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2
Review Article
Periorbital Hyperpigmentation: Overcoming the Challenges
in the Management
Agrawal S
Professor, Department of Dermatology and Venereology, B.P. Koirala Institute of Health Sciences, Nepal
Abstract
Periorbital hyperpigmentation, also referring as dark circles or periorbital melanosis, is not a medical problem but can
be a significant cosmetic concern for a large number of individuals and they try to find a treatment for this condition.
This condition affects individuals in a wide range of ages, both sexes and all races. The therapeutic approach must vary
with cause as it is multifactorial. Possible causes include excessive pigmentation, volume loss, skin laxity, tear trough,
increased prominence and density of subcutaneous vasculature and orbital structural problem. Treatment modalities
include topical bleaching agents, chemical peeling, and lasers, injectable fillers, fat transfer, high intensity focused
ultrasound and surgery as monotherapy or in combination therapy to target the contributing factors of periorbital
hyperpigmentation.
Key words: Bleaching agents; chemexfoliation; hyperpigmentation; melanosis; reactive oxygen species
Address of Correspondence:
Prof. Sudha Agrawal, MD; M. Phil
Department of Dermatology & Venereology
B.P. Koirala Institute of Health Sciences
Dharan, Nepal
E-mail: sudha92@yahoo.com
How to cite this article
Agrawal S. Periorbital hyperpigmentation: Overcoming the
challenges in the management. Nepal Journal of Dermatology
Venereology and Leprology. 2018;16(1):2-11. doi: http://dx.doi.
org/10.3126/njdvl.v16i1.19411
Licensed under CC BY 4.0 International License which permits
use, distribution and reproduction in any medium, provided
the original work is properly cited.
Submitted: 15th February 2018
Accepted: 5th March 2018
Published: 21st March 2018
Introduction
Periorbital hyperpigmenta on (POH) is a common
dermatological condi on, which is also known as
periorbital melanosis, periocular hyperpigmenta on,
dark circles under the eyes (DC), infraorbital
discolora on, infraorbital darkening, or idiopathic
cutaneous hyperchromia of the orbital region.1,2 It
presents as bilateral, homogeneous hyperchromic
macules and patches primarily involving the lower
eyelids but also some mes extending towards the
upper eyelids, eyebrows, malar regions, temporal
regions and lateral nasal root.3 This condi on aff ects
individuals with a wide range of age, both sexes and
all races.4 The age of onset is usually a er puberty
or in early adulthood (16-25 years). Females are
frequently aff ected by POH because of either of the
two reasons:1) More cosme cally concern and 2)
Greater dermal vessels conges on and stasis related
extravasa on during menstrual cycles.
POH is a condi on that does not cause morbidity but
it makes the individuals look red, sad, or hung over.1
There is popular demand for treatment of POH which
is judged by the amount of adver sing of cosme cs
marketed to treat this condi on. It is a cosme c
concern for a large number of individuals especially
women who are really bothered and concerned
about it and rela ng it with signifi cant impairment on
their quality of life.5 Concealing the lesions is almost
mandatory for some individuals who depend on a
well-cared and posi ve appearance for their work or
social ac vi es.3
Despite pa ents with POH o en seen by the
dermatologists, there is not much a en on received
in the dermatology literature. There are only a
few published studies on its prevalence, causes,
pathogenesis and evidence-based treatment
modali es. The aim of the review is to highlight the
clinical approach to a case of POH for the management.
http://dx.doi.org/10.3126/njdvl.v16i1.19411
3NJDVL. Vol 16, No.1, 2018
Etiology
Periorbital hyperpigmenta on is a mul -factorial
en ty. The pathogenesis of POH remains elusive.
