What are the treatment options for hyperpigmentation under the eyes?

Treatment of Periorbital Hyperpigmentation (Under-Eye Dark Circles)

Start with topical hydroquinone 2-4% combined with tretinoin 0.05-0.1% as first-line therapy, as this is the established treatment for facial hyperpigmentation including the periorbital area. 1, 2

First-Line Topical Therapy

• Hydroquinone 4% is FDA-approved for gradual bleaching of hyperpigmented skin conditions and should be your initial treatment choice for periorbital hyperpigmentation 1
• Combine hydroquinone with tretinoin 0.05-0.1% for enhanced efficacy, as this combination is the established standard treatment 2
• Apply nightly to the affected under-eye area, avoiding direct contact with eyes 1
• Expect gradual improvement over 8-12 weeks of consistent use 1

Alternative Topical Agents (If Hydroquinone Not Tolerated)

• Azelaic acid 15-20% is as efficacious as hydroquinone but causes less irritation, making it suitable for the delicate periorbital skin 2
• Kojic acid alone or combined with glycolic acid inhibits tyrosinase and has shown good results for facial hyperpigmentation 2
• Tretinoin alone is especially useful when photoaging contributes to the hyperpigmentation 2

Essential Adjunctive Measures

• Mandate strict broad-spectrum sunscreen use daily, as UV exposure is a primary exacerbating factor for periorbital hyperpigmentation 2, 3
• Avoid sun exposure and ultraviolet lamps entirely during treatment 2
• Use preservative-free formulations if applying products more than 4 times daily to prevent additional irritation 4

Second-Line Options: Chemical Peels

• Chemical peels with trichloroacetic acid, Jessner's solution, alpha-hydroxy acids, or kojic acid have shown good results when topical agents fail 2
• Chemical peeling is significantly more effective than platelet-rich plasma (PRP) for periorbital hyperpigmentation specifically, with 38% achieving excellent improvement versus 0% with PRP 5
• Peels are particularly useful for refractory cases in darker-skinned patients 2

Emerging Option: Platelet-Rich Fibrin (PRF)

• PRF injections show promise as a safe alternative treatment, though evidence suggests it is less effective than chemical peels for hyperpigmentation specifically 5, 6
• PRF demonstrates improvements in periorbital hyperpigmentation, skin thickness, and overall skin freshness with high patient satisfaction 6
• Administer using 30G needles or 22G cannula for safety in the delicate under-eye area 6
• Requires 3 treatment sessions spaced 21 days apart, with maintenance every 6 months 6
• PRF is safer than chemical fillers as an autologous material, with minimal side effects (temporary bruising and swelling) 6

Critical Diagnostic Considerations

• Identify the primary cause before initiating treatment: genetic/hereditary factors (most common at 61.1%), postinflammatory hyperpigmentation from atopic or allergic contact dermatitis, excessive vascularity, or shadowing from skin laxity 7, 8, 3
• Examine for contributing dermatologic conditions including rosacea, atopic dermatitis, or contact dermatitis that may require concurrent treatment 5
• Rule out underlying periorbital edema or vascular causes that may require different management approaches 3

Treatments to Avoid

• Laser therapies have NOT produced satisfactory results for periorbital hyperpigmentation and can induce further hyperpigmentation and recurrences 2
• Avoid intralesional steroid injections near the periorbital area due to severe risks including hypopigmentation and fat atrophy 4

Important Caveats

• Periorbital hyperpigmentation is notoriously resistant to treatment, particularly in darker-skinned patients (Fitzpatrick III-VI), so set realistic expectations with patients 7, 8
• Current treatments are often not highly effective, with many patients experiencing refractory hyperpigmentation despite therapy 7
• A multimodal approach combining topical agents with sun protection and potentially chemical peels offers the best chance of improvement 8, 3
• Compliance with maintenance regimens and preventive measures (especially sun protection) is essential for sustained results 8