, alcohol
overuse, and smoking, although not
clinically substantiated.3
Treatment
There are a number of treatment
options available for POH. Among the
available treatment options for POH
include topical depigmenting agents,
such as hydroquinone, kojic acid,
azelaic acid, topical retinoic acid, and
physical therapies, including chemical
peels, surgical corrections, and laser
therapy, most of which are tried
scientifically for melasma, another
common condition of
hyperpigmentation, which also occurs
on the face.1-3 The aim of treatment
should be to identify and treat the
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Figure 1. Periorbital hyperpigmentation due to postinflammatory hyperpigmentation
Figure 2. Tear trough deformity presenting as dark circles
[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ]
52
primary cause of hyperpigmentation as
well as its contributing factors. Also
different modalities are used according
to cause of POH.
Topical agents. Topical phenolic
or nonphenolic bleaching agents are
used in the treatment of
hyperpigmentation, particularly
hydroquinone and tretinoin. The
mechanism of action of most bleaching
agents is inhibition of tyrosinase
enzyme, which inhibits the conversion
of dopa to melanin, hence leading to a
reduction of the melanin content of
the epidermis.
Hydroquinone. Also known as 1,4
dihydrobenzene, hydroquinone is the
most prescribed bleaching agent
worldwide. It is used in strengths of 2
to 6%. The effect of treatment
generally becomes evident after 5 to 7
months of therapy, hence the
treatment should be given for at least
three months.21,22
Frequently observed acute side
effects include mild skin irritation,
itching, postinflammatory
hyperpigmentation, and transient
hypochromia. Long-term use can lead
to exogenous ochronosis,
leukomelanoderma en confetti, nail
discoloration, and colloid millium.23,24
Hydroquinone was reported to
cause cancer in rodents, yet human
carcinogenicity has not been
established. A number of studies have
shown that hydroquinone is safe and
no cases of skin cancer or internal
malignancy have been reported with
topical application of hydroquinone,
which has been used for more than 50
years.25 Hydroquinone has also been
used safely in the periocular area.26
Triple combinations. The United
States Food and Drug Administration
(FDA) has approved a modified
combination of the Kligman’s formula,
containing 4% hydroquinone, 0.05%
tretinoin, and 0.01% fluocinolone
acetonide for use in melasma and
various other pigmentary disorders,27
but its long-term use in the periorbital
area is a concern since it contains a
topical steroid.
Kojic acid. Kojic acid is a naturally
occurring fungal derivative produced
by Aspergillus species and
Penicillium species. It acts by
inhibiting tyrosinase, and is used in a
concentration ranging from 1 to 4%.28,29
In a study conducted by Lim et al,28
it was found that the addition of kojic
acid to a gel containing 10% glycolic
acid and 2% hydroquinone further
improves pigmentation in melasma.
Although there are no studies, kojic
acid has been tried anecdotally in the
treatment of periorbital
hyperpigmentation and has been
found to be effective. Side effects of
kojic acid include erythema and
contact dermatitis.28
Azelaic acid (AzA). Azelaic acid
(1,7- heptanedicarboxylic acid) was
initially developed as a topical anti-
acne agent, but because of its effect on
tyrosinase, it has also been used in the
treatment of hyperpigmentary
disorders such as melasma. Its
mechanism of action includes the
inhibition of DNA synthesis and
mitochondrial enzymes, thereby
inducing direct cytotoxic effects on
the melanocyte.30,31
In vitro studies show that AzA
interferes with DNA synthesis and
mitochondrial enzymes in abnormal
melanocytes and fibroblasts,32 thus
neither leukoderma nor exogenous
ochronosis are associated with its use.
It can be used safely for prolonged
periods of time. Since it was found to
be effective for facial postinflammatory
hyperpigmentation, it is a potentially
promising agent for periocular
hyperpigmentation due to
postinflammatory hyperpigmentation.
