What is the best treatment approach for a 50-year-old woman with periorbital melanosis?

Treatment for Periorbital Melanosis in a 50-Year-Old Woman

Chemical peeling with TCA 3.75% and lactic acid 15% combination is the most effective first-line treatment for periorbital melanosis, showing excellent improvement in 93-97% of patients and superior results compared to PRP and other modalities. 1

Treatment Algorithm

First-Line: Chemical Peeling

• TCA 3.75% combined with lactic acid 15% is the gold standard, requiring 4 sessions performed weekly 1, 2
• This combination demonstrates excellent improvement in 38% of cases and fair-to-excellent improvement in 93.3% (physician assessment) and 96.7% (patient assessment) 1, 2
• Results persist for 4-6 months with appropriate sun protection 2
• Alternative chemical peels include 20% glycolic acid (more effective than lactic acid alone but higher side effect profile) or 15% lactic acid alone 3

Common pitfall: Chemical peeling carries risks of worsening hyperpigmentation if not performed carefully in darker skin types, so proceed with caution and start conservatively 4

Second-Line: Autologous Platelet Concentrates (if chemical peeling fails or is contraindicated)

The hierarchy of effectiveness among platelet-based treatments is:

1. Plasma Gel - Most effective platelet-based option, requiring 2 sessions one month apart, showing significantly better results than conventional PRP 5, 1

2. PRF (Platelet-Rich Fibrin) - Effective for periorbital rejuvenation with improvement in hyperpigmentation, requiring 4 sessions one month apart using intradermal injection with 30G needles 5, 1

3. PRP (Platelet-Rich Plasma) - Shows 47.8-60.9% improvement in periorbital dark circles, requiring 3-4 sessions at 2-4 week intervals, but less effective than plasma gel 5, 1

4. Carboxytherapy - Slightly more effective and better tolerated than PRP, with weekly sessions 5, 1

Third-Line: Combination Therapy for Refractory Cases

• Chemical peeling plus PRP demonstrates superior results compared to either treatment alone 1
• PRF combined with microneedling enhances outcomes 1

Technical Considerations for Periorbital Area

• Use small gauge needles (30G) for injections due to thin periorbital skin 5
• Lower microneedling device depth to 0.25mm maximum 5
• If using Alb-PRF formulation, employ 22G × 2 inches cannula for enhanced safety around the eyes 5
• The periorbital area is particularly challenging due to thin skin, constant blinking motion, and proximity to the eye 5

Alternative Modalities (Lower Evidence Quality)

• Topical 20% vitamin C: Shows only 26.67% achieving >50% improvement, significantly less effective than chemical peels 3
• Q-switched ruby laser: May offer benefit for patients with increased melanin deposition, but requires experienced operators 6
• Microneedling with serum infusion (DermaFrac™): Limited evidence from single case reports 7

Critical Safety Points

• Sun protection is cornerstone of therapy and essential for maintaining results 4
• Avoid aggressive treatments that may worsen pigmentation, particularly in darker skin types 4
• Without intervention, periorbital melanosis typically progresses over time, so early treatment is encouraged 4
• Patients should expect multiple sessions over weeks to months, not immediate results 1

What to Rule Out First

Before proceeding with aesthetic treatments, ensure periorbital melanosis is not secondary to:

• Underlying dermatitis or allergic conditions 4
• Systemic disorders 4
• Sleep disturbances 4
• Nutritional deficiencies 4