Various exogenous and endogenous factors are possibly
concerned in its pathogenesis. The proposed possible
causa ve factors include gene c or heredity, excessive
pigmenta on, periorbital edema, thin and translucent
lower eyelid skin, venous conges on with hemosiderin
deposi on, orbital structural problem and shadowing
due to skin laxity & tear trough. Other factors such as
underlying systemic, metabolic, hormonal diseases,
nutri onal defi ciencies, drugs, allergic reac ons,
atopic derma s, sleep disorders, stress, alcohol
consump on, smoking, frequent cosme c use,
frequent eye rubbing and lack of correc on for errors
of refrac on like myopia are also implicated to POH.6
Gene c
Periorbital hyperpigmenta on is considered to have
a gene c basis.2 It is more dis nct in Mediterranean
ethnic group and is also o en seen in mul ple
members of the same family.3
Excessive pigmenta on
Excessive pigmenta on is seen in POH because
of dermal melanocytosis and post infl ammatory
hyperpigmenta on secondary to atopic derma s
or allergic contact derma s. In allergic individuals
(atopic and allergic contact derma s) frequent
causes are due to rubbing or scratching the skin
around the eyes and accumula on of fl uid due to
facial allergy.3 Excessive pigmenta on can also be due
to post infl ammatory hyperpigmenta on secondary
to other dermatological condi ons (e.g., lichen planus
pigmentosus) and can be drug induced.7 According
to Gathers8 chronic use of a few drugs such as
hormone-replacement therapy, oral contracep ves,
an psycho cs, chemotherapeu c compounds, gold
can cause periorbital hyperpigmenta on.
Dermal melanocytosis can be due to congenital
and environmental causes, which is histologically
characterized by the presence of melanocytes in
the dermis. Clinically, these lesions are iden fi able
by the dis nc ve grey or blue-grey appearance.2
Nevus Ota if infraorbitally located, it can be a cause
of periorbital hyperpigmenta on.1 Similarly, nevus
of Hori may extend to involve the periocular area,
causing POH.2 Environmental causes that result in
dermal melanocytosis include excessive sun exposure
and drug inges on.1
Periorbital edema
The eyelid region appears to have a ‘sponge’ property,
which can help in the accumula on of fl uid in systemic
or local edema causes. An eyelid fl uid deposit is
characterized by its worsening in the morning or a er
a salty meal, the purplish color, and the undefi ned
outlines of the regional fat complements.9
Minimal subcutaneous fat, thin skin and superfi cial
loca on of vasculature
Another important cause of POH may be due to the
minimal infraorbital subcutaneous fat, superfi cial
loca on of the orbicularis oculi muscle, and thin,
translucent skin of the lower eyelid. This may lead to a
violaceous appearance due to the visible prominence
of the subcutaneous vascular plexus or vasculature
contained within the muscle.10 It is more prominent
in the inner aspect of the lower eyelids and is usually
accentuated during episodes of physical and mental
stress including menstrual period and pregnancy and
thus may worsen periorbital hyperpigmenta on.1
Orbital structural problem
Advancing age related anatomic changes of the midface
so ssue include subcutaneous fat atrophy and
volume loss, hypertrophy of orbicularis oculi muscle,
pseudohernia on of suborbicularis oculi fi broadipose
ssue and volume loss in the malar region. These
features further the appearance of the POH.
Skin laxity and tear trough (Shadowing eff ect)
Shadowing due to the skin laxity and tear trough
is another cause of POH. These are the result
from a combina on of advancing age and chronic
photodamage. Over me, collagen and elas n in
the thin ssue of the eyelids and periorbital skin
undergo degenera on.11 In addi on, the damaged
epidermis releases collagenases also contribute to
degenera on of collagen and therefore the skin laxity
confers a shadow eff ect on the lower eyelids. The tear
trough is a depression centered over the medial side
of the inferior orbital rim. It deepens as the pa ent
ages because infraorbital fat is displaced anteriorly
due to the loss of periorbital subcutaneous fat with
thinning of the skin over the orbital rim ligament
that confers hollowness to the orbital rim area9 along
with pseudohernia on of the infraorbital fat that
accentuate the shadowing eff ects. This shadowing
eff ects is light dependent, o en masked with the use
of direct fl ash photography.12
Other causes
Drugs: Ocular hypotensive eye drops drugs
as prostaglandin analogues (latanoprost and
bimatoprost, travoprost etc.) can also cause periorbital
hyperpigmenta on a er 3-6 months of treatment.13
The possible mechanisms of the pigmenta on are
