How to treat hyperpigmentation under the eyes with dryness?

Treatment of Periorbital Hyperpigmentation with Dryness

For hyperpigmentation under the eyes with dryness, prioritize treating the dryness first with preservative-free artificial tears containing methylcellulose or hyaluronate at least twice daily, then address the hyperpigmentation with topical hydroquinone 4% cream combined with a retinoid and short-term low-potency corticosteroid, while avoiding the immediate eye area. 1, 2, 3

Initial Management: Address the Dryness First

The periorbital area presents unique challenges due to thin skin and proximity to the eye, making it essential to restore the skin barrier before treating pigmentation 2.

First-Line Therapy for Dryness

• Apply preservative-free artificial tears or moisturizers containing methylcellulose or hyaluronate at least twice daily, increasing frequency up to hourly based on symptom severity 1, 2
• Use ceramide-containing moisturizers specifically for periorbital skin, as these are particularly effective for improving skin hydration and barrier function 2
• Switch to preservative-free formulations when applying more than four times daily to prevent irritation and toxicity to the delicate periorbital skin 1, 2
• Apply hypoallergenic moisturizing creams or ointments at least once daily to restore the skin's lipid barrier and prevent moisture loss 4

Environmental Modifications

• Humidify ambient air and avoid direct air drafts by using side shields on spectacles 1, 2
• Lower computer screens below eye level to decrease eyelid aperture and reduce evaporative loss 1, 2
• Use tepid water for cleansing and pat (don't rub) the skin dry, avoiding hot water and harsh soaps that strip natural lipids 4

Treating Hyperpigmentation After Barrier Restoration

Once the dryness is controlled and the skin barrier is restored, hyperpigmentation can be addressed safely.

Triple Combination Therapy (Most Effective)

The gold standard approach combines three agents applied to hyperpigmented areas only, avoiding direct contact with the eye:

• Hydroquinone 4% cream applied twice daily as the primary tyrosinase inhibitor for up to 6 months 3, 5
• Retinoid (tretinoin or adapalene) applied nightly to enhance penetration and accelerate cell turnover 6, 3
• Mid-potent topical corticosteroid (such as hydrocortisone 1%) applied twice daily for 2 weeks initially, then weekends only to reduce inflammation and prevent irritation 4, 3

Alternative Depigmenting Agents

If hydroquinone causes irritation or is not tolerated:

• Azelaic acid as a non-phenolic tyrosinase inhibitor 6, 5
• Kojic acid, arbutin, or licorice extract as botanical alternatives 6, 5
• Niacinamide, ascorbic acid, or N-acetyl glucosamine as emerging therapies 5

Treatment Algorithm Based on Severity

Mild Cases (Few Lesions)

• Use spot therapy applying the triple combination directly to hyperpigmented areas 3
• Continue preservative-free moisturizers to surrounding skin 2

Moderate to Severe Cases (Extensive Involvement)

• Use field therapy applying treatment to the entire affected periorbital area 3
• Consider advanced options if no improvement after 3-4 months 2, 7

Refractory Cases

• Chemical peeling with TCA 3.75% and lactic acid 15% has shown excellent improvement in periorbital hyperpigmentation 2
• Platelet-Rich Fibrin (PRF) demonstrates promising outcomes for periorbital skin rejuvenation, improving hyperpigmentation and skin thickness 2
• Laser therapy may be considered for recalcitrant cases 7, 5

Critical Pitfalls to Avoid

Do not apply topical acne medications (retinoids, benzoyl peroxide) near the eyes initially as they cause excessive dryness and irritation that will worsen both conditions 4. The retinoid in the triple therapy should only be introduced after the dryness is controlled.

Avoid prolonged use of topical corticosteroids on the face beyond the recommended 2-week intensive period, as this can cause skin atrophy, telangiectasia, and increased intraocular pressure 4, 3. After 2 weeks, limit to weekend-only application.

Never use preserved formulations more than four times daily as preservatives cause toxicity to the already compromised periorbital skin 1, 2.

Do not treat hyperpigmentation before addressing the underlying dryness, as irritated, dry skin will worsen with depigmenting agents and may develop post-inflammatory hyperpigmentation 5.

When to Refer to Specialists

Refer to ophthalmology immediately if:

• Visual symptoms develop (blurred vision, eye pain, photophobia) 4
• Moderate or severe eye pain occurs 8
• Corneal infiltration or ulceration is suspected 8

Refer to dermatology if:

• No improvement after 3-4 months of appropriate therapy 4, 7
• Concern for melanoma or atypical pigmentation patterns 7
• Extensive disease requiring procedural interventions 2, 7

Monitoring and Maintenance

Reassess response every 4-6 weeks to adjust therapy and monitor for adverse effects such as irritation, which can be managed with a short drug holiday or increased moisturizer use 3. Photoprotection with broad-spectrum sunscreen is essential to prevent worsening of hyperpigmentation, though application technique near the eyes requires care 5.