How to manage periorbital hyperpigmentation?

Approach to Periorbital Hyperpigmentation

Chemical peeling with TCA 3.75% and lactic acid 15% is the most effective first-line treatment for periorbital hyperpigmentation, showing superior results to PRP and other modalities, with 38% achieving excellent improvement. 1, 2

Initial Clinical Assessment

Before initiating aesthetic treatment, identify underlying medical causes that may present as periorbital hyperpigmentation:

• Screen for systemic disorders: sleep disturbances, nutritional deficiencies, allergic conditions, and atopic dermatitis 3
• Evaluate for dermatologic causes: postinflammatory hyperpigmentation from atopic or allergic contact dermatitis, periorbital edema, excessive vascularity 4
• Assess structural factors: skin laxity, tear trough deformity, and shadowing effects associated with aging 4
• Document medication history: identify photosensitizing drugs that may worsen pigmentation 5

Treatment Algorithm by Efficacy

First-Line: Chemical Peeling

Chemical peeling is the most effective, tolerable, and satisfying procedure for periorbital hyperpigmentation. 1, 2

• Protocol: TCA 3.75% combined with lactic acid 15%, administered in multiple sessions at 2-4 week intervals 1
• Expected outcomes: 38% achieve excellent improvement, 47.6% achieve good improvement 1, 2
• Side effects: Mild itching (14.3%) and redness (14.3%) that are generally well-tolerated 2
• Critical safety measure: Apply broad-spectrum sunscreen (SPF 15 or greater) daily to prevent repigmentation, as even minimal sunlight sustains melanocytic activity 5, 3

Second-Line: Autologous Platelet Concentrates

When chemical peeling is contraindicated or patient preference dictates:

Plasma Gel is superior to conventional PRP for periorbital rejuvenation 6, 1

• Two sessions spaced one month apart 1
• Administered via intradermal injection 6

PRF (Platelet-Rich Fibrin) shows promising results for natural treatment seekers 6, 7

• Four sessions at one-month intervals 1
• Improves deep and fine wrinkles, periocular hyperpigmentation, and skin thickness 6, 7
• Use 30G needles for injection or 22G × 2-inch cannula for Alb-PRF formulation 6
• Warn patients about bruising and swelling, which are common but temporary 7

Conventional PRP is less effective than chemical peeling but still viable 6, 1

• 3-4 sessions at 2-4 week intervals 1
• 80% achieve fair to good improvements 1
• Improves periorbital dark circles (47.8-60.9%) and wrinkles (73.9-78.3%) 1
• Only 4.8% achieve good improvement compared to 47.6% with chemical peeling 2

Carboxytherapy is slightly more effective and better tolerated than PRP 6, 1

• Weekly sessions for optimal results 1

Third-Line: Topical Depigmenting Agents

Hydroquinone 2-4% alone or combined with tretinoin 0.05-0.1% 4, 8

• Critical FDA warnings: Contains sodium metabisulfite that may cause anaphylactic reactions in susceptible individuals 5
• Risk of exogenous ochronosis: Gradual blue-black darkening of skin, more common in Black patients but also occurs in Caucasians and Hispanics 5
• Mandatory sun protection: Must use broad-spectrum sunscreen or protective clothing as hydroquinone formulations contain no sunscreen 5
• Pregnancy category C: Use only if clearly needed 5
• Test for sensitivity: Apply small amount to unbroken skin patch; check within 24 hours before full treatment 5

Alternative topical agents 4, 8:

• Azelaic acid 15-20% (less irritating than hydroquinone) 8
• Kojic acid (alone or combined with glycolic acid or hydroquinone) 8
• Tretinoin (especially useful for photoaged skin) 8

Special Consideration: Periorbital Dermatitis

If dermatitis is the underlying cause:

Topical calcineurin inhibitors are first-line therapy 1

• Adults: Tacrolimus 0.1% ointment applied once daily to external eyelids including lid margins for 2-4 weeks 1
• Children (2-17 years): Tacrolimus 0.03% ointment, ideally following ophthalmology advice 1
• Contraindication: History of ocular-surface herpes simplex virus or varicella zoster virus 1
• Safety measure: Arrange ophthalmology review within 4 weeks when initiating periocular treatments, particularly in children or when applying to lid margins 1

Combination Therapy for Refractory Cases

Chemical peeling plus PRP shows better results than either treatment alone 1

PRF plus microneedling enhances outcomes 1

• Use 0.25 mm depth for microneedling devices in the delicate periorbital area 6

Critical Safety Considerations

The periorbital area is particularly challenging due to thin skin, constant blinking motion, and proximity to the eye 6, 9

Avoid worsening pigmentation 3:

• Exercise extreme caution with chemical peeling, filler injection, and laser therapy
• Laser therapies have not produced completely satisfactory results and can induce hyperpigmentation and recurrences 8

Sun protection is the cornerstone of all therapy 5, 3:

• Apply broad-spectrum sunscreen (SPF 15 or greater) daily
• Use protective clothing to cover treated skin
• Avoid unnecessary solar exposure to prevent repigmentation

Treatment Expectations and Maintenance

Most treatments require multiple sessions over weeks to months; patients should not expect immediate results 1

Without intervention, periorbital hyperpigmentation usually progresses over time, so early intervention is encouraged 3

Maintenance therapy is essential 5:

• Continue sun protection indefinitely
• Consider maintenance treatments every 6 months for platelet concentrate therapies 7
• Maintain good home care routine 7