4
NJDVL. Vol 16, No.1, 2018
increased melanogenesis in dermal melanocytes and
increased transfer of melanin to basal epidermis,
though rare, but an acquired orbital lipodystrophy may
develop owing to the potent an androgenic eff ects of
prostaglandin F2.14
Underlying systemic, metabolic, hormonal disorders:
It has been found that certain underlying systemic,
metabolic, hormonal diseases, nutri onal defi ciencies
may lead to pigmenta on of the periorbital area,
however no substan al evidenced in the literature.15
Life style factors: Some life style factors such as sleep
disorders, stress, alcohol consump on, smoking,
frequent cosme c use, frequent eye rubbing and
lack of correc on for errors of refrac on like myopia
are also implicated to POH although not clinically
substan ated.16
Clinical Features
Clinically, POH is characterized by light to dark-
colored, brownish black pigmenta on surrounding the
eyelids. It may present as a curved band of brownish
to black pigmenta on on the skin of the lower
eyelids approxima ng the shape of the orbital rim
with frequent involvement of the upper eyelids or it
may present as irregular patches of brownish or grey
pigmenta on on the skin on the upper, lower or both
eyelids with features of lichenifi ca on, accentua on of
skin creases, and eczematous papules or patches in the
surrounding areas. Some mes it presents as erythema
predominantly involving the inner aspect of the lower
eyelids, with prominent capillaries or telangiectasia
(capillaries) or the presence of bluish discolora on of
the lower eyelid and visible bluish veins that becomes
more prominent when the overlying skin is stretched.17
Evaluation
The diagnosis of periorbital hyperpigmenta on is
mainly clinically, however, a thorough history and
clinical assessment is necessary to iden fy the
contribu ng e ologic factors and thus provide the
targe ng therapies for an individual pa ent of POH.
A detailed history including dura on of the condi on,
family history, history of atopy or drug intake,
associated faulty habit or lifestyle, use of cosme cs,
precipita ng factor such as photosensi vity, allergies,
seasonal varia ons, presence of associated other
cutaneous disorder in other areas of the face and
presence of any concomitant illness such as anemia,
gastrointes nal diseases, hepato-biliary diseases, renal
diseases, thyroid diseases, etc. should fi rst be elicited.
The cutaneous examina on should be evaluated to
detect the involvement of eyelids, extend beyond
the periorbital region, color of hyperpigmenta on,
presence of any dermatological disease or scar in the
periorbital region, presence of any visible bulging, skin
laxity, tear trough, superfi cial visible vasculature (i.e.,
capillaries or veins) in the infraorbital region, pallor
in palpebral conjunc va, presence of pigmenta on
in other areas a er washing the face with soap and
water.
The pa ent must be examined under the direct light
to iden fy the POH due to shadow eff ect. Tear trough
gets accentua on with hard light from direct fl ash
digital photography while masking with 45-degree
so light from a strobe light source. The medial and
central aspects of the tear trough may be accentuated
with an upward gaze, whereas the lateral border
may be accentuated with an upward outward gaze
contralaterally.18
If possible, ask the pa ent to provide the prior
photographs that can help to dis nguish the normal
anatomic varia on from age-related changes.
Eyelid stretch test
Eye lid stretch test or manual stretching of the lower
eyelid skin can help to diff eren ate between true
pigmenta on and shadowing eff ect. Although the
former retains its appearance with stretching, the
la er improves or resolves en rely. if the violaceous
hyperpigmenta on on manual stretching of the lower
eyelids is worsen, then it is because of subdermal
vascularity.14
Wood’s lamp examina on
Some mes, there may be a problem in diff eren a ng
brown or blue purple hue in mixed type of POH
because the blue hue may be missed at fi rst site due
to hyperpigmented background that’s when wood’s
lamp examina on is done to diff eren ate between the
epidermal and dermal pigmenta on.19 The varia ons
in epidermal pigmenta on become more apparent
under Wood’s light. For dermal pigmenta on, this
contrast is less pronounced2. The Wood’s lamp is also
assisted in the diff eren a on of the pigmented (P) and
mixed (M) types from the vascular type (V) of POH.
However, there is no change in vascular, structural and
vascular-structural of mixed type.21
Other tests that are useful in the diagnosis of periorbital
hyperpigmenta on are dermatoscopy, histopathology
and imaging.