Arbutin. Arbutin is an extract of
leaves of the bearberry shrub and the
cranberry, pear, or blueberry plants. It
inhibits tyrosinase activity, but also
inhibits melanosome maturation. Its
effects are dose-dependent, but high
concentrations of arbutin can cause
hyperpigmentation. It is available in a
concentration of 3%.33
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Figure 3. Periorbital hyperpigmentation with pigmentary demarcation line (G type)
[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ] 53
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A randomized open study by Ertam
et al33 found that gel containing topical
arbutin was effective in reducing
pigmentation in melasma patients.
Arbutin can also be used in other facial
hyperpigmentation including POH.
Topical vitamin C. Vitamin C, an
antioxidant, has also been used for the
treatment of hyperpigmentation.
Because ascorbic acid is unstable in
many topical preparations, esterified
derivatives, such as L-ascorbic acid 6-
palmitate and magnesium ascorbyl
phosphate are used in compounds.
L-ascorbic acid is the predominant
cutaneous antioxidant. It scavenges
the free oxygen radicals in the aqueous
compartment which trigger
melanogenesis. Vitamin C promotes
collagen production and conceals color
of blood stasis, which could improve
appearance of dark circles under the
lower eye lid.34
Ohshima et al34 showed that vitamin
C and its derivatives, such as
magnesium ascorbyl phosphate and
ascorbic acid glucoside, inhibit
melanogenesis in human melanocytes.
They used two types of 10% vitamin C
lotion, sodium ascorbate and ascorbic
acid glucoside for six months in a split-
faced manner for dark circles. Melanin
index, erythema index, thickness, and
echogenecity of the dermis of the
bilateral eyelid was measured and it
was found that there was lightening of
pigmentation owing to an increase in
dermal thickness due to concealment
of dark discoloration from congested
blood. However, they did not find any
significant difference in melanin index.
Sunscreens. Hyperpigmentation
can be improved with sunscreen alone
as reported by Guevara and Pandya in
a study conducted in patients with
melasma.35 Patients should be cautious
while using chemical sunscreen in the
delicate eye area. Similarly, broad
spectrum sunscreen and ultraviolet
(UV) coated sunglasses are considered
to be beneficial in POH.
Chemical peels. Chemical peels
may be used alone or in combination
with treatments such as topical
bleaching agents. Glycolic acid is the
most widely used alpha hydroxy acid
for chemical peeling. Glycolic acid 20%
can also be used for periocular
hyperpigmentation. Lactic acid 15%
has been used in periorbital
hyperpigmentation in combination
with trichloroacetic acid (TCA) 3.75%
by Vavouli et al36and it was found that
almost all the patients showed
significant esthetic improvement.For
treatment of POH in medium to darker
skin, it is best to extend the peel to the
entire face to avoid post-peel
demarcation. For optimal outcome,
pretreatment with a tretinoin and
hydroquinone bleaching agent for 2 to
4 weeks is recommended before
undergoing a chemical peel. The most
disturbing side effect of chemical peels
can be postinflammatory
hyperpigmentation. This may be
minimized with the help of priming
agents, such as hydroquinone and
tretinoin.
Lasers. In recent time, lasers have
been used increasingly in cosmetic
dermatology. Periorbital
hyperpigmentation has been
successfully treated with various
noninvasive lasers that target pigment
and vascularity. Various lasers that
have been used for treating dark
circles are: Q switched ruby laser (694
nm), Q switched alexanderite laser,
and Nd:Yag laser (1064nm).1,2
In a study conducted by Watanabe
et al,12 patients with homogenous
bilateral pigmented macules in the
periorbital region were selected for
study of dark circles. Five patients
with infraorbital dark circles received 1
to 5 treatments with the Q switched
ruby laser (694nm); four patients
showed good response and two
patients showed excellent results.8
In another study on POH,
Momosawa et al26 combined Q
switched ruby laser with a bleaching
agent containing 0.1% tretinoin and
5% hydoquinone. The bleaching agent
was applied for six weeks before the
laser treatment. The purpose of this
treatment was to improve epidermal
pigmentation by accelerated discharge
of epidermal melanin by tretinion and
suppressing new epidermal
melanogenesis by hydroquinone
ointment. Fifteen out of 18 patients
showed excellent or good results after
3 to 4 laser treatments with no
complications. Thus, it was concluded
that in treating POH, the Q switched
ruby laser should be considered as
first-line treatment and it was found
effective in both dermal and epidermal
pigmentation.26 The Nd:Yag laser
(1064nm) is also effective in reducing
the pigmentation and vascular
component of infraorbital dark circles.
