Periorbital Dark Circles

Shraddha Desai

Macrene Alexiades

Jeffrey T.S. Hsu

BACKGROUND

Periorbital dark circles, otherwise known as periorbital darkening, periorbital hyperpigmentation, periocular hyperpigmentation, dark circles, periorbital melanosis, infraorbital darkening or discoloration, or idiopathic cutaneous hyperchromia of the periorbital region, is a benign yet frustrating condition characterized by relative darkening of the lower eyelids.¹,² It can affect any age group or ethnicity but is more common in skin of color.³ Owing to its transient nature, there is a lack of studies to determine incidence and prevalence.¹ However, in an Indian study by Sheth et al, this hyperpigmentation was found to be more prevalent in those aged 16 to 25 years and in women more than in men.⁴ Underlying causes include genetics, prominent vasculature, volume loss, and postinflammatory hyperpigmentation and are often multifactorial.¹,²,⁵ Although not harmful, the discoloration can diminish quality of life.¹ Often patients complain of appearing tired or older and present for treatment. There is no gold standard for treatment, but a variety of topical and procedural therapies are available.

PRESENTATION

Patients complain of appearing tired or older and present with darkening below and/or around the orbital region.

DIAGNOSIS

Clinical Diagnosis

On examination, the presenting signs are hyperpigmented brown to gray-blue and/or blanchable vascular patches or infraorbital anatomical depressions or shadows in the periorbital region. The patches may be linear to triangular extending from the eyelid margins.

Vascular Patches

In the case of vascular patches, they are typically infraorbital and more prominent in the lower eyelid proximal to the medical canthus but may involve the upper eyelid as well. They appear as violaceous linear patches. Pressing on the lower lid demonstrates blanching.

Anatomic Shadowing

In the case of anatomic shadowing, manual stretching of the skin may differentiate between shadowing cast into the infraorbital sulci from pigmentation. Tear troughs become progressively depressed with age, centered over the inferomedial orbital rim. The hollowness of the infraorbital sulcus and overlying pseudoherniation of the infraorbital fat accentuate the shadowing in the tear trough causing dark circles, depending on lighting.

Hyperpigmentation

Dermal Melanocytosis. In cases of dermal melanocytosis, the patches present clinically as distinctive gray or blue-gray. Nevus of Ota, also known as oculodermal melanocytosis or nevus fuscoceruleus ophthalmomaxillaris, is congenital dermal melanocytosis involving the areas innervated by the first and second divisions of the trigeminal nerve. Appearing as speckled or mottled brown-gray to blue-black patches, they may involve the skin, conjunctiva, sclera, tympanic membrane, or oral and nasal mucosa of the affected dermatomes. When infraorbitally localized, it can present with periorbital hyperpigmentation. Nevus of Hori is an acquired form of bilateral nevus of Ota-like macules. Clinically, blue-brown to slate-gray mottled hyperpigmentation is present over the malar region and may extend to involve the periocular area causing dark circles. The absence of ocular or mucosal involvement differentiates the nevus of Hori from other forms of dermal melanocytosis.

Pigmentary Demarcation Lines. Genetically determined, pigmentary demarcation lines (PDLs) are borders of abrupt transition between hyperpigmented and lighter colored areas. These are also called Futcher or Voight lines, and there have been many described and labeled A through H.

Among the various types of PDLs, 2 types of these well-demarcated regions of hyperpigmentation may appear in the periorbital region. PDL type F is bilaterally symmetrical “V” shaped or inverted cone-shaped on the lateral aspect of the face in the region between the malar prominence and the temple.⁶ In type G, there are 2 inverted cones forming the letter W, with a faint strip of normal pigmentation in between.⁶ Periorbital PDLs are observed in Asian and darker skin types.⁷

Postinflammatory Hyperpigmentation. In postinflammatory hyperpigmentation, the presence of the underlying condition allows for the diagnosis to be made. The presence or history of atopic or allergic contact dermatitis, chronic rubbing of the area, lichen planus, erythema dyschromicum perstans, or drug eruption may suggest this diagnosis.

Drug-Induced Hyperpigmentation. Medication-induced hyperpigmentation may be established in the setting of use of prostaglandin analogs. Such agents include latanoprost and bimatoprost, ocular hypotensive agents for glaucoma that are also used for eyelash growth and can elicit periorbital hyperpigmentation. Patients typically develop the hyperpigmentation between 3 and 6 months of initiating therapy. Reversal of periocular pigmentation is expected after discontinuation of bimatoprost.