Dermatoscopy: It is a noninvasive diagnos c technique
5NJDVL. Vol 16, No.1, 2018
for the in vivo observa on of pigmented skin lesion
allowing a be er visualiza on of surface and subsurface
structures and being easy and feasible to use. It can
be used to diff eren ate the type of POH whenever
there is doubt while examining with naked eyes. The
dermatoscopic fi ndings of POH are- a) Vascular type:
diff use erythema pa ern or mul ple thin blood vessels
or diff use vascular network, b) Pigmented type: a
pa ern of mul ple dots with diff erent sizes and colors
or a diff use network of pigments and c) Mixed type:
Combina on of vascular and mixed type.21
Histopathology: Histopathologic evalua on of
epidermal characteris c, increase melanocytes
pigmenta on in the epidermis itself and increase
in dermal melanocytes or pigmenta on is the gold
standard for a be er understanding of the underlying
e opathogenesis.22 However, it has certain limita on
in the form of development of scar at the site of the
biopsy, which may be a concern for the pa ent.
Imaging: imaging with VISIA system (Canfi eld
Scien fi c, Inc, Fairfi eld, NJ) can highlight blood vessels
and pigmenta on with UV light and cross-polarized
fl ash photography
Digital photography: Standardized, high-quality
pretreatment and pos reatment digital photography
with appropriate light is needed for the assessment of
the treatment response.
Clinical Pattern Classifi cation of POH
The classifi ca on of diff erent pa erns and severity
score of POH are important in introducing the
therapeu c modali es on the basis of POH type, as
diff erent types of POH respond to diff erent types of
treatment.
Ranu et al in 2011 classifi ed Periorbital
hyperpigmenta on on the basis of four parameters:
Color pa ern, boundaries, skin texture, associated
skin disorders on and around the eyelids in order to
determine the primary cause of POH.17
a. Cons tu onal - The presence of a curved band
of brownish to black pigmenta on on the skin
of the lower eyelids approxima ng the shape of
the orbital rim with frequent involvement of the
upper eyelids.
b. Post infl ammatory - Presence of irregular patches
of brownish or grey pigmenta on on the skin on
the upper, lower or both eyelids with features
of accentua on of skin creases, lichenifi ca on
and eczematous papules or patches in the
surrounding areas. Personal and/or family history
of atopy may or may not be present.
c. Vascular - Presence of erythema predominantly
involving the inner aspect of the lower eyelids,
with prominent capillaries or telangiectasia
(capillaries) or the presence of bluish discolora on
of the lower eyelid and visible bluish veins that
becomes more prominent when the overlying
skin is stretched. This type of dark circle appears
to be due to a combina on of transparency of the
overlying skin and dermal vascularity.
d. Shadow eff ect - Presence of a dark shadow under
an overhanging tarsal muscle, eye bags, or the
presence of a deep tear trough over the medial
aspect of the inferior orbital rim, which disappear
with direct light.
e. Others - POH from other causes, including anemia,
hormonal disturbances, nutri onal defi ciencies,
acanthosis nigricans, skin laxity, associated
chronic illness, habits, etc.
Recently Huang et20 proposed a classifi ca on on the
basis of clinical pa ern of pigmenta on and vasculature
as the hue of POH poten ally indicates its cause and
pathogenesis and can be well prac ced in clinical
consulta on. The Periorbital hyperpigmenta on
is classifi ed into pigmented type (brown color),
vascular type (blue/pink/purple color with or without
periorbital puffi ness), structural type (skin color
structural shadows formed by facial anatomic surface
contours due to loss of fat or so ssue volume with
bony prominence that disappear a er illumina ng
with front light), and mixed type (combines two or
three of the above appearances). The mixed type of
dark eye circle includes four subtypes as pigmented-
vascular (PV), pigmented-structural (PS), vascular-
structural (VS), and a combina on of the three (PVS).
POH Severity Assessment
Severity score of POH is done in comparison to the
surrounding skin and has been scored as 0 - skin
colour comparable to other facial skin areas, 1 - faint
pigmenta on of infraorbital fold, 2 - pigmenta on
more pronounced, 3 - deep dark color, all four lids
involved and 4 - grade 3+ pigmenta on spreading
beyond infraorbital fold.15
Association of other Pigmentary
Conditions with POH
There are various condi ons, which may be associated
with periorbital hyperpigmenta on such as pigmentary
line of demarca on, Acanthosis nigricans, melasma,
6
NJDVL. Vol 16, No.1, 2018
Erythema dyschromicum perstans, fi xed drug
erup on, ecchymosis, amyloidosis, dermatomyosi s
etc. Therefore, these underlying health issue must be
evaluated prior to formula ng a treatment plan for the
POH.
