Periorbital Hyperpigmentation in Asians: An Epidemiologic

Study and a Proposed Classification

HARNEET RANU, MBBS, MRCP(UK), MSCCLIN DERM(LOND), MMED INT MED(SING),
STEVEN THNG, MBBS, MRCP(UK), BOON KEE GOH, BSC(HONS), MBCHB(LEEDS), MRCP(UK), FAMS,
ALLAN BURGER, PHD,y AND CHEE LEOK GOH, MD, MBBS, MRCP(UK), FRCPE, FAMS

BACKGROUND Periorbital hyperpigmentation (POH) presents with a dark area surrounding the eyelids.
It is an ill-defined condition, and the pathogenesis can be multifactorial.
OBJECTIVE This epidemiologic study was conducted to assess the prevalence of periorbital hyper-
pigmentation in Singapore in an attempt to propose a classification.
MATERIALS AND METHODS One thousand consecutive patients attending the general dermatology
clinic at the National Skin Center were enrolled in the study to assess for POH, of whom 200 with POH
were examined and investigated to define the cause of POH. The possible causes were determined
according to a detailed history, clinical examination, and assessment by three dermatologists. The
extent of the POH was measured using a mexameter.
RESULTS The commonest form of POH was the vascular type (41.8%), followed by constitutional
(38.6%), postinflammatory hyperpigmentation (12%), and shadow effects (11.4%). The vascular type
was seen predominantly in Chinese, whereas as the constitutional type was most common in Indians
and Malays.
CONCLUSION The vascular form of POH was the predominant type. We propose a comprehensive
classification for POH that we hope will influence the choice of treatment modalities used in managing
POH in the future.
Unilever R&D Trumbul, USA provided funding for this study.

D ermatologists often see patients with periorbital

hyperpigmentation (POH). Despite the lack of
attention received in the dermatologic literature, POH
can be a significant cosmetic problem. Given the
number of advertisements for products that improve
or cover POH, the condition is a major cosmetic
concern for men and women alike. The pathogenesis
of POH remains elusive. Possible causative factors that
have been proposed include excessive constitutional
pigmentation, thin and translucent lower eyelid skin,
shadowing due to skin laxity, and venous congestion.1
The skin over the lower eyelid is thinner and looser
than other sites because it contains less collagen,
elastin, and glycosaminoglycans.2,3 Factors such as
melanin and hemoglobin content, hemoglobin oxygen
saturation, and blood flow rates have been measured
and compared, but the exact mechanism is unclear,
and effective treatments are lacking. Most of the lit-
erature on POH has focused on Caucasian popula-
tions. Because the problem of POH may be more
prevalent or of greater concern in Asian populations,
data in these groups are needed. By better character-
izing the types of POH seen in Asians, we hope to
facilitate clinical trials for the treatment of POH in the
near future.
Materials and Methods
Patients
This was a single-center, cross-sectional, descriptive,
anonymous study conducted with the approval of
the institutional review board.

National Skin Center, Singapore; yUnilever R&D, Trumbull, Connecticut

& 2011 by the American Society for Dermatologic Surgery, Inc.  Published by Wiley Periodicals, Inc. 
ISSN: 1076-0512  Dermatol Surg 2011;37:1297–1303  DOI: 10.1111/j.1524-4725.2011.02065.x