Edema

Periorbital edema may also be a contributor to infraorbital dyschromia. Diagnostic features include worsening in the morning or after eating salty meals. When compared with normal orbital fat, edema is still present in downward gaze and does not change in upward gaze.

Dermal Filler Excess

Filler-induced infraorbital darkening, the Tyndall effect, most commonly due to hyaluronic acid fillers, may present as a bluish hue to the undereye area. The area often appears edematous or plaquelike with a faint clear-bluish discoloration.

Histopathology

When periorbital dark circles are due to hyperpigmentation, histological analysis typically reveals both epidermal and dermal pigment. Fontana-Masson silver stain may be requested to stain melanin. In cases secondary to vascular stasis, hemosiderin deposits are also seen resulting from extravasation of red blood cells and the superficial localization of dermal papillary vessels, which may be identified with Perl’s stain. In PDLs, histopathological examination of the pigmented area has shown an increase in the basal layer pigmentation and few perivascular lymphocytes in upper dermis.¹

In cases of dermal melanocytosis, a histological distinction may be made between nevi of Ota and Hori. In nevus of Ota, melanocytes are distributed diffusely throughout the papillary and reticular dermis. In Hori nevus, irregularly shaped, bipolar melanocytes are dispersed in the papillary and mid dermis, particularly in the subpapillary dermis, without disturbance of normal skin architecture (Algorithm 4.4.1).

ALGORITHM 4.4.1 Algorithm of periorbital dark circle treatments. CO₂, carbon dioxide laser; DC, discontinue; IPL, intense pulsed light; KTP, potassium titanyl phosphate laser; LP, long pulsed; Nd:YAG, neodymium:yttrium aluminium garnet laser; PDL, pulsed dye laser; SMAS, superficial muscular aponeurotic system. (Courtesy of Macrene Alexiades, MD, PhD.)

Subtypes

Ranu et al⁸ classified periorbital dark circles as follows (Table 4.4.1):

Constitutional: a well-demarcated brown band over the lower eyelid approximating the orbital rim, which may also involve the upper eyelid.
Postinflammatory: irregular brown or gray patches often with lichenification on the upper, lower, or both eyelids. There may be a personal or family history of atopy.
Vascular: erythema or bluish discoloration involving the lower eyelids that is more prominent with stretching of the skin. This is often due to translucent overlying skin.
Shadow effect: dark shadow formation from fat pad prominence or presence of a deep tear trough.
Others: pigmentation from medical causes such as anemia, nutritional deficiencies, and skin laxity.¹,⁴,⁸,⁹

Huang et al¹⁰ proposed a classification of periorbital dark circles according to the clinical pattern of pigmentation and vasculature (Table 4.4.1):

Pigmented: brown color
Vascular: blue/pink/purple color
Structural: skin color
Mixed: pigmented-vascular, pigmented-structural, vascular-structural, and a combination of the three²,¹⁰

PATHOGENESIS

The pathogenesis of periorbital dark circles is multifactorial, including endogenous and exogenous factors. Genetics, excessive pigment deposition, postinflammatory hyperpigmentation, edema, increased vascularity, skin laxity, and tear trough formation are the contributing factors.¹,²

Genetics

Familial inheritance of periorbital pigmentation appearing during early childhood and worsening with age has been reported.¹¹

Dermal Melanocytosis

Dermal melanocytosis, the presence of melanocytes in the dermis, may cause periorbital hyperpigmentation. This condition may be congenital or acquired. The 2 most well-described forms are nevi of Ota and Hori, which are commonly found in Asian populations.

Nevus of Ota

Also referred to as oculodermal melanocytosis or nevus fuscoceruleus ophthalmomaxillaris, nevus of Ota is a form of congenital dermal melanocytosis in the anatomic territories innervated by the first and second divisions of the trigeminal nerve. When located infraorbitally, this form of dermal melanocytosis causes periorbital hyperpigmentation.

Nevus of Hori

Nevus of Hori, also termed acquired bilateral nevus of Ota-like macules and nevus fuscoceruleus zygomaticus, is a late-onset, acquired, bilateral form of nevus of Ota-like macules associated with sun exposure, pregnancy hormonal changes, and chronic atopic dermatitis. The spots are usually blue-brown or slate-gray and present in women after the third decade of life. The pathogenesis appears to be a genetic predisposition followed by an additional trigger such as ultraviolet radiation and excessive sex hormone or inflammation, which induces activation of existing immature melanocytes via c-KIT and/or tyrosinase-related 2 protein.¹²

Postinflammatory Hyperpigmentation

Periorbital cases of postinflammatory hyperpigmentation may occur as a result of chronic rubbing, atopic and allergic contact dermatitis, lichen planus pigmentosus, erythema dyschromicum perstans, and drug reactions, such as fixed drug eruptions.