Treatment
Despite a great number of available medica ons and
therapies to a enuate periorbital hyperpigmenta on,
there is lack of evidence-based studies to support their
use.1 Periorbital hyperpigmenta on is o en refractory
to the treatment. Therefore, the pa ent may be treated
either as monotherapy or in combina on therapy
targe ng the contribu ng factors. These include
bleaching creams, topical re noic acid, chemical peels,
platelet rich plasma therapy, lasers and light therapy,
so ssue augmenta on by autologous fat injec on
and hyaluronic acid so ssue fi llers, micro-focused
ultrasound therapy and surgery.
General measures
Sun protec on is a cornerstone of therapy. It is essen al
by avoiding peak hours of sunlight (in the tropics,
between 11 AM 4 PM), using shady side for ac vi es
and making use of sunshades like parasols and broad
brimmed hats. Use of opaque sunscreens containing
zinc oxide, 10% (and SPF of 30) have the dual benefi t of
camoufl aging and preven ng photoinduced darkening.
Cosme c camoufl age may be used during treatment
to improve the quality of life.
Topical Applications
Topically applied products are the most suitable
treatment to start with for the majority of pa ents.23
These have been considered to improve the blood
circula on and/or reduce melanin. Bleaching agents
may be used as a monotherapy or combina on
therapy with other procedures. The most bleaching
agents inhibit tyrosinase ac vity, inhibit DNA synthesis
in hyperac ve melanocytes, reduce the epidermal
content of melanin, and thickening of the epidermis.24
The various topical bleaching agents are hydroquinone,
kojic acid, a triple combina on, azelaic acid, arbu n,
topical vitamin C. Out of these topical agents the most
widely used is hydroquinone, used in a strength of 2%
to 6% with the eff ect of treatment being evident a er
5 to 7 months of treatment. Some mes, it is associated
with fewer side-eff ects like mild skin irrita on,
itching, transient hypochromia, post-infl ammatory
hyperpigmenta on.
Triple combina on (hydroquinone, tre noin and
steroid), though available in the market in various
combina on and is being used for the treatment of
melasma and other pigmentary condi ons, there is no
evident based study on its use in the POH.
Kojic acid is a natural occurring fungal deriva ve
produced by aspergillus species and penicillium
species, has been tried in trea ng POH anecdotally in
a concentra on ranging from 1 to 4% and has been
found to be eff ec ve with side-eff ects like erythema
and contact derma s though there are no studies yet.
Azelaic acid was ini ally developed for trea ng acne
but because of its eff ect on tyrosinase and further
with no development of leukoderma and exogenous
ochronosis on prolonged use, it has been used for
facial post-infl ammatory hyperpigmenta on and
thus it is a poten ally promising agent for periocular
hyperpigmenta on due to post-infl ammatory
hyperpigmenta on.
Arbu n is an extract of leaves from bearberry shrub
and cranberry, pear or blueberry leaves has been
found eff ec ve in trea ng melasma. So, it can be used
in other hyperpigmenta on including POH but with
cau on as high doses may lead to hyperpigmenta on.
It is available in a concentra on of 3%.
Topical vitamin C is an an oxidant that scavenges free
oxygen radicals in aqueous compartment which triggers
melanogenesis and promotes collagen produc on and
conceals color of blood stasis, which improves the
appearance of POH. But as ascorbic acid is unstable,
esterifi ed deriva ves in the form of L-ascorbic acid,
6-palmitate and magnesium ascorbyl phosphate are
used.2 Ohshima and colleague25 studied 14 subjects
with dark circles of the lower eyelids and applied
sodium ascorbate 10% or ascorbic acid glucoside 10%
in a split faced manner for 6 months. They conclude
that sodium ascorbate may improve dark circles by
thickening the eyelid dermis and concealing dark
colora on due to congested blood but there was no
change in the melanin index.
Chemical peels
Chemical peels may be used alone or in combina on
with topical bleaching agents. Glycolic acid is the most
widely used alpha hydroxy acid for chemical peeling.
Glycolic acid 20% can also be used for periorbital
hyperpigmenta on however higher concentra on
should be avoided to remove melanin from dermis.
This may lead to dyspigmenta on and scarring as the
skin is thin in this area.
