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

table 5
>75% clearance = 4. Clinical grades ranged from 1 to 4, with an average score of 2.5, corresponding to approximately 50% improvement 9 weeks after laser resurfacing Posttreatment melanin readings (mean value = 1.14) were not significantly different from those obtained preoperatively (mean value = 1.25), and thus did not correlate with the favorable clinical findings seen. Four patients experienced transient infraorbital hyperpigmentation postoperatively lasting 8 weeks.37
Another study used a CO2 laser followed by a Q-switched alexandrite laser, effectively targeting pigmentation in the dermis and epidermis.38 Several authors including Tierney, Hanke, and Moody have commented on the effectiveness of nonablative fractional photothermolysis (FP) for the treatment of POH.36,38 The fractionated 1550nm erbium doped fiber laser creates microscopic, pixels of wounding in the dermis results in significant skin pigmentary and textural improvements without the adverse effects of prolonged wound healing and risks of dyspigmentation associated with traditional ablative resurfacing. 39 The nonablative fractionated 1550-nm erbium-doped fiber laser been proven to treat a variety of pigmented conditions effectively, including photoaging and melasma. The proposed mechanism of action is fractionated photothermolysis with preservation of the stratum corneum while creating microscopic treatment zones (MTZs) of thermal injury in the epidermis and dermis.39,40 The laser functions to eliminate melanin pigment from the epidermis and dermis through a “melanin shuttle,” which exudes the pigment from the skin through the MTZs.40,41 Moody et al, reported one case of a Fitzpatrick II female diagnosed with POH who underwent four non ablative laser treatments spaced out at 4 week intervals with a 1550nm fractionated erbium-doped fiber laser over a 4 month period. They used a 15mm spot, energy fluency of 70 J/cm2 treatment level of 10-11, 4 passes for a total surface area coverage of 29-32%. This was used in conjunction with a Zimmer chilling cryo system that kept the epidermis cool during the treatment. Two months after the last treatment the physician and patient noted significant improvement of the POH.40 What must be stressed in this successful case report is the skin type of the patient and these settings must be readjusted in skin of color patients (Case 1 and Case 2). In 2010 a consensus panel of experts convened to communicate best practices for fractional photothermolysis42 Ruiz Esparza examined the efficacy of nonablative radiofrequency (NARF) to tighten noninvasively the skin laxity of the lower eyelids by treating the periorbital area.43 Nine patients with skin flaccidity of the lower eyelids had a single treatment session with NARF in a small area of skin in the periorbital region, specifically the zygomatic and/or temporal areas. His results indicated that all of the nine patients in the study achieved cosmetic improvement of the eyelids ostensibly through skin contraction. All patients were able to return to their normal routines immediately. Results were gradual and patient satisfaction was remarkable. No complications were seen in this study. He concluded that NARF was successful in providing a safe, noninvasive, cosmetic improvement in patients with excessive skin laxity of the lower eyelids. Similar findings for NARF were also seen in 2008 by Sukai.44

Injectable Filler

While there have been no randomized controlled studies analyzing the effectiveness of treating POH in isolation, there is evidence based medicine that dermal fillers have shown efficacy in repairing the tear trough deformity that may be an important contributing factor to some cases of POH especially in the skin of color patient. Carruthers, Sadick, and others have worked to classify this complex and multidynamic area.45,46 The European and North and South American aesthetic experts convened at an academic workshop to develop keys to optimal outcomes.47 The best practice guidelines recommended from the consensus group for midface and infraorbital hollow injections were the vertical supraperiosteal depot technique (VSDT) or linear threading for infraorbital hollow augmentation.48 Sharad has recently done a comprehensive review of the tear trough anatomy, treatment techniques, and clinical outcomes. I recommend the reader to this article.49

Ten Clinical Pearls for Tear Trough Injection

  1. It is an advanced technique not for novice injectors
  2. The skin should be sanitized with antiseptic and gloves should be worn throughout the session.
  3. Caution with injecting too quickly either with needle or cannula.
  4. Low-viscosity HA can be safely injected to correct tear trough deformity. High-viscosity HA and permanent fillers should be avoided and only done in the hands of an experienced injector.