PERIORBITAL HYPERPIGMENTATION

INTRODUCTION

It is also known as periocular hyperpigmentation, periorbital melanosis, dark circles, infraorbital darkening, and idiopathic cutaneous hyperchromia of the orbital region.¹

CLASSIFICATION

Huang et al. classified POH into four types, namely pigmented (brown color), vascular (blue/pink/purple color), structural (skin color), and mixed type.

Ranu et al  classified periorbital pigmentation as

1. Constitutional
2. Post inflammatory
3. Vascular
4. Shadow effect
5. Others – POH from other causes including anemia, hormonal disturbances, nutritional deficiencies, acanthosis nigricans, skin laxity, associated chronic illness, habits, etc.

CLINICAL FEATURES ²

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.

Fig 2³– Extension of pigmentary demarcation line-F leading to periorbital pigmentation

ETIOLOGY ¹

POH has multifactorial etiology. Various proposed etiologic factors include

• Constitutional pigmentation,
• Thin and translucent eyelid skin leading to vascular prominence,
• Shadowing effect due to lax skin and ageing- Because of ageing, there is a loss of facial fat leading to inflexible ligaments causing hollowing effect on orbital rim. There is worsening of shadowing due to hollowness, which is mainly seen in the tear trough area in inferomedial orbit. The thin eyelid skin contributes to the prominence of the underlying soft tissue and subcutaneous vascular network and the orbicularis oculi muscle, due to which the overlying skin appears dark.
• Periorbital edema.
• Dermal melanocytosis,
• Postinflammatory hyperpigmentation which includes atopic and allergic contact dermatitis as well as rubbing and scratching the skin around the eyes
• Extension of pigmentary demarcation lines (fig 2)
• Ocular hypotensive drugs – Prostaglandin analogues, such as latanoprost and bimatoprost
• Periorbital melasma,
• Periorbital lichen planus pigmentation,
• Periorbital acanthosis nigricans,
• Environmental causes such as ultraviolet (UV) radiation, atopy, lack of sleep, stress, alcohol, and smoking
• Medical disorders including disorders of liver, heart, thyroid or kidney, hereditary blood disorders, vitamin K deficiency, Addison disease, or circulatory conditions, which result in excess fluid retention, can also lead to POH.
• DERMOSCOPY¹

  On dermoscopy, pigmented type POH, the pattern of multiple dots with different sizes and colors or a diffuse network of pigment is seen, whereas vascular type shows diffuse erythema or multiple thin blood vessels or diffuse vascular network.

  The mixed type shows the combination of the above-described patterns.Dermoscopy helps in the differentiation of cause of lesions as the treatment depends on etiology.

  Eyelid stretch test can be used to differentiate the shadowing effect from other causes as stretching the eyelids leads to the disappearance of pigmentation effect.

• TREATMENT ⁴
  • Identification and removal of contributing factors, counselling of patients, and aesthetic modalities, whenever suitable

   

  • Topical agents include hydroquinone, kojic acid, azelaic acid, arbutin, vitamin C, etc. Like any other facial pigmentary disorder, POH responds well to sunscreens, particularly broad-spectrum sunscreen and ultraviolet (UV)-coated sunglasses. Chemical peels (glycolic acid 20% and lactic acid 15%) are useful in POH

   

  • Chemical peels

   

  • Concealers and cosmeceuticals

   

  • Physical and surgical management

   

  • Q switched lasers, Intense pulsed light (IPL), pulsed dye lasers and radiofrequency have also been used with variable success. Other management options include chemical peeling agents, fillers,  platelet-rich plasma and fat transfer techniques and surgery

   

  • Blepharoplasty – Removal or repositioning of periorbital fat and/or excess skin

  • REFERENCES

     

    1. Daroach M, Kumaran MS. Periorbital hyperpigmentation − An overview of the enigmatous condition. Pigment Int 2018;5:1-3

     

    2. Sarkar R, Ranjan R, Garg S, Garg VK, Sonthalia S, Bansal S. Periorbital Hyperpigmentation: A Comprehensive Review. J Clin Aesthet Dermatol. 2016;9(1):49-55.

     

     

    3. Sheth PB, Shah HA, Dave JN. Periorbital hyperpigmentation: A study of its prevalence, common causative factors and its association with personal habits and other disorders. Indian J Dermatol 2014;59:151-7

     

    4. Sarkar R, Das A. Periorbital hyperpigmentation: What lies beneath?. Indian Dermatol Online J 2018;9:229-30

     

    5. Ellen C. Gendler, MD, Treatment of Periorbital Hyperpigmentation, Aesthetic Surgery Journal, Volume 25, Issue 6, November 2005, Pages 618–624,`