7NJDVL. Vol 16, No.1, 2018
Lac c acid 15% has been used in periorbital
hyperpigmenta on in combina on with trichloroace c
acid (TCA) 3.75% every week for four treatments and
it was found that almost all the pa ents showed
signifi cant esthe c improvement.26 For treatment of
POH in medium to darker skin, it is best to extend the
peel to the en re face to avoid post-peel demarca on.
For op mal outcome, pretreatment with a tre noin
and hydroquinone bleaching agent for 2 to 4 weeks
is recommended before undergoing a chemical peel.
The most disturbing side eff ect of chemical peels can
be post-infl ammatory hyperpigmenta on. This may
be minimized with the help of priming agents, such as
hydroquinone and tre noin.
Lasers
Periorbital hyperpigmenta on has been successfully
treated with various lasers that target pigment,
vascularity and skin laxity and tear trough.
Q-switched lasers
Q-switched lasers with nanosecond (and recently
picosecond) pulse dura ons and wavelengths within
the absorp on range of melanin are useful for targe ng
the pigmenta on in POH. The typical clinical endpoint
of these treatments is immediate lesion whitening
without pinpoint bleeding. Lower energy se ngs
should be used ini ally to minimize the occurrence of
PIH.3
Q switched ruby lasers (QSRL)
Rapid delivery of high-intensity energy at the 694-nm
wavelength of QSRLs is moderately absorbed by
melanin but poorly absorbed by hemoglobin,
which disrupts melanosomes within kera nocytes,
melanocytes, and melanophages and is considered
as fi rst-line treatment for both dermal and epidermal
pigmenta on in Fitzpatrick skin types I-II.
QRSL treatment is performed with 2 to 4 J/cm2 using
a 5-mm spot size (or varied accordingly) at 1.5 Hz.
Watanabe et al27 showed good response in infraorbital
hyperpigmenta on a er 1 to 5 treatments sessions
with the Q switched ruby laser (694nm). Combining
Q switched ruby laser (694nm) with a bleaching agent
containing 0.1% tre noin and 5% hydroquinone has
also led to signifi cant improvement in this site. The
purpose of this treatment is to improve epidermal
pigmenta on by accelerated discharge of epidermal
melanin by tre noin and suppressing new epidermal
melanogenesis by hydroquinone cream.28
Q switched alexandrite lasers (QSAL)
The Q-switched alexandrite laser (755-nm wavelength)
penetrates deeper with a lower absorp on coeffi cient
for melanin and is emi ed over a longer pulse dura on
(50–70 ns) than that of QSRL, which may serve to
decrease adverse events (eg, PIH) in dark-skinned
pa ents as a result of milder melanosomal hea ng.
Fitzpatrick skin types of IV or lower are performed with
3- to 5-mm spot sizes and 4 to 8 J/cm2. Lower fl uences
may lead to equal effi cacy with decreased PIH.29
Q switched Nd-YAG lasers
Q switched Nd-YAG laser with a wavelength of 1064
nm allow for much deeper energy penetra on and
minimal melanin absorp on compared with QSRL
or QSAL. Therefore, Fitzpatrick skin types V and VI
can be treated with minimal risk of pos reatment
dyspigmenta on. In a study conducted by Xu et al30 in
thirty Chinese female pa ents with under-eye circles,
8 low-fl uence treatments (3.5-mm spot size, 4.2 J/
cm2, 2 passes) at 3- to 4-day intervals showed a mean
global improvement of 50% to 75% at 3 and 6 months,
and 93.3% subjects reported good to excellent results
without signifi cant adverse events.
Pulsed-Dye Lasers
Pulsed-dye lasers (585 and 595 nm wavelengths and
pulse widths less than or equal to 40 ms) allow for
selec ve photothermolysis of larger, deeper ecta c
vessels and a far greater purpuric threshold.31 Dark
skinned pa ents should be treated with longer pulse
dura ons and lower fl uences. Treatment endpoint
is immediate vessel spasm and transient purpura
indica ve of intravascular coagula on. Care should
be taken when using cryogen cooling, because the
cryogen is likely to enhance PIH.
Pulse stacking and mul ple passes at subpurpuric
fl uences with adequate epidermal protec on (cryogen
or convec on cooling) lead to signifi cant improvement
in vessel clearance without added adverse events, but
mul ple treatment sessions may be needed. Superfi cial
telangiectasias are treated with pulse dura ons and
fl uences of 6 ms and 7 to 9 J/cm2 (less than 0.6 mm) or
10 ms and 8 to 12 J/cm2 (greater than 0.6 mm) using
a 7-mm spot size, with marginally overlapping pulses.