Skin laxity and tear trough
deformity are age-related changes that
they can be treated with lasers. Alster
and Bellew37treated 67 patients with
dermatochalasia and periorbital
rhytides using CO2laser resurfacing
and found significant improvement.
Although ablative laser resurfacing
is a well-accepted treatment modality
for improving the appearance of photo-
induced rhytides coexisting with
periocular hyperpigmentation, but due
to untoward side effects such as
prolonged erythema, pigmentation,
and infection, and in some cases
scarring, great interest has been shown
toward less invasive methods to treat
photo-induced rhytides effectively.
These include the pulsed dye laser,
diode laser, 1064nm Nd:YAG laser,
1320nm Nd:YAG laser, 1540nm erbium
glass laser, and intensed pulsed light
laser sources.
Autologous fat transplantation.
Autologous fat transplantation is used
to treat periorbital hyperpigmentation
[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ]
54
due to thin and translucent lower
eyelid skin overlying the orbicularis
oculi muscle.
Fillers. Hyaluronic acid gel is used
as a filler for three-dimensional
reshaping of periorbital complex.
Patient satisfaction is high, but some
patients with dark circles noted darker
pigmentation after hyaluronic acid gel.
Bosniak et al38 treated 12 patients with
POH, tear trough deformity, or
prominent nasojugal groove with the
hyaluronic acid push technique. All
patients experienced immediate
improvement after the procedure.
Excellent tear trough contour
improvement was achieved in all
patients and under eye dark circle
improved. Minor post-injection
erythema and edema were observed,
which resolved within 72 hours.
Platelet-rich plasma. Recently,
platelet-rich plasma has been used in
treating dark circles due to tear trough
deformity and wrinkles. A single
session with intradermal injections of
1.5mL platelet-rich plasma was given
into the tear trough area and wrinkles
of crow’s feet. Effect was compared
three months after treatment with
baseline. The improvement in
infraorbital color homogeneity was
statistically significant.39
Surgery. Blepharoplasty.
Blepharoplasty helps in eliminating
dark circles caused by shadows that
are cast by fat deposits or excess
skin.40 Transconjunctival
blepharoplasty is a better approach
than transcutaneous blepharoplasty so
that no external visible scar is created.
Epstein used transconjunctival
blepharoplasty and deep depth phenol
peel simultaneously to treat
hyperpigmentaion of skin and
pseudoherniation of orbital fat, which
is a contributing cause for infraorbital
dark circles.40
Carboxytherapy. Paolo et al41
used subcutaneous injections of CO2
once a week for seven weeks in the
periorbital area and found
significant improvement in fine lines
and POH.
Conclusion
Periorbital hyperpigmentation is a
commonly encountered condition. It is
less responsive to standard therapies
due to its multifactorial etiology and
deposition of melanin in both dermis
and epidermis. However, even a mild-
to-moderate improvement in
appearance can cause an improvement
in the quality of life of the patient,
hence topical therapies and simple
physical therapies such as chemical
peels can be used to treat the patients
who want to improve the cosmetic
appearance of their face.
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[ J a n u a r y 2 0 1 6 V o l u m e 9 N u m b e r 1 ] 55
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Drs. Sarkar, Ranjan, Garg V, and Bansal are from the Department of Dermatology, Maulana Azad Medical College and
LokNayak Hospital, New Delhi, India. Dr. Garg S is from the Department of Dermatology, Army College of Medical Sciences,
Base Hopsital, Delhi Cantt-10, India. Dr. Sonthalia is from Skinnocence Clinic, Gurgaon, Haryana, India. Disclosure: The
authors report no relevant conflicts of interest in the preparation or content of this manuscript.
