Periorbital Hyperpigmentation: Review of Etiology, Medical Evaluation, and Aesthetic Treatment

April 2014 | Volume 13 | Issue 4 | Original Article | 472 | Copyright © April 2014

Wendy E. Roberts MD

Generational and Cosmetic Dermatology, Rancho Mirage, CA

Periorbital hyperpigmentation (POH) is a common worldwide problem. It is challenging to treat, complex in pathogenesis, and lacking straightforward and repeatable therapeutic options. It may occur in the young and old, however the development of dark circles under the eyes in any age is of great aesthetic concern because it may depict the individual as sad, tired, stressed, and old. While “dark circles” are seen in all skin types, POH is often more commonly seen in skin of color patients worldwide.1 With a shifting US demographic characterized by growing number of aging patients as well as skin of color patients, we will encounter POH with greater frequency. As forecasted by the US Census, by 2030 1 in 5 Americans will be 65 plus years old and greater than 50% of the population will possess ethnic skin of color.2 The disparity in the medical community’s understanding of POH versus popular demand for treatment is best illustrated when you have only 65 cited articles to date indexed on PubMed line3 compared to the 150,000,000 results on Google search engine.4 Most importantly POH may be a final common pathway of dermatitis, allergy, systemic disorders, sleep disturbances, or nutritional deficiences that lends itself to medical, surgical, and cosmeceutical treatments. A complete medical history with ROS and physical examination is encouraged prior to treating the aesthetic component. Sun protection is a cornerstone of therapy. Safety issues are of utmost concern when embarking upon treatments such as chemical peeling, filler injection, and laser therapy as not to worsen the pigmentation. Without intervention, POH usually progresses over time so early intervention and management is encouraged. The objective of this study was to review the current body of knowledge on POH, provide the clinician with a guide to the evaluation and treatment of POH, and to present diverse clinical cases of POH that have responded to different therapies including non-ablative fractional photothermolysis in two skin of color patients.

J Drugs Dermatol. 2014;13(4):472-482.


Periorbital Hyperpigmentation (POH) is also known by the following names: periorbital melanosis, periorbital circles, dark circles, dark eye circle, underye circles, perioccular pigmentation, perioccular melanosis, infraorbital melanosis, and idiopathic cutaneous hyperchromia of the orbital region (ICHOR).5,6 It is a common condition that occurs in both sexes with an increasing frequency in females. Globally, skin of color patients are affected more than Caucasians. POH is often a presenting cosmetic concern in our skin of color patients and may be considered to be normal variants of pigmentation.7 There is most likely a familial component as it may be seen in family members over generations. Periorbital hypermelanosis is a complex entity with a multifactoral etiology and an expanding knowledge base. Clinical severity like the etiology may vary, however POH usually presents as bilaterally symmetric hyperpigmented patches around the eyes. One eye may be more involved than the other. It can affect either upper or lower eyelid or both upper and lower. It may extend to involve the glabella and upper nose. Periorbital hyperpigmentation may be seen in young and old8 and with advancing age it is a significant cosmetic concern because it may make patients seem sad, tired, stressed, and feel older than they are.9,10 The etiology of POH may be multifactorial with no one etiologic agent predominating.10,11 However, importantly for clinicians, it may be a sign of an underlying systemic disease, skin disorder, allergic reaction, nutritional deficiency, or sleep disturbance. The patient should be medically evaluated as not to miss underlying systemic disease or lifestyle inadequacy that can be corrected (Table 1). POH may also be the earliest sign of periorbital aging, heralding skin, and musculo-ligamentous laxity. POH may also be the earliest sign of periorbital aging, heralding skin and musculo-ligamentous laxity.12 Successful outcomes may be punctuated with chronic recurrences. With that in mind, there are promising treatments for POH on the horizon. Successful outcomes may be punctuated with chronic recurrences. With that in mind, there are promising treatments for POH on the horizon. Multimodality treatment will probably be the most efficacious and long lasting. In best hands multimodal treatment plan may take months to take effect. As this may be a chronic and relapsing condition, preventive and maintenance regimens that involve UV protection and patient education should be integrated into the treatment plan. A clinical approach to the treatment of POH should include identification and therapeutic targeting of each contributing etiologic factor for an individual patient. Medical treatments involve correcting the underlying condition. Aesthetic treatments include microdermabrasion, chemical peels, lasers, radiofrequency, injectable fillers, surgery, fat transfer, hydroquinone (HQ), non-HQ skin bleaching agents, topical retinoids, and