Thicker facial vessels require 20 to 40 ms pulse widths
and sub-purpuric fl uences as high as 13 to 15 J/cm2.
One to 3 sessions at 4- to 8-week intervals are o en
needed.
Long-pulsed Nd-YAG Lasers
Long-pulsed 1064 nm Nd:YAG lasers are ideal for the
treatment of larger, deeply situated facial vessels (eg,
re cular veins) due to the more penetra on of laser
energy at this wavelength. Fitzpatrick skin types V and
VI can be treated with low risk of epidermal injury
8
NJDVL. Vol 16, No.1, 2018
because of the low absorp on coeffi cient for melanin
at 1064 nm. Treatment parameters for periorbital veins
are based directly on vessel size and a 3.5-mm (range,
2 to 10) spot size; 1-mm re cular veins are treated with
a 25-ms pulse dura on and fl uences of 160 to 190 J/
cm2, whereas 1- to 3-mm veins require up to 50 ms and
190 to 210 J/cm2. Vessel spasm or thrombosis is the
endpoint of treatment, demonstrated by immediate
vessel blanching or darkening.
In a study, twenty-six Chinese subjects with under-
eye dark circles having prominent re cular veins (1.0
to 2.5 mm) were treated with a 6-mm spot size, 120
to 140 J/cm2 fl uence, and 6- to 10-ms double-pulsing
with a 20-ms delay at monthly sessions using a contact
cooled long-pulsed Nd:YAG laser.32 At 12-month follow-
up, all subjects were found to have complete vessel
resolu on. A retrospec ve study confi rmed nearly
100% subjec ve and objec ve improvement a er 1 to
2 sessions with appropriate se ngs.
Abla ve Tradi onal and Frac onal Lasers
Tradi onal Abla ve Lasers
Pulsed CO2 and erbium: YAG lasers preferen ally
absorbed by water, leading to confl uent epidermal
vaporiza on and thermal damage of the superfi cial
dermis, leads to contrac on and denatura on of
collagen. Alster and Bellew33 treated 67 pa ents with
dermatochalasia and periorbital rhy des using CO2
laser resurfacing and found a signifi cant improvement.
Abla ve Frac onal Lasers
Frac onated lasers create columnar microthermal
treatment zones, which leave up to 95% of the
cutaneous surface intact and thus provide an
endogenous reservoir for rapid healing and barrier to
infec on. Signifi cant improvement in deep wrinkles,
fi ne lines, texture irregularity, laxity, and dyschromia
can be achieved with a single treatment.
Tierney and colleagues34 treated twenty-fi ve subjects
with lower eyelid laxity with 2 to 3 sessions of abla ve
frac onal resurfacing (AFR) using a CO2 laser (25%
coverage, 30 W, 1-ms dwell me). A mean improvement
of 65.3% and 62.1% in laxity and rhy des, respec vely
were found at 6-month follow-up.
However, abla ve lasers are associated with greater
discomfort, side eff ects, a weeklong down me, and an
intense postopera ve care.
Non-abla ve Frac onal Lasers (NAFR)
NAFR laser causes dermal coagula on necrosis
limited to microthermal treatment zones eventua ng
in collagen remodeling but spares the overlying
epidermis, leading to rapid recovery and reduced
adverse events a er the procedure A study by Sukal
and colleagues35 found 50% to 100% improvement
in eyelid skin ghtening in 55% of subjects a er 3
to 7 sessions (17 to 20 mJ, 500 to 750 microthermal
treatment zones per cm2) with a 1550-nm NAFR.
Intense Pulsed Light (IPL)
IPL can be used for periorbital pigmenta on and
vascularity. For telangiectasia and re cular veins
in infraorbital area, minimal pressure should be
applied against the skin with the hand piece to avoid
compression of target vessels. A typical pa ent requires
1 to 3 sessions to achieve signifi cant improvement,
with subsequent semiannual maintenance treatments.
Inappropriate use of lasers and light in periorbital
area may result in eye problems, including blindness,
dryness and photophobia. Therefore, safety should be
emphasized when trea ng periocular area with lasers
and light by the use of proper eyewear (eye shields).1
Soft tissue augmentation by autologous
fat transplantation and soft tissue fi ller
The violaceous appearance of POH which is due to li le
or no subcutaneous fat is treated by using autologous
fat transplanta on or so ssue fi ller.