... All with varying outcomes, costs and long-lasting results 2,6 . Due of its multifactorial ethiology 7 , there is not specific effective treatment for each individual patient and treatment options must be tailored 8 . ...
... There are several conditions for the development of dark circles under the eyes, although the pathogenesis of periorbital hyperpigmentation is unclear 7 . In this case, the patient has a multifactorial etiology that includes genetics, heredity, antihypertensive drugs, and chronic allergy. ...
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Objectives: Dark circles under the eyes are a common condition worldwide with multiple treatment options. The aim of this paper is to report a case of dark circles treated with ozone therapy which showed a very reasonable clinical improvement. Case report: A case of dark circles under the eyes treatment with ozone therapy concentrations and doses was reported. We searched MEDLINE treatment options for dark circles. Literature on this subject is scarce. CARE guidelines have been adopted for this case report RESULTS: Ozone therapy is a really effective biostimulator, that reduces spots and wrinkles. In this case, the patient and healthcare professionals were satisfied with just two ozone therapy sessions. This is an interesting alternative treatment for this common condition. Conclusions: Ozone therapy is a safe, inexpensive, and quick treatment for dark circles under the eyes. It can be used alone or in combination with other methods.
... The most frequent hyperpigmentation concerns include periorbital hyperpigmentation, post inflammatory hyperpigmentation, and melisma [101]. Periorbital hyperpigmentation occurs as a result of a genetic predisposition that results in the development of bilateral, round, and homogenous pigments on the skin [102]. Post-inflammatory hyperpigmentation may occur as a result of superficial damage to the skin including acne lesions, ingrown hairs, wounding, and insect bites [101]. ...
... Post-inflammatory hyperpigmentation may occur as a result of superficial damage to the skin including acne lesions, ingrown hairs, wounding, and insect bites [101]. Although the biochemical pathway involved in the development of melisma is not yet fully understood, the disorder is associated with exposure to sunlight, as well as the oral use of contraceptives or hormone treatments (melasma) [102]. Hyperpigmentation is often treated with the application of skin-lightening agents that target hyperplastic melanocytes and inhibit important dysfunctional biochemical pathways in melanin synthesis [103]. ...
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Africa is counted amongst the cosmetic market contributors; however, South Africa’s remarkable plant diversity is still largely untapped in terms of its potential for medicinal and cosmetic purposes. Thus, we aim to provide a critical assessment of the advancements made in South African cosmeceuticals with emphasis towards online local companies/brands that are manufactured by small, medium and micro enterprises (SMMEs). For the current study, we limited our search of herbal cosmeceutical products to SMMEs with online websites, or products traded in other online cosmetic directories such as ‘Faithful to Nature’ and ‘African Botanicals’ using a simple Google search. We recorded more than 50 South African SMME companies/brands involved in the trade of cosmeceuticals. Skin and hair care were the major product categories widely traded in these online platforms. Furthermore, few patents were recorded from South African researchers and institutions thereof, which is quite alarming considering the extensive research that has been undertaken to study these commercially valuable plants. Based on the increasing number of new products and the wide pool of economically important plants coupled to their associated rich indigenous knowledge systems, the cosmeceutical sector can contribute to the economy, job creation, entrepreneurship skills, socio-economic development and intellectual property generation.
... The above classi cation can be useful to guide the selection of the appropriate therapeutic modalities, as di erent types of POH respond to di erent types of treatment. 21 Clinical examination (including manual stretching of the lower eyelid skin) can help to di erentiate between true pigmentation and shadowing e ect, that may occur due to tear trough. On manual stretching of the lower eyelids, true pigmentation retains its appearance, a shadowing e ect improves or resolves entirely, while in case of thin eyelid skin or hypervascularity of lower eyelid, an increase in violaceous discoloration is noted. ...
... On manual stretching of the lower eyelids, true pigmentation retains its appearance, a shadowing e ect improves or resolves entirely, while in case of thin eyelid skin or hypervascularity of lower eyelid, an increase in violaceous discoloration is noted. 21,22 Dermoscopy is a non-invasive diagnostic technique for the evaluation of POH, that better visualises subtle clinical patterns of skin lesions and subsurface structures, not normally visible to an unaided eye. Hence, it can be used to determine if the origin of pigment is due to melanin or due to underlying vasculature i.e. it helps to di erentiate the type of POH (vascular, pigmented, mixed). ...