1297
 P E R I O R B I TA L H Y P E R P I G M E N TAT I O N I N A S I A N S
One thousand consecutive patients, aged 18 to 70
and attending the general dermatology clinic of a
tertiary dermatology referral center in Singapore
were asked whether they had POH. If the answer
was affirmative, the patient was enrolled into the
study. After informed consent was obtained, the re-
cruited patients were asked to fill in a questionnaire.
One of the authors conducting the study examined
the patients and confirmed the presence or absence
of hyperpigmentation. Digital photographs were
taken to document the extent of the hyperpigmen-
tation, and readings were obtained using a
Mexameter MX-18 (CK Electronic GmbH, Koln,
Germany). Two hundred of the 1,000 patients
surveyed reported having POH. Sixteen of the 200
were excluded from the study because they refused
photography or had no apparent POH.
Assessment of Patients
One of the authors examined all patients who re-
ported POH. The characteristics of their periorbital
hyperpigmentation, including the boundaries, color,
pattern, skin texture, and associated skin disorders on
and around the eyelids, were recorded. Digital photo-
graph was taken of all patients. Photographs of the
patients’ faces from the frontal hairline to the nasal tip
were taken. Three dermatologists then assessed these
photographs to determine the primary cause of the
POH and classify them based on the following
observational criteria into five different types.
ConstitutionalFpresence of a curved band of
brownish to black pigmentation on the skin of the
lower eyelids approximating the shape of the orbital
rim with a velvety or coarse texture with frequent
involvement of the upper eyelids (Figure 1).
Postinflammatory hyperpigmentation (PIH)Fpres-
ence of irregular patches of brownish or gray pig-
mentation on the skin on the upper, lower, or both
eyelids with features of lichenification, accentuation
of skin creases, and eczematous papules or patches in
the surrounding areas (Figure 2).
1298 D E R M AT O L O G I C S U R G E RY
Figure 1. Constitutional type of periorbital hyperpigmenta-
tion. Note the presence of a curved band of brownish pig-
mented skin approximating the shape of the orbital rim
involving the lower eyelids, with a velvety or coarse texture.
Shadow effectsFpresence of a dark shadow under
an overhanging tarsal muscle, eyebags, or the pres-
ence of a deep tear trough over the medial aspect of
the inferior orbital rim that disappear with direct
lighting (Figure 3).
Vascular (capillaries and veins)Fpresence of ery-
thema predominantly involving the inner aspect of
the lower eyelids, with prominent capillaries or tel-
angiectasia (capillaries) or the presence of bluish
discoloration of the lower eyelid and visible bluish
veins that become more prominent when the over-
lying skin is stretched. This type of dark eye circle
appears to be due to a combination of transparency
of the overlying skin and dense dermal vascularity.
The capillaries and veins may coexist in the same
individual (Figures 4–6). A comprehensive summary
of these findings can be found in Figure 8.
OtherFPOH from other cause including skin laxity,
dry skin, hormonal disturbances, nutritional defi-
ciencies, and associated chronic illness.
Figure 2. Postinflammatory hyperpigmentation type of peri-
orbital hyperpigmentation. Note the presence of irregular
patches of brownish skin involving both eyelids, with fea-
tures of lichenification, accentuation of skin creases, and
eczematous papules or patches in the surrounding areas.

Figure 3. Shadow effect type of periorbital hyperpigmenta-
tion. Note the presence of a dark shadow under an over-
hanging tarsal muscle and eyebags.
Mexameter readings were taken from both lower
eyelids and a second reading from normal skin on
the cheeks. The index of difference was calculated
for each subject by subtracting the value of the
reading from the unaffected cheek from the highest
reading from the eyelid most affected by the
pigmentation.
Statistical Analysis
Statistical analysis using the Tukey multiple-com-
parison test among proportions was performed to
determine statistically significant differences be-
tween the different types of POH with respect to sex,
sleep deprivation, family history, eczema, asthma,
allergic rhinitis, and ethnicity.
Results
One hundred eighty-four of the 1,000 patients who
reported having POH were included in the study;
Figure 4. Vascular/capillary type of periorbital hyperpig-
mentation. Note the presence of erythema predominantly
involving the inner aspect of the eyelids, with visible prom-
inent capillaries.
RANU ET AL
Figure 5. Vascular/vein type of periorbital hyperpigmenta-
tion. Note the presence of the bluish discoloration of the
lower eyelid, with visible prominent veins predominantly
over the outer aspects of the lower eyelids.
115 (62.5%) were male and 69 (37.5%) females.
The mean age was 26.4 (range 16–58). The racial
distribution was 74.5% Chinese, 12.5% Malay, and
9.2% Indian. This racial distribution corresponded
to the racial distribution in the local population.
Patients were of Fitzpatrick skin type IV (111,
60.3%), type III (34, 18.5%), and type V (33,
17.9%). Fitzpatrick skin types I, II, and VI consti-
tuted less than 4% (n = 6) of the study population.
The commonest form of POH observed was the
vascular type (n = 77, 41.8%) followed by constitu-
tional (n = 71, 38.6%), PIH (n = 22, 12%), and
shadow effects (n = 21, 11.4%) (Table 1). Of the
vascular type (n = 77), capillaries caused 51 (66.2%),
underlying veins caused 12 (15.6%), and capillaries
and veins caused 14 (18.2%). Figure 7 shows the age
distribution of patients with POH. The age of onset
in the majority of patients (63%) was in early
adulthood (20–40). A comprehensive summary of
these findings can be found in Figure 8.
In our study, 94 (51.1%) and 83 (41.5%) patients
reported sleep deprivation and insomnia, respec-
tively, as aggravating factors to their POH. One
Figure 6. Vascular/capillary and vein type of periorbital
hyperpigmentation. Note the erythema and violaceous dis-
coloration, especially over the lower eyelids.
37:9:SEPTEMBER 2011 1299
 P E R I O R B I TA L H Y P E R P I G M E N TAT I O N I N A S I A N S