Autologous fat transplanta on
It is a technique by which fat ssues are removed
from other parts of the body, usually thigh, bu ock,
belly by liposuc on and then the ssues are processed
into liquid and injected into the lower eyelid skin
overlying the orbicularis oculi muscle. Roh and Chung1
treated 10 pa ents with infraorbital dark circles due to
increased vascularity and translucency of the skin by
at least one autologous fat transplanta on, and follow-
up evalua ons was done at least 3 months a er the
last treatment. These pa ents showed an average of
78% improvement.
Fillers
Hyaluronic acid gel is used as a fi ller for three-
dimensional reshaping of periorbital complex. The
ease of use, minimal incidence of complica ons and
lack of down me associated with this product makes
it nearly ideal for trea ng infraorbital volume loss.
Though, pa ent sa sfac on is high, some pa ents may
get darker pigmenta on a er hyaluronic acid gel.
Bosniak et al,36 treated 12 pa ents with POH, tear
trough deformity, or prominent nasojugal groove
with the hyaluronic acid push technique. All pa ents
9NJDVL. Vol 16, No.1, 2018
experienced immediate improvement a er the
procedure.
Platelet-rich plasma
Platelet rich plasma is a therapy using blood with high
levels of platelet containing growth factors, esp. for
accelera on in healing and regenera on. Recently.
platelet-rich plasma has been used in trea ng dark
circles due to tear trough deformity and wrinkles.
A single session with intradermal injec ons of 1.5ml
platelet-rich plasma was given into the tear trough area
and wrinkles of crow’s feet. The eff ect was compared
to three months a er treatment with baseline. The
improvement in infraorbital color homogeneity was
sta s cally signifi cant.37
Micro-focused ultrasound
Micro-focused (or intense focused) ultrasound
corrects mild to moderate skin and so ssue laxity by
short dura on (25 to 50 ms) pulses of transcutaneous
ultrasound energy with frequencies in the megahertz
(MHz) range to create precise areas of spa ally focused,
chromophore-independent thermal coagula ve
damage, sparing intervening ssues or overlying
skin.38 A single treatment session of intense focused
ultrasound for infraorbital laxity treatment has shown
increase re cular dermal collagen and thickness.39
Surgery
Blepharoplasty helps in elimina ng dark circles caused
by shadows that are cast by fat deposits or excess skin.
Transconjunc val blepharoplasty is a be er approach
than transcutaneous blepharoplasty so that no external
visible scar is created. Targe ng the contribu ng
causes for infraorbital dark circles, the combina on
of transconjunc val blepharoplasty and deep-depth
phenol chemical peel for pseudohernia on of the
orbital fat and treatment of hyperpigmenta on of the
skin have found be er outcome.40
Others
Carboxytherapy: Carboxytherapy employs injec ons
to infuse gaseous carbon dioxide below the skin into
subcutaneous ssue through a needle and Paolo et al41
found a signifi cant improvement in fi ne lines and POH
a er the use of subcutaneous injec ons of carbon
dioxide once a week for seven weeks in the periorbital
area.
Normobaric oxygen therapy: Recently oxygen was
administered via a nasal cannula at a rate of 1lt/min,
for 1 hour twice weekly for 3 weeks. The major clinical
changes following treatment included lightening
of the color and reduc on in size of darkened area
and decrease in pigmenta on and erythema on
dermascopy.42
Conclusion
POH is a common benign facial cosme c problem
with mul ple factorial e ology. Though, there are a
number of treatment op ons available for periorbital
hyperpigmenta on, there is a lack of evidence-
based studies for the treatment. It is important to
iden fy the pa ern of POH to adapt the treatment
modali es in the individual pa ent. Pigmented POH
may be eff ec vely treated with bleaching agents
(hydroquinone, a triple combina on, kojic acid etc.),
chemical peels, pigmented lasers, whereas vascular
POH may be treated with topical vitamin K products,
vascular lasers and IPL. Structural POH may be treated
with Platelet rich plasma, frac onal lasers, fi llers,
autologous fat transplanta on, blepharoplasty and
mixed POH may be treated with the combina on of the
above-men oned modali es to improve the quality of
life of the pa ents.
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