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Objective: We sought to determine the efficacy and safety of a topical under-eye serum (Melalumin™; Menarini India Pvt Ltd.) in patients with periorbital hyperpigmentation (POH). Methods: In this prospective, open-label single-arm study, 90 patients aged 18 to 55 years with Grade I to IV pigmentary POH, were given the under-eye serum for three months. Follow-up visits were scheduled at one, two and three months from baseline. Effectiveness was evaluated by two independent dermatologists using a skin colorimeter (Dermacatch) and dermoscopy (FotoFinder Systems, Inc., Medical Imaging Systems; Columbia, Maryland), as well as global photographs and patient-reported satisfaction ratings (excellent, very good, good, not satisfied). Adverse events were recorded. The colorimeter values were evaluated using the paired T test and the single-mean T test was used for dermoscopy and global clinical photographs. Results: Of the 90 patients included, 85 completed the study. Significant reductions in colorimeter values were noted in both melanin (from 708 to 621) and erythema (from 450 to 417) over three months (p<0.05). Mean improvement in dermoscopic assessment was 48.41 percent; Most (n=73/85; 85.88%) patients achieved >25-percent improvement; over one-third (n=31/85; 36.47%) showed >50-percent improvement. Global photographs improved by 49.47 percent; most (n=75/85; 88.24%) patients showed >25-percent improvement, over one-third (n=38/85; 44.71%) showed >50-percent improvement. Patient satisfaction levels were high (Excellent: 16 [18.82%]; Very good: 38 [44.71%]); Good: 26 [30.59%]; Not satisfied: 5 [5.88%]). No adverse events were noted. Conclusion: This study demonstrates safety and effectiveness of the studied under-eye serum in patients with pigmentary POH. In addition to clinical improvements noted by the investigators, significant improvements were also noted in colorimeter values, dermoscopy results, and global photographs. Patients exhibited high satisfaction levels with treatment outcomes. No safety concerns were noted.
... Infraorbital dark circles (IDC) are generally defined as bilateral semicircular hyperpigmentation in the infraorbital region. 1 As a common presentation of periorbital melanosis, this entity is frequently consulted in dermatology practice not only due to aesthetic blemish but also to a negative impact on the quality of life. 2 To date, there is little evidence reported on its global prevalence. We have identified limited data on some reported cases, mostly researching literature. ...
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... Patients with AD commonly suffer from many symptoms and signs, including pruritis, pain, erythema, excoriation, and sleep disturbances [2][3][4]. Difficulties during outdoor activities and periorbital hyperpigmentation are common complaints of active adolescents and women, respectively [5][6][7][8]. The treatment of AD might be particularly challenging for certain patients, including those with severe AD [9][10][11][12][13], frequent relapses, extensive area of involvement [14,15], and steroid-phobia, those without experience of full recovery, thereby making rapport difficult [16,17], and the elderly with weak, thin skin. ...
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... Nonsurgical treatments for periorbital rejuvenation include topical therapies in the form of sunscreens, retinoids, peptides, antioxidants, chemical peels, laser and mechanical resurfacing, botulinum toxin, nonablative and microneedle radio frequency devices and dermal fillers, boosters, carboxytherapy, and platelet-rich plasma. [12][13][14][15][16][17][18][19][20] Dermal threads are increasingly being used for lift and rejuvenation, especially on the face, as they stimulate fibroblasts, induce collagenization, and neo-angiogenesis, thus improving the skin texture, laxity, and wrinkles. [2,21,22] They can, thus, be used in areas that are classically the no-go areas for other procedures such as the infraorbital for botulinum toxin in infraorbital wrinkling. ...
