Periorbital Dark Circles

Periorbital Dark Circles

Shraddha Desai

Macrene Alexiades

Jeffrey T.S. Hsu


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.


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


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


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


Clinical Appearance


Clinical Appearance


Clinical Appearance


Well-defined brown band along lower eyelids


Brown color


Blanchable vascular patches in the infraorbital region


Irregular gray/brown patches +/− lichenification on upper and/or lower eyelids


Pink, blue, or purple color


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


Pink or blue discoloration of the lower eyelids


Skin color


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






Translucent compressible swelling exacerbated in morning or post salt consumption. Persistent in downward gaze and does not change in upward gaze


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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Jun 29, 2020 | Posted by in Dermatology | Comments Off on Periorbital Dark Circles
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