TABLE 1. Distribution of Population According to Population and Type of Periorbital Hyperpigmentation

Postinflamma-
Consti- tory Hyper- Shadow Capillaries
Population tutional pigmentation Effects Vascular Capillaries Veins and Veins Other

Total 71 (38.6) 22 (12.0) 21 (11.4) 77 (41.8) 51 (27.7) 12 (6.5) 14 (7.6) 6 (3.3)

(N = 184)
Chinese 33 (24) 17 (12) 20 (15) 74 (54) 50 (36) 11 (8) 13 (9) 4 (3)
(n = 137)
Malay 15 (65) 5 (22) 1 (4) 2 (8.7) 1 (4.3) 1 (4.3) 0 (0) 1 (4)
(n = 23)
Indian 16 (94) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (6)
(n = 17)

hundred two of the patients (55.4%) reported a
positive history of atopic dermatitis, asthma, or al-
lergic rhinitis, 78 (42.2%) had a positive family
history of POH, and 33 (17.9%) reported a history
of smoking and nine (4.9%) of alcohol intake. Sta-
tistical analysis performed to study the possible as-
sociation between these factors and POH failed to
show any statistical significance. Pairwise testing
was performed to correlate the symptoms of sleep
deprivation, a positive family history of POH, and a
personal history of atopy with the different types of
POH. The Tukey multiple comparison test among
proportions of the different types of POH did not
show any statistically significant correlation between
sleep deprivation and POH.
A positive family history (63%) was associated with
the PIH type of POH significantly more than the
other types of POH.
The vascular type of POH was the most common
type in the Chinese population, the predominant
population in Singapore. The constitutional type
of POH was the most predominant type in Indians
and Malays. A summary of these findings is
displayed in Table 1.

Men seemed to be more affected than women by the

PIH and vascular types of POH, although this
difference was not statistically significant.

The vascular type was predominantly seen in

Chinese (96.1%) with lighter skin (type I–IV).
Vascular/capillaries as the cause of POH was four
times as frequent as vascular/veins. One-fifth of
patients with the vascular type of POH had the
capillaries and veins type. The Tukey multiple com-
parisons test among proportions confirmed that
Chinese were significantly more likely to have the
vascular type of POH than Malays and Indians.

The constitutional type of POH was more commonly

Figure 7. Bar chart showing age-of-onset distribution. seen in Malays (65%) and Indians (94%) (Fitzpat-

1300 D E R M AT O L O G I C S U R G E RY
 RANU ET AL

rick skin type V and VI). The Tukey multiple com-

thema
Value

24.0
45.0

24.0
Ery-
parisons test showed that the correlation was sta-

0.0

6
tistically significant.

Melanin
Others

Level

84.0
54.8

89.5
63.5
In the PIH type of POH, 77.3% of patients had a

6
history of endogenous eczema, allergic rhinitis, or

Capillaries & Veins

thema
Value

41.6
46.7

19.5
90.5
asthma, significantly higher than observed in the

Ery-

14
constitutional, shadow effect, and vascular types.

Melanin
Statistical analysis showed that Malays had a

Level

64.6
46.0

49.0
68.8

14
statistically significantly higher chance of having the
PIH type of POH than Indians.

thema
Value

49.1
60.2

27.5
86.0
Ery-

12
The shadow effect type was not significantly seen in

Melanin
any ethnic group or sex.

Veins

Level

76.3
39.3

66.5
73.8

12
TABLE 2. Mean Mexameter Readings for the Different Types of Periorbital Hyperpigmentation
The index of difference in the Mexameter readings

thema
Value
was higher in the constitutional and PIH types than

68.8
52.8

64.0
77.5
Ery-

51
in the vascular and shadow effect types. Mean

Capillaries
Mexameter readings according to type of POH and

Melanin
Level

62.0
44.0

46.0
37.5
ethnicities are shown in Tables 2 and 3.

