Shadows Under the Lens: Clinico-Dermoscopic Study of Periorbital Hypermelanosis - A Cross-Sectional Study

INTRODUCTION

Periorbital hypermelanosis (POH), commonly referred to as dark circles under the eyes, is a prevalent dermatological and cosmetic concern, especially among individuals with darker skin phototypes. It is characterised by bilateral hyperpigmentation around the periorbital region, particularly affecting the lower eyelids. Although not medically harmful, POH significantly impacts facial aesthetics and psychological well-being, often being perceived as a sign of fatigue, ageing, or poor health.^[1]

The aetiology of POH is multifactorial and can be broadly categorised into four types: constitutional, vascular, pigmented, and structural. Among the common contributing factors are genetic predisposition, periorbital skin laxity, dermal melanocytosis, and post-inflammatory hyperpigmentation. Additionally, lifestyle-related factors such as insufficient sleep, prolonged screen time, chronic eye rubbing, and stress have emerged as significant predisposing factors, especially among young adults and professionals with sedentary lifestyles.^[2]

Dermoscopy, a non-invasive diagnostic technique, enhances the visualisation of subsurface skin structures and plays a pivotal role in evaluating POH. It helps in distinguishing between pigmentary and vascular components, which is essential for accurate classification and targeted management. Dermoscopy of vascular POH typically shows reticular, linear, or curved vessels arranged in a bluish, violaceous, or reddish pattern, while pigmented POH shows brown globules, dots, and homogeneous pigmentation. Mixed types may exhibit overlapping features of both.^[3,4]

This clinico-dermoscopic study aims to assess the clinical patterns of POH and correlate them with dermoscopic features in patients presenting to the dermatology outpatient department. The study also intends to evaluate potential contributing factors, including sleep habits and screen time, to provide a holistic understanding of the condition. By integrating clinical assessment with dermoscopic evaluation, the study seeks to improve diagnostic accuracy, enhance individualised treatment strategies, and contribute to better cosmetic outcomes in patients with POH.^[5]

MATERIAL AND METHODS

This hospital-based observational study was conducted in the Dermatology Outpatient Department over a period of 24 months. A total of 100 patients presenting exclusively with POH were included after obtaining Ethics Committee approval (Ref No. SSMC/MED/IEC-031/March-2023).

Patients were evaluated through a detailed clinical history, including demographic details, duration of pigmentation, associated symptoms, history of sun exposure, cosmetic use, and any underlying medical conditions. A thorough dermatological examination was performed to assess the distribution, extent, and characteristics of periorbital pigmentation.

Dermoscopy (Dermalite DL 5 and iPhone 14 Pro Max camera) was used as a non-invasive diagnostic tool to examine POH. A handheld dermoscope with polarised and non-polarised light was utilised to identify specific pigmentary patterns, vascular structures, and associated skin changes. Based on dermoscopic findings, patients were categorised into different subtypes of POH.

Socio-demographic factors such as age, gender, occupation, skin phototype, and lifestyle habits were assessed and correlated with different patterns of POH. Statistical analysis was conducted using chi-square tests to establish associations between dermoscopic findings and socio-demographic parameters.

RESULTS

Dermoscopy findings

Dermoscopy findings showed that the exaggerated pigment network was the most prevalent pattern, observed in 40% of cases. This was followed by a cobblestone pattern in 35%, a globular pattern in 15%, blotches in 7%, and vascular structures in 3% [Table 3]. Clinical photographs of patients with periorbital pigmentation and their dermatoscopic findings have been summarised in Figures 1(a–b), 2(a–b), 3(a–b), and 4(a–b).

Table 3: Dermoscopic patterns observed in periorbital hypermelanosis

Dermoscopic pattern	Frequency (n = 100)	Percentage (%)
Exaggerated pigment network	40	40.0
Cobblestone pattern	35	35.0
Globular	15	15.0
Blotches	7	7.0
Vascular	3	3.0

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Figure 1: (a) 38-year-old male with periorbital hypermelanosis. (b) Dermoscopy shows epidermal pigmentation (cobblestone) with vascular pattern (blue arrow - combinations of polarised and nonpolarised, 100x).

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Figure 2: (a) 25-year-old male with periorbital hypermelanosis, (b) Dermoscopy shows an epidermal and dermal cobblestone pattern with exaggerated skin markings (oval circle) (combinations of both polarised and non-polarised, 50x).

