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

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