51
thema
There was no significant correlation between the

Value

60.8
53.5

55.0
92.0
Ery-

77
mean value of the index of Mexameter readings and
type of POH. Mexameter measurements do not ap-
Vascular

Melanin
Level

64.7
43.4

49.0
47.0
pear to be a useful tool to differentiate the different

77
types of POH.
thema
Value

106.0
68.0
52.4

78.0
Ery-
Shadow Effects

21
Discussion
Melanin

A recent article by Ruyong and colleagues4 reviewed

Level

70.2
48.5

61.0
49.0

21

the causes of and possible treatment options for

POH. The authors concluded that the possible
thema
Value
Postinflammatory

85.5
65.9

64.0
87.0
Ery-
Hyperpigmenta-

causative factors of infraorbital dark circles include

22

excessive pigmentation, thin and translucent lower

Melanin

eyelid skin, and shadowing due to skin laxity and

Level

100.0

102.0
Periorbital Hyperpigmentation

42.9

59.3
tion

22

tear trough. Because multiple factors are frequently

at play, the authors stressed that it is essential to
thema
Value

103.5
65.5
62.6

61.0
Ery-

identify the cause and choose the appropriate treat-

71
Constitutional

ment according to the cause.

Melanin
Level

94.5
73.7

77.0
76.5

71

Oshima and colleagues,5 who conducted a study on

14 subjects with and 28 without POH, recently re-
deviation

Interquartile

ported the use of a new image-processing method to

Standard

Ratio
Statistic

Median
Mean

measure erythema index and melanin index. They

n

found that the erythema and melanin index were

37:9:SEPTEMBER 2011 1301

 P E R I O R B I TA L H Y P E R P I G M E N TAT I O N I N A S I A N S

TABLE 3. Mean Mexameter Readings According to Ethnicity

Chinese Malay Indian Other

Melanin Erythema Melanin Erythema Melanin Erythema Melanin Erythema

Statistic Level Value Level Value Level Value Level Value

Mean 74.3 68.3 85.5 54.5 125.2 279.5 98.4 73.4

Standard 49.9 55.6 42.9 57.1 94.8 875.1 117.4 50.9
deviation
Median 62 63 85 32 89 54 26 82
Interquartile 61 94 57 85 95 103 135 51.5
Ratio
n 137 137 23 23 17 17 7 7

significantly higher in subjects with POH on image
analysis. Using ultrasound images, they found the
dermis of the lower eyelids to be significantly thinner
in subjects with POH than in those without. This
could be a major contributing factor to the devel-
opment of the vascular type of POH. In their study,
there was no differentiation between the different
types of POH as was found in our study. We believe
that POH is not a uniform pigmentary skin disorder.
We propose that POH can be classified into different
types, each with its own unique characteristics. We
believe that different types of POH probably respond
to different types of treatment.
Periorbital skin rejuvenation techniques for the
treatment of POH that have been reported in the
literature include topical steroids; topical vitamin K,
C, and E; topical retinoids; alpha-hydroxyl acids;
chemical peeling; dermabrasion; botulinum toxin
and collagen injections; intense pulsed light (IPL);
erbium-doped yttrium aluminum garnet and carbon
dioxide laser resurfacing; autologous fat transplant;
and blepharoplasty. Mitsuishi and colleagues,6 in a
open-label study of 57 adult Japanese women,
studied the effect of a topical application of
phytonadione, retinol, and vitamins C and E on
POH and concluded that this formulation was
effective in cases of hemostasis (stasis of bloodstream
in the infraorbital region) but was not effective in
reducing pigmentation. Topical phytonadione has
been used in the treatment of traumatic purpura.7,8
The role of vitamin K as an integral factor in
hepatic biosynthesis of coagulation factors is well
known, although the mechanism by which it is useful
in removing hemostasis is unknown.9,10 In another
study by Oshima and colleagues, vitamin C was
found to be effective in the treatment of POH by
concealing vascular congestion by increasing
dermal thickness.11

As shown in our study, the vascular type of POH is

Figure 8. Summary of findings shown in pie charts. the predominant type of POH in the Singaporean