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The periorbital region, a major impressionable area holds a special place in aging of the face. It reflects chronological aging which are reflected not only as structural changes but also emotive expressions of sadness and tiredness. Dermal threads have been used in combination with other aesthetic procedures, however their use as monotherapy especially in periorbital region needs evaluation. Aim: To evaluate the improvement in wrinkling and skin texture in the infero-lateral periorbital region with monofilament dermal threads. Settings and design: A prospective observational study in a tertiary hospital was conducted between January 2019 and February 2020 after institutional ethical clearance and patient consent. Materials and methods: 25 adults between 40 and 65 years of age reporting for infero-lateral periorbital rejuvenation and opting for dermal threads, with no history of aesthetic treatment in this region for the past three months were included after their informed consent. 10 monofilament dermal threads (5 each in lateral and infraorbital) in either periorbital region were inserted. Cases were assessed with Lemperle's wrinkle scale and visual analog scale (VAS) and photographic record maintained before procedure and after 16 weeks of procedure. Change in wrinkle grade was analysed using paired t-test and VAS was used to assess patient's perception of the result. Results: 25 cases were included in the study, 21 completed the follow-up and 4 were lost to follow up. The mean preprocedure wrinkle score was 2.29 and postprocedure mean scores were 1. This finding was statistically significant. 16 cases were satisfied with their textural improvement (VAS >+2) while 4 reported mild improvement (VAS 2+) and 1 reported no improvement. Side effects observed were bruising in two cases and thread displacement in one case within 24 hours. Conclusions: Polydioxanone monothreads offer an alternative aesthetic procedure for periorbital rejuvenation.
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Periorbital hyperpigmentation (POH) is a common aesthetic concern that impacts patients' emotional well-being and quality of life. POH can be difficult to manage as the etiology is often multifactorial or difficult to elucidate. An understanding of different contributing factors and ability to classify hyperpigmentation can aid in the management of POH. Classification of POH is divided into pigmented, vascular, structural, and mixed subtypes. A wide array of treatment options has been proposed belying the challenges inherent to improving POH. Modalities vary from topical therapies, chemical peels, dermal fillers, and lasers, to surgical intervention. Because POH can be multifactorial, successful management of POH will depend on elucidating the etiology and often requires a combination of therapies.
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Background: Periorbital melanosis (POM) describes the light-to-dark-colored, brownish-black pigmentation surrounding the eyelids. It can affect an individual's quality of life. Dermoscopic features of POM are not frequently reported in the literature. Materials and methods: This study comprised 100 patients aged above 16 years, who attended our outpatient department (OPD) from November 2018 to October 2019. A detailed history, clinical features, and the dermoscopic study of color, pattern of pigment, and pattern of the blood vessel were recorded with the Dermlite-3N dermoscope (3Gen, San Juan Capistrano, California). On the basis of the eyelids' pigmentation and involvement, patients were clinically graded as Grade 0 to 4, with 4 being deep dark color extending beyond the infraorbital fold. The clinical patterns and the dermoscopic features were correlated. Results: Most patients were women (76) and the common age group was 16-25 years. Most of the patients had both the eyelids involved (58%), followed by lower eyelids (28%). The majority of the patients were having POM of grade 2 (47%). Seventeen patients (17%) had a positive family history of POM. The most common clinical form of POM observed was constitutional type (77) followed by postinflammatory type (12). Of 100 patients, 52 had pigmentary, 15 had vascular, and 33 had mixed pigmentary-vascular pattern. Cell phone usage (>4 h) and refractory errors (38% each) were the common risk factors observed. Stress and respiratory allergy were significantly associated. In the pigmentation patterns, epidermal (54%), dermal (14%), and mixed (17%) subsets were observed. The reticular pattern was the most common vascular pattern (65%). Conclusion: POM is a multifactorial entity. Multiple risk factors play a role in the pathogenesis and aggravation. Clinical forms did not show any specific dermoscopic patterns. Dermoscopy of POM helps to know the underlying pathology, which in turn paves the way to the effective treatment.
