Periorbital Hyperpigmentation (POH) Treatment

  • POH is also called as periorbital melanosis, periocular pigmentation, dark circles, dark ring, or simply under eye circles.
  • It is one of the major cosmetic concern in both male and female patients and one of the commonest problems encountered by the dermatologists.
  • Other aesthetic changes such as thinning, wrinkling, loosening and sagging of skin, fluid retention, excess fat accumulation, pseudo herniation of fat occurring due to ageing, photoaging, gravity, etc. in the periorbital area give the patient old, sad, tired, unhealthy hangover look.

Causes:

  • Exact etiology of POH is unknown and it is thought to be multifactorial in origin with no single factor predominating.
  • Presence of melanin (melanin etiology) and hemosiderin (vascular etiology) pigments in the affected sites are distinctive features in its etiopathogenesis.
  • There are two etiological types of dark circles: One with predominantly melanin and other with vascular etiology. Most commonly encountered is the mixed type (presence of both melanin and hermosiderin). Melanin hyperpigmentation is due to increase in the production of melanin and affects epidermis or the dermis or both.
  • The multifactorial causes that induce /contribute to /exacerbate this condition are as follows: genetic/ constitutional, PIH induced due to constant rubbing/ itching, secondary to atopic or contact allergic dermatitis, ageing thinning of skin, volume loss and atrophy of soft tissue, descent of mid face fat: leading to stretching, drooping, wrinkling of skin along with pseudo herniation of fat, prominence of infra-orbital, rim, and tear through formation).
  • Other contributing factors are subcutaneous edema such as under–eye bags due to fragile capillaries, leakage of plasma fluid with interstitial fluid accumulation, defective lymphatic drainage, inflammation and loss of support to cutaneous microvascular structure due to photoageing and disorders that give rise to fluid retention and palpebral edema (thyroid disorders, nephropathies, cardiopathies, pneumopathies etc.)
  • Deficiency of vitamin K (vital for the blood coagulation that can lead to repeated small hemorrhage), hormones (menstruation, pregnancy, OC pills hormone replacement therapies can act by stimulating melanogenesis), drugs (eye drops for glaucoma, antipsychotics, chemotherapeutic agents, gold, mercury, and silver salts), lifestyle (alcoholics, workaholics, and sleep deprivation can lead to vasodilatation, blood stasis, leakage, fluid retention, and puffy eyes), smoking (vasoconstrication effect of nicotine causes generalized pale appearance of the skin).

Clinical Features:

  • POH is defined as bilateral homogeneous macular or pigmented patches involving the lower eyelids and infra-orbital regions.
  • It can also extend to upper eyelids lateral nasal root, and sometimes surrounding eyebrows, temporal and malar area.
  • However, usually it appears as a curved band of brownish, slatish, or brownish bluish skin approximating the shape of the underlying inferior orbital rim.
  • It is a mere colour difference between the palpebral skin and the remaining facial skin.
  • POH usually presents along with one or more of the following three characteristics, contributing to the discolouration:

4.Pigment:

Diffuse or concentrated melanin deposits (hyperpigmentation). It is of brown or brownish slatish colour when superficial and involving epidermis.

5.Vascular:

Presence of erythema predominantly involving the inner aspect of the lower eyelids, with prominent dermal capillary network (telangiectasia) or presence of bluish discolouration of the lower eyelid secondary to the visible subcutaneous venous network. In dark skinned, this variety is more contributing and becomes more prominent when the overlying skin is stretched.

6.Shadow Effect:

It is due to the changes in the contour of the lower eyelid (nasojugal groove). There is skin laxity due to ageing and photoageing. Along with it, there is volumetric loss and descent of soft tissue and fat of cheek with loss of subcutaneous fat and thinning of skin over the orbital rim area inducing depression (tear trough) centered over its medical aspect.

Management:

  • Proper diagnosis
  • Control of precipitating factors
  • Identification and therapeutic targeting of each contributing etiologic factors for an individual patient (customized), sunscreens, skin –lightening agents, topical retinoic acid, chemical peels, injection of botulinum toxin Injectable fillers, mesotherapy, PRP, lasers, IPL, blepharoplasty, camouflage either as monotherapy or in combination.
  • Dietary supplements that contain soy extracts, fish, proteins, polysaccharides, extracts from white tea, grape seed, tomatoes, vitamins C and E as well as zinc from chamomile extract are found to be useful.
  • Change in lifestyle with adequate sleep and stress reducing strategies help in managing POH.