1302 D E R M AT O L O G I C S U R G E RY

population and in particular among the Chinese.
This observation may explain why skin lightening
creams have often failed to produce results in
Singapore. The underlying problem in these patients
is predominantly vascular in origin. Because Chinese
constitute more than 70% of the population, a
treatment that could address this type of POH
would be desirable. A topical agent that could
diminish the appearance of these underlying capil-
laries and veins by increasing dermal thickness,
causing vasoconstriction, or a vascular laser such as
the pulsed dye laser may improve the vascular type
of POH. Topical steroid creams, on the other hand,
may increase the appearance of vascular POH by
causing dermal atrophy.
Other treatments that have been reported to have
treated POH successfully in the recent literature
include IPL,12 Q-switched ruby laser,13 autologous
fat transplantation,14 and a combination of fat
grafting and blepharoplasties,15 but responses to
these treatments probably depend on the type of
POH encountered. As with any other cause of
hyperpigmentation, ultraviolet radiation aggravates
POH, so the use of broad-spectrum sunscreens
should be advocated regardless of the type of POH.
It is possible that the melanin associated with the
constitutional type of POH may respond to pigment-
specific lasers and IPL devices.
The shadow type of POH may respond to fillers and
blepharoplasties and the vascular type to vascular
lasers and IPL, and the PIH type may respond better
to topical corticosteroids. Therapeutic studies are
necessary to confirm our hypotheses. These research
studies should use our proposed classification system
to stratify patients clinically and clarify possible
therapeutic strategies.
References
1. Lowe NJ, Wieder JM, Shorr N, Boxrud C, et al. Infraorbital
pigmented skin. Preliminary observations of laser therapy.
Dermatol Surg 1995;21:767–70.
RANU ET AL
2. Lee Y, Hwang K. Skin thickness of Korean adults. Surg Radiol
Anat 2002;24:183–9.
3. Oresajo C, Dickens M, Znaiden A. Eye area problems puffiness,
bags, dark eye circles and crowsfeet. Cosmet Toiletries
1987;102:29–34.
4. Roh MR, Chung KY Infraorbital dark circles: definition, causes
and treatment options. Dermatol Surg 2009;35:1163–71.
5. Ohshima H, Takiwaki H. Evaluation of dark circles of the lower
eyelids: comparison between reflectance meters and image pro-
cessing and involvement of dermal thickness in appearance. Skin
Res Technol 2008;14:135–41.
6. Mitsuishi T, Shimoda T, Mitsui Y, Kuriyama Y, et al. The effects of
topical application of phytonadione, retinol and vitamin C and E
on infraorbital dark eye circles and wrinkles on the lower eyelids.
J Cosmet Dermatol 2004;3:73–5.
7. Elson ML. Topical phytonadione (Vitamin K1) in the treat-
ment of actinic and traumatic purpura. Cosmet Dermatol 1995;
8:25–7.
8. Lou WW, Quintana AT, Geronemus RG, Grossman MC.
Effects of topical vitamin K and retinol on laser-induced
purpura on nonlesional skin. Dermatol Surg 1999;25:
942–4.
9. Lupo MP. Antioxidants and vitamins in cosmetics. Clin Dermatol
2001;19:467–73.
10. Shah NS, Lazarus MC, Bugdodel R, Hsia SL, et al. The effects of
topical vitamin K on bruising after laser treatment. J Am Acad
Dermatol 2002;47:241–4.
11. Ohshima H, Mizukoshi K, Oyobikawa M, Matsumoto K, et al.
Effects of vitamin C on dark eye circles of the lower eyelids:
quantitative evaluation using image analysis and echogram. Skin
Res Technol 2009;15:214–7.
12. Cymbalista NC, Prado de Oliveira ZN. Treatment of idiopathic
cutaneous hyperchromia of the orbital region with intense pulsed
light. Dermatol Surg 2006;32:773–84.
13. Watanabe S, Nakai K, Ohnishi T. Condition known as
dark rings under the eyes in the Japanese population is a
kind of dermal melanocytosis which can successfully be
treated with Q-switched ruby laser. Dermatol Surg 2006;32:
785–9.
14. Roh MR, Kim TK, Chung KY. Treatment of infraorbital
dark eye circles by autologous fat transplantation: a pilot study.
Br J Dermatol 2009;160:1022–55.
15. Trepsat F. Periorbital rejuvenation combining fat grafting and
blepharoplasties. Aesthetic Plast Surg 2003;27:243–53.
Address correspondence and reprint requests to: Harneet
Ranu, MBBS, MRCP(UK), MScClin Derm(Lond), MMed
Int Med(Sing), Registrar in Dermatology, National Skin
Center, 1 Mandalay Road, 308205 Singapore, or e-mail:
harneet.ranu@gmail.com, krharneet@nsc.gov.sg
37:9:SEPTEMBER 2011 1303