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Pigmentary disorders and hyperpigmentation are widespread. Dark skin types in particular show a tendency to formation of melasmas and to hyperpigmentation. Light skin types have a tendency to ephelides and solar lentigines. In addition to topical treatment with lightening substances, superficial chemical peeling as well as combined procedures of topical treatment with chemical peeling play an important role in the treatment of hyperpigmentation. A strict avoidance of UV light and consequent daily application of sun protectíon factor 50+ are mandatory for successful treatment.
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We experienced severe post-inflammatory hyperpigmentation of groin flap that was transferred for the release of post-burn neck contracture. Inconsistency of the color between flap and recipient skin caused significant cosmetic problems. In order to improve the discoloration of the flap, combined therapy using Q-switched ruby (QSR) laser and bleaching treatment with tretinoin and hydroquinone was provided. The treatment was composed of two steps. The first step was a topical bleaching treatment using tretinoin gel and hydroquinone ointment (4-6 weeks), and the second step was QSR laser irradiation. Both steps were repeated. The protocol was especially developed for the treatment of hyperpigmented lesions resulting from both epidermal and dermal pigmentations. In our case also, the protocol was effective for the improvement of intractable hyperpigmentation of groin flap without any complication.
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Blue-brown macules of the face occurring on both sides of the forehead, temple, eyelids, malar area, alae of the nose, and root of the nose are often observed in middle-aged Japanese women. These lesions histologically are a form of dermal melanocytosis as shown by electron microscopic examination. They differ clinically from nevus of Ota. The differential diagnosis includes nevus of Ota, Riehl's melanosis (female facial melanosis), and melasma. The differences between them are discussed.
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Dark under-eye circles are a common cosmetic complaint among patients, spanning all age groups and skin types. We review the anatomic and physiologic features of dark circles and highlight the varied treatment options available, including lasers to target pigment and superficial vasculature, fillers to reverse volume loss, and resurfacing to improve skin laxity and wrinkling. Copyright © 2015 Elsevier Inc. All rights reserved.
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Background: Melasma is difficult to clear. Many agents have been used, such as hydroquinone, and glycolic acid and glycolic acid peels, kojic acid, a tyrosinase inhibitor in the fungus Aspergilline oryzae. Objective: To see if the addition of 2% kojic acid in a gel containing 10% glycolic acid and 2% hydroquinone will improve melasma further. Methods: Forty Chinese women with epidermal melasma were treated with 2% kojic acid in a gel containing 10% glycolic acid and 2% hydroquinone on one half of the face. The other half was treated with the same application but without kojic acid. The side receiving the kojic acid was randomized. Determination of efficacy was based on clinical evaluation, photographs and self-assessment questionnaires at 4 weekly intervals until the end of the study at 12 weeks. The non-parametric Wilcoxon's rank sum test was used for statistical analysis. Results: All patients showed improvement in melasma on both sides of the face. The side receiving the kojic acid did better. More than half of the melasma cleared in 24/40 (60%) patients receiving kojic acid compared to 19/40 (47.5%) patients receiving the gel without kojic acid. In 2 patients, there was complete clearance of melasma, and this was on the side where kojic acid was used. Side effects include redness, stinging, and exfoliation. These were seen on both sides of the face, and they settled by the third week. Conclusion: The addition of kojic acid to a gel containing 10% glycolic acid and 2% hydroquinone further improves melasma.
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Periorbital hyperpigmentation (POH) is one of the most commonly encountered conditions in routine dermatology practice. There are only few published studies about its prevalence, classification, and pathogenesis but none showing its association with habits, and other medical conditions in Indian patients. To determine prevalence and type of POH, common causative factors, and its association with personal habits and other disorders within various age and sex groups. Two hundred patients attending the dermatology OPD were included in study and were subjected to detailed history, careful clinical and Wood's lamp examination, eyelid stretch test and laboratory investigations. Clinical photographs of all patients were taken. POH was most prevalent in 16-25 years age group (47.50%) and in females (81%) of which majority were housewives (45.50%). Commonest form of POH was constitutional (51.50%) followed by post inflammatory (22.50%). Lower eyelids were involved in 72.50%. Grade 2 POH was seen in 58%. Wood's lamp examination showed POH to be dermal in 60.50%. Faulty habits were observed viz. lack of adequate sleep (40%), frequent cosmetic use (36.50%), frequent eye rubbing (32.50%), and lack of correction for errors of refraction like myopia in 12% patients. Strong association of POH with stress (71%), atopy (33%) and family history (63%) was noted. Periorbital hyperpigmentation is a multi-factorial entity. It is absolutely essential to classify the type of POH and determine underlying causative factors in order to direct appropriate measures for better and successful outcome in future.