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Figure 3: (a) 19-year-old male with periorbital hypermelanosis, (b) Dermoscopy shows epidermal pigmentation with cobblestone-type brown macules with central hypopigmentation showing melanin in the epidermis around the infundibula (black circle - combinations of both polarised and non-polarised, 20x).

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Figure 4: (a) 27-year-old woman with periorbital hypermelanosis, (b) Dermoscopy shows globular blotchy dermal pigmentation (blue arrow - combinations of both polarised and non-polarised, 100x).

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DISCUSSION

POH, commonly referred to as dark circles, is a prevalent dermatological concern characterised by bilateral, homogenous, hyperchromic macules and patches primarily involving the lower eyelids. The aetiology of POH is multifactorial, encompassing genetic predisposition, lifestyle factors, systemic conditions, and environmental exposures. This discussion delves into the demographic distribution, occupational associations, skin phototype prevalence, sun exposure history, familial predisposition, and cosmetic usage patterns associated with POH, integrating both the provided data and pertinent literature.

The age distribution of POH shows a higher prevalence among young to middle-aged adults. In the current study comprising 100 participants, the 31–40 years age group exhibited the highest frequency at 30%, followed closely by the 21–30 years group at 28%. The ≤20 and >50 years groups each accounted for 12% of cases, while the 41–50 years group represented 18%. These findings are similar to previous studies; for instance, Sheth et al.^[1] reported a mean age of onset at 31.96 years, with the majority of patients falling within the 21–30 years bracket (40.2%). Similarly, a study by Mahesh et al.^[6] observed a mean age of 28.18 years among POH patients. The higher prevalence in younger adults may be attributed to lifestyle factors such as increased screen time, sleep deprivation, and stress, which are more common in this demographic.

In the present study, females constituted 62% of the cohort, while males accounted for 38%. Multiple studies corroborate this trend; Sheth et al.^[1] reported that 60% of POH patients were female, and Mahesh et al.^[6] found a female-to-male ratio of approximately 4:1. The higher prevalence among females may be influenced by hormonal factors, cosmetic usage, and greater health-seeking behaviour. Additionally, cultural and societal aspects of facial aesthetics may prompt more women to seek medical attention for POH.

In our study, a positive family history of periorbital melanosis (POM) was reported by 35% of participants, suggesting a possible hereditary component in the development of the condition. These are similar to findings from previous literature, reinforcing the role of genetic predisposition. For instance, Nayak et al. reported a positive family history in 16% of patients with POM, supporting the hypothesis that familial or genetic factors may influence melanogenic pathways or dermal vascular architecture, contributing to the development of pigmentation in the periorbital region.^[7] Sharma and Rana^[8] reported a family history in 29.3% of their POH patients, reinforcing the hereditary component of the condition. Recognising familial patterns can aid in the early identification and management of individuals at risk.

Genetic susceptibility may manifest as inherited traits such as thin periorbital skin, dermal vascular congestion, or increased baseline melanocyte activity, which collectively make individuals more prone to developing POH. Moreover, pigmentation disorders often run in families, particularly among individuals with darker skin types, due to inherent differences in melanosome number, size, and distribution. The higher proportion in our study population may reflect differences in genetic background, sample size, or regional variation in awareness and reporting.

Occupational factors appear to influence POH prevalence, with indoor workers slightly more affected than outdoor workers. In the current study, 52% of participants were indoor workers, while 48% were engaged in outdoor occupations. Sheth et al.^[1] observed that housewives and students were the most commonly affected occupational groups. The marginally higher prevalence among indoor workers may be linked to prolonged exposure to artificial lighting, increased screen time, and sedentary lifestyles, which can contribute to factors like eye strain and sleep disturbances, exacerbating POH.

Skin phototype plays a significant role in POH manifestation. In this study, individuals with Fitzpatrick skin types III–IV constituted the majority at 33%, followed by types I–II at 15% and types V–VI at 53%. This distribution shows a higher susceptibility among individuals with medium to darker skin tones. Flament et al.^[9] showed that darker skin phototypes are more prone to various pigmentation issues, including POH. The increased melanin content in darker skin may lead to more pronounced hyperpigmentation in the periorbital region, especially when compounded by other risk factors.

Sun exposure is a well-recognised exacerbating factor for POH. In the present study, 54% of participants reported a history of significant sun exposure. Ultraviolet (UV) radiation can stimulate melanogenesis, leading to increased melanin production and subsequent hyperpigmentation. Roohaninasab et al.^[10] emphasised the role of sun exposure in the pathogenesis of POH and reported that laser therapy targeting pigmentation yielded satisfactory results in patients with sun-induced POH. These findings underscore the importance of sun protection measures in the management and prevention of POH.

