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

adverse effects of erythema, edema, frosting, dryness, and telangiectasia. The authors reported the treatment results remained for at least 4-6 months in the majority of patients with appropriate sun protection.31

Laser and Device

This is becoming increasingly integrated into the treatment of POH, however, there is still a lot to be learned. While there are randomized controlled studies for periorbital rejuevenation with laser, there is a paucity of data for the treatment periorbital hyperpigmentation. Before embarking upon a laser treatment it is important to understand the skintype of your patient. This goes beyond Fitzpatrick skintype because your Caucasion patient (phenotypic Fitzpatrick I or II ) may have a brown or dark complexioned parent and or grandparent. The patient’s skin may respond like the darker skinned relative and result in dyschromia. Both hypo and hyperpigmentation have been seen as laser complications in ethnic skin of color. The Roberts Skin Type Classification System is an efficient way to document and communicate your patients ancestry, liklihood for dyschromia post laser procedure, and assist in the selection of safe laser settings (Table 4).32,33 Laser safety is of utmost importance. Patient protective eyewear such as eyeshields should be used as necessary. Innappropriate use of laser in this area may result in eye problems including blindness, dryness and photophobia.34 Importantly, IPL is not indicated for the treatment of POH. The pigmented iris absorbs light in the same wavelength range of IPL. The IPL when applied to the perioccular area is absorbed by the pigment of the iris and can result in severe eye damage that may include photophobia, pain, and anterior uveitis.34,35 As we have histologic data showing that dermal melanosis is one of the etiological factors in POH, laser treatment used to target the melanin has been investigated.25 An emerging practice is combination of device and topical product for the treatment of POH. One group recommends the use of topical hydroquinone and tretinoin in addition to Q-switched ruby laser sessions; they postulate that these topical treatments not only enhance treatment efficacy, but also lower the risk for PIH secondary to laser treatments.35 Skin laxity has been sighted as a causative factor of POH and ablative and nonablative lasers and devices are being investigated.36 In 1998 ,West and Alster conducted a study to determine the effectiveness of cutaneous CO2 laser resurfacing in reducing infraorbital hyperpigmentation.
Twelve female patients (age range, 27–56 years; mean, 44 years) presented for either full-face or periorbital CO2 laser resurfacing. It is an important laser safety tip to note all patients had skin types I, II, or III. There were no skintypes IV –VI in this study. Prior to the laser resurfacing procedure and at 3, 6, and 9 weeks after treatment, the average of three melanin measurements was obtained from the infraorbital regions using a handheld reflectance spectrometer (Dermaspectrometer; Cortex Technology, Haugland, Denmark). Photographs were taken
table 4
using identical lighting and camera settings preoperatively and at each of the three scheduled follow-up visits. Simultaneous projection of pre- and posttreatment photographs (Mirror Image, Virtual Eyes, Inc., Kirkland, WA) were scored independently by two blinded assessors. Clinical improvement was rated on a 1–4 scale with <25% lightening = 1, 25–50%= 2, 51–75%= 3, and