tion. He presented with a dark blue/grey patch involving the
right suborbital area. The etiology of his infraorbital pigmentation
was diagnosed as PIH. His first line treatment was two
treatments with fractional photothermolysis with 1550-nm
fractionated erbium-doped fiber laser (Fraxel Restore, Solta
Medical, Haywood, CA). This was followed by four weeks
of once nightly application of triple combination bleaching
agent containing Fluocinolone acetonide 0.01% , 4% Hydroquinone,
.05% Tretinoin (Triluma, Galderma, Houston Texas).
POH remains a complex entity. While we have excellent randomized
controlled studies looking at treatments for periorbital
rejuvenation primarily for the elimination of rhytids and facial
hyperpigmentation; there is a lack of evidence based studies for
the treatment of POH. We do have excellent case reports, use
studies, large global patient studies and anecdote to guide us in
making safe and efficacious clinical treatment plans.
Periorbital Hypermelanosis is a complex entity with a multifactoral
etiology and an expanding knowledge base. It is
most often observed in darker races and may be considered
to be normal variants of pigmentation. There is most likely a familial component as it may be seen in family members over
generations. Though patients are distressed and usually seek
medical attention because of their appearance it is not strictly
a cosmetic issue and may be a sign for underlying health issues.
POH has specific histology and may be a final common
clinical pathway of dermatitis, allergy, sleep disturbances or
nutritional deficiences that lend 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. Cosmetic camouflage may be used during treatment.
Procedural and surgical treatments may improve the
appearance of POH. 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 author has not disclosed any relevant conflicts. Wendy E.
Roberts is a consultant/speaker/advisor for the following companies
for Allergan, Kythera, La Roche Posay, L’Oreal, MelaScience,
Neostrata, SkinMedica, Top MD, Theraplex, and Valeant.
- Epstein JS. Management of infraorbital dark circles. Arch Facial Plast Surg. 1999;1:303–9.
- PubMed Central® www.ncbi.nlm.nih.gov/pubmed
- Maruri CA, Diaz LA, Dark Circles around the eyes. Cutis 1969;5:979
- Cestari T, Freitag FM, Cestari TF. What causes dark circles under the eyes? J Cosmet Dermatol. 2007;6:211–5.
- Grimes, PE. Aesthetic and Cosmetic Surgery for Darker Skin Types. 2007 Lippincott.
- Mashood AA. Treatment of hyperpigmentation disorders. J Pakistan Assoc Dermatol. 2006;16-65.
- Gendler EC Treatment of Periorbital hyperpigmentation. Aesth Surg J. 2005;25:618.
- Gathers RC Dermatology For Skin of Color p.341-343 McGraw Hill-2009
- Alsaad S, Mikhail M Perioccular Hyperpigmentation: A Review of Etiology and Current Treatment Options. J Drugs Dermatol. 2013;12(2):154-157
- Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg. 2010;125(2):699-708.
- Goodman RM, Belcher RW. Periorbital hyperpigmentation. An overlooked genetic disorder of pigmentation. Arch Dermatol. 1969 Aug;100(2):169-74.
- Gupta MA, Gupta AK. Dissatisfaction with skin appearance among patients with eating disorders and non-clinical controls. Br J Dermatol. 2001;145:110-3.
- Landeck L, Schalock PC, Baden LA, Gonzalez E. Periorbital contact sensitization Am J Ophthalmol. 2010 Sep;150(3):366-370
- Sarkar R. Idiopathic cutaneous hyperchromia at the orbital region or periorbital hyperpigmentation. J Cutan Aesthet Surg. 2012 Jul;5(3):183-4.
- Verschoore M, Gupta S, Sharma V, Ortonne JP. Determination of Melanin and Haemoglobin in the Skin of Idiopathic Cutaneous Hyperchromia of the Orbital region (ICHOR): A Study of Indian Patients. J Cutan Aesthet Surg. 2012 Jul-Sep; 5(3): 176–182.
- Malakar S, Lahiri K, Banerjee U, Mondal S, Sarangal S. Periorbital melanosis is an extension of pigmentary demarcation line-F on face. Indian J Dermatol Venereol Leprol. 2007;73:323–5.
- Ranu H, Thng S, Goh BK, Burger A, Goh CL. Periorbital hyperpigmentation in Asians: an epidemiologic study and a proposed classification. Dermatol Surg. 2011 Sep;37(9):1297-303.
- Huang YL, Chang SL, Ma L, Lee MC, Hu S. Clinical analysis and Classification of dark eye circle. Int J Dermatol. 2014 Feb 53(2) 164-70.