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Background Infraorbital skin hyperpigmentation, commonly called dark circles, and crow's feet wrinkles are common cosmetic concerns. Various methods of treatment have been evaluated with variable outcomes.Objective This study was performed to assess the efficacy of platelet-rich plasma (PRP) injection for treating periorbital dark circles and crow's feet.Methods Ten participants with a mean age of 41.2 years were treated in a single session with intradermal injections of 1.5 mL PRP into tear trough area and crow's feet wrinkles on each side. The effects on melanin content, color homogeneity of the treated area, epidermal stratum corneum hydration, and wrinkle volume and visibility index were compared 3 months after treatment with baseline. Physician's global assessment and participants' satisfaction and any potential side effects were also assessed.ResultsThe improvement in infraorbital color homogeneity was statistically significant (P = 0.010), but no statistically significant changes were observed in melanin content, stratum corneum hydration, wrinkle volume, and visibility index. Participant's satisfaction score and physician's global assessment score were 2.2 and 1.7, respectively, on a 0–3 scale.Conclusion Platelet-rich plasma may have the potential to improve infraorbital dark circle in terms of color homogeneity of the region, though this remains to be proven using larger, controlled studies using multiple injections.
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Periorbital dark circles are relatively common, affecting individuals regardless of age, sex, and race. Available treatment includes bleaching creams, topical retinoid acid, chemical peels, laser therapy, autologous fat transplantation - injectable fillers, surgery (blepharoplasty), and chemical peeling. To evaluate the efficacy of a combination of trichloroacetic TCA 3.75% and lactic acid 15% on improving the periorbital hyperpigmentation. Thirty patients with periorbital dark circles and skin types II, III, or IV were included in the study. Chemical peeling was performed every week for a series of four treatments. The effect was photo-documented, and a patient's and physician's global assessment was evaluated. Almost all the patients showed significant esthetic improvement. Physicians assessed a fair, good, or excellent improvement in 93.3% of the patients. Patient's global assessment rated a fair, good, or excellent response in 96.7% of the patients. The procedure itself had only mild and temporary adverse effects, such as erythema, edema, frosting, dryness, and telangiectasias. The effects of treatment remained for at least 4-6 months in the majority of patients with appropriate sun protection. The combination of trichloroacetic TCA 3.75% and lactic acid 15% showed encouraging results on improving periorbital hyperpigmentation.
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Dark eye circle (DEC) is a common problem that usually lacks detailed classification in the etiology and structural variations. A newly-developed DEC Assessment Score using Wood's lamp and ultrasonogram will provide a more precise evaluation of DEC for improving treatment results. Sixty-five cases, including eight males and 57 females with a mean age of 38.9 years, were enrolled. DEC were classified into pigmented (brown), vascular (blue to purple), structural, and mixed type by Wood's lamp and ultrasonogram. A scoring system with nine parameters, including brown hue, pigmented lesions, blue/pink/purple hue, periorbital puffiness, shadow hue, infraorbital palpebral bags, infraorbital grooves, blepharoptosis, and skin type, was used for clinical evaluation. Pigmented, vascular, structural, and mixed types of DEC represented 5%, 14%, 3%, and 78%, respectively. Thirty-three cases with periorbital puffiness were found to have higher "pre-septal thickness" than those of 20 controlled cases (P = 0.032). Fourteen patients with infraorbital palpebral bags were proved to have protruded retroseptal fat pads by ultrasonography. Pigmentation and vascular and structural components may play important roles in DEC. Detailed classification of DEC types will access physicians in the decision of appropriate therapeutic modalities.