Cosmetic usage, particularly around the periorbital area, was prevalent among 60% of participants. The application of cosmetics can lead to allergic reactions, irritant contact dermatitis, and subsequent post-inflammatory hyperpigmentation. Udayanga et al.^[11] found that 75.3% of cosmetic users experienced adverse skin effects, including dryness, acne, and rashes, which can contribute to or exacerbate POH. Educating patients on proper cosmetic use and encouraging hypoallergenic products may mitigate these risks.

In the present study, vascular structures were observed as a dermoscopic pattern in 10 (10.0%) patients with POH. This shows a possible vascular contribution to pigmentation in a subset of individuals. The study by Ramakrishnan et al. showed vascular features such as dilated veins and telangiectasia in 50% and 32% of subjects, respectively.^[5]These findings show that vascular components, while less common, may play a role in the pathophysiology of POH and can be effectively detected via dermoscopy.

Analysis of lifestyle factors showed several significant associations. A history of smoking was reported by 18 (18.0%) participants and showed a statistically significant relationship with POH (p = 0.048). Although specific studies linking smoking directly to POH are limited, the association is biologically plausible.

As noted by Ortiz et al., approximately one-third of tobacco users exhibit visible oral pigmentation, underscoring the systemic pigmentary impact of tobacco exposure that may extend to periorbital skin as well. The thin, highly vascular periorbital region is particularly susceptible to such pigmentary changes due to repeated oxidative stress, dermal inflammation, and hypoxia caused by smoking.^[12]

Sarkar et al. also reported that several lifestyle factors, including smoking, stress, lack of sleep, and excessive alcohol use, may contribute to the development and exacerbation of POH. These factors are known to influence cutaneous circulation and melanin synthesis, either directly or indirectly. Smoking in particular contributes to vasoconstriction, collagen degradation, and accumulation of reactive oxygen species, all of which compromise skin integrity and pigmentation patterns.^[13]

22 (22.0%) participants reported alcohol consumption, but it was not significantly associated with POH in this study (p = 0.120). While alcohol is associated with facial flushing and vascular dilatation, its role in the pathogenesis of POH remains unclear, and current literature lacks direct evidence to support this association.

Sunscreen use was reported by only 30 (30.0%) participants and showed a statistically significant inverse association with POH (p = 0.032), showing a protective effect. UV radiation is a well-known trigger for increased melanogenesis, particularly in sun-exposed regions like the periorbital area. This finding is consistent with Sarkar et al.,^[13], who emphasised the role of photoprotection in reducing UV-induced hyperpigmentation, particularly in individuals with Fitzpatrick skin types III–V. Hence, routine sunscreen use may serve as an important preventive strategy for POH.

Sleep deprivation was another significant factor in this study. A total of 46 (46.0%) participants reported getting less than 8 hours of sleep daily, and this was significantly associated with POH (p = 0.008). Inadequate sleep is known to contribute to periorbital darkening due to vascular stasis, impaired lymphatic drainage, and skin thinning. Supporting this, Kim et al.^[14] found that poor sleep quality was correlated with increased severity of periorbital pigmentation.

Prolonged screen time (≥4 hours/day) was reported by 41 (41.0%) participants and was significantly associated with POH (p = 0.014). Excessive screen exposure may lead to digital eye strain, fatigue, and behavioural habits such as frequent eye rubbing, all of which can aggravate periorbital pigmentation. A recent study by Alnahdi et al.^[15] showed that increased screen time is linked to ocular surface irritation and visual fatigue, potentially contributing to secondary skin changes in the periorbital region.

Our findings show the multifactorial aetiology of POH, with significant contributions from vascular changes, UV exposure, lifestyle habits, and behavioural factors. Dermoscopy serves as a valuable, non-invasive tool to delineate vascular and pigmentary patterns. Targeted interventions addressing modifiable risk factors, such as improving sleep hygiene, reducing screen exposure, smoking cessation, and encouraging sunscreen use, may play a critical role in the prevention and management of POH.

CONCLUSION

In conclusion, POH was more prevalent among females and individuals with skin phototype V–VI, with the most common dermoscopic pattern being the pigment network. Significant associations were observed with lifestyle factors such as inadequate sleep, prolonged screen time, smoking, and lack of sunscreen use, showing the role of modifiable risk factors. Dermoscopy proved to be a useful tool in pattern recognition, particularly in relation to skin phototypes. These findings emphasise the need for preventive strategies and individualised management approaches.