Vascular Patches

A common cause of periorbital dark circles is prominent, dilated, superficial vasculature beneath thin translucent eyelid skin in the region overlying the orbicularis oculi muscle.

Anatomic Depression

Tear troughs located over the inferior-medial orbital rim become progressively depressed with aging. These

progressive infraorbital anatomic depressions worsen over time owing to osteoporosis, loss of subcutaneous fat, and loss of collagen and elastin in the overlying skin and orbital rim ligaments, combined with cheek laxity, exacerbating hollowness to the orbital rim and infraorbital sulcus.

TABLE 4.4.1 Classification of Periorbital Pigmentation

Ranu et al		Huang et al		Alexiades Classification
Type	Clinical Appearance	Type	Clinical Appearance	Type		Clinical Appearance
Constitutional	Well-defined brown band along lower eyelids	Pigmented	Brown color	Vascular		Blanchable vascular patches in the infraorbital region
Postinflammatory	Irregular gray/brown patches +/− lichenification on upper and/or lower eyelids	Vascular	Pink, blue, or purple color	Anatomic		Depression and shadowing in the inferiomedial orbital rim worsened by overlying pseudoherniation of the infraorbital fat. Periorbital fat diminishes on downward gaze and alters on upward gaze
Vascular	Pink or blue discoloration of the lower eyelids	Structural	Skin color	Hyperpigmentation	Dermal melanocytosis	Gray or blue-gray patches; Nevus of Ota: speckled or mottled browngray to blue-black patches in territory of trigeminal nerve I and II may include ocular or mucosal involvement; Nevus of Hori: acquired bilateral nevus of Ota blue-brown to slate-gray mottled hyperpigmentation over the malar region +/− periocular area—no ocular or mucosal involvement
					Pigmentary demarcation lines	Borders of abrupt transition between hyperpigmented and lighter colored areas. Type F: bilaterally symmetrical “V” shaped or inverted cone-shaped on the lateral aspect between malar prominence and the temple. Type G: 2 inverted cones letter W pattern, with faint intervening patch of normal pigmentation
					Postinflammatory hyperpigmentation	In presence of underlying atopic or allergic contact dermatitis, lichenification, lichen planus, erythema dyschromicum perstans, hyperpigmented light tan to brown patches
					Drug-induced hyperpigmentation	In setting of use of prostaglandin analogs, periorbital light tan to brown patches
Shadow effect	Shadow formation on the lower eyelids from deep tear trough or prominent fat pad	Mixed Pigmented-vascular Pigmented-structural Vascular-structural Combination	Combination	Edema		Translucent compressible swelling exacerbated in morning or post salt consumption. Persistent in downward gaze and does not change in upward gaze
Others	Pigmentation from other medical conditions			Dermal filler		Hyaluronic acid fillers as edematous or plaquelike with a faint clear-bluish hue from Tyndall effect; other fillers as fleshcolored firm plaques
Data from Ranu H, Thng S, Goh BKet al. Periorbital hyperpigmentation in Asians: an epidemiologic study and a proposed classification. Dermatol Surg. 2011;37:1297-1303.

Periorbital Edema

Periorbital fluid accumulation may occur due to positional dependence, systemic disorders causing edema, or after eating salty meals.

Drug Reactions

Prostaglandin analogues cause increased melanogenesis in dermal melanocytes and increased transfer of melanin granules to basal epidermis, which is the likely mechanism of bimatoprost-induced hyperpigmentation.

Excess Dermal Fillers

The accumulation, migration, or expansion of injectable dermal fillers are a common cause of periorbital dark circles. In this instance, the Tyndall effect from the reflection of short blue wavelengths of light by dermally placed hyaluronic acid fillers causes a blue hue.

Extension of Pigmentary Demarcation Lines of Face

PDLs are the borders of abrupt transition in melanocyte distribution, which are genetically determined. In Japanese and African populations, a dominant inheritance pattern has been suggested. Other studies have implicated a form of cutaneous mosaicism. Sarma et al have proposed that PDLs closely conform with the Blaschko lines on face.¹³,¹⁴

Environmental Causes

Ultraviolet radiation triggers hyperpigmentation due to the aforementioned predisposing genetic and acquired factors. Several lifestyle factors have been reported to worsen periorbital dark circles, including lack of sleep, stress, alcohol overuse, and smoking.¹

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