|Year : 2021 | Volume
| Issue : 3 | Page : 153-158
Cross-sectional pilot study of clinical and histopathological features of periorbital dark circles in South Asians
Tara Rao1, Allison L Wang2, Ildiko Polyak3, Jag Bhawan3, Amit G Pandya1
1 Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
2 Divison of Dermatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
3 Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts, USA
|Date of Submission||28-Apr-2020|
|Date of Decision||20-Jul-2020|
|Date of Acceptance||21-Oct-2020|
|Date of Web Publication||24-Nov-2021|
Allison L Wang
Divison of Dermatology, Cook County Health and Hospital Systems, 1950 W. Polk St. Chicago IL 60612
Source of Support: None, Conflict of Interest: None
Background: Periorbital dark circles are common in all races. Proposed causes include increased vasculature, tear-trough deformity, pigmentary demarcation lines, spongiotic dermatitis, lichenoid dermatitis, acanthosis nigricans, post-inflammatory hyperpigmentation, and heredity. Aims: To evaluate the clinical features and histopathological features of dark circles compared to nearby unaffected skin in South Asians. Methods: Clinical evaluation, skin biopsies, and narrow-band reflectance spectrophotometry of periorbital dark circles and nearby unaffected skin were performed on all subjects. Results: There was a positive correlation between the clinical severity of dark circles and increased melanin based on spectrophotometry. Histological evaluation showed increased dermal melanin content in dark circles compared to normal skin. Limitations: Single-center pilot study. Conclusion: Dark circles in this cohort of South Asians are associated with increased dermal melanin. Other contributing factors may include exaggerated tear trough depression, translucency of eyelid skin, and pigmentary demarcation lines.
Keywords: dark circles, melanin, melanocytes, periorbital, pigmentary demarcation lines, pigmentation, skin of color, South Asian
|How to cite this article:|
Rao T, Wang AL, Polyak I, Bhawan J, Pandya AG. Cross-sectional pilot study of clinical and histopathological features of periorbital dark circles in South Asians. Pigment Int 2021;8:153-8
|How to cite this URL:|
Rao T, Wang AL, Polyak I, Bhawan J, Pandya AG. Cross-sectional pilot study of clinical and histopathological features of periorbital dark circles in South Asians. Pigment Int [serial online] 2021 [cited 2022 Nov 30];8:153-8. Available from: https://www.pigmentinternational.com/text.asp?2021/8/3/153/330889
Key Messages: Periorbital dark circles are common but difficult to manage. Dark circles in South Asians are associated with increased melanin based on spectrophotometry. Histological evaluation revealed increased dermal melanin.
| Introduction|| |
Periorbital dark circles are a common complaint from patients presenting to dermatologists. Lesions are usually bilaterally symmetrical and tend to involve the lower eyelids more commonly than upper eyelids. Patients complain of a “tired, sad or hung-over” appearance [Figure 1]. Dark circles are commonly associated with aging or transient episodes of fatigue, illness, or dehydration. However, many individuals experience a fixed darkening that does not change over time. The exact cause of dark circles is often difficult to ascertain and the proposed causes include tear trough depression, venous congestion, acanthosis nigricans, and atopic dermatitis. Few studies have examined dark circles histologically. Although dark circles may appear in any racial/ethnic group, several authors have suggested that dark circles are more pronounced in certain ethnic groups, particularly Asians. The current study was undertaken to better understand the cause of periorbital dark circles in South Asians.
|Figure 1 Periorbital dark circles in a South Asian female giving a “tired, sad or hung-over” appearance.|
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| Methods|| |
Subjects were recruited via flyers at the University of Texas Southwestern Medical Center (UTSW), local South Asian grocery stores, and advertisement on a local Indian radio station. All subjects gave informed consent in this study, which was approved by the UTSW institutional review board. Inclusion criteria included age >18 years, South Asian descent (India, Pakistan, Bangladesh, Sri Lanka, and Nepal), and history of dark circles around the eyes for at least 1 year to exclude those with dark circles due to an isolated, acute, or self-limited event such as fatigue, dehydration, or illness. Those with a history of trauma to the orbit or treatment of dark circles were also excluded.
Subjects were asked about exposure to irritants, allergens, skincare regimens, and any current or past use of medications that are known to cause pigmentation. They were also asked how the dark circles affected their day-to-day life and to describe their personal opinion about their dark circles.
Subjects were examined by a dermatologist for the presence of hyperpigmentation, erythema, scale, lichenification, exaggerated tear trough depression, pseudo-herniation of orbital fat, and translucency of the lower eyelid skin. All subjects were scored for clinical severity of dark circles as 1 (mild), 2 (moderate), or 3 (severe).
A narrow-band reflectance spectrometer (Mexameter, Courage-Khazaka Inc., Cologne, Germany) was used to measure the intensity of pigmentation and erythema in affected and nearby unaffected skin in the temple region. Evaluation of erythema was performed to study the role of vascular congestion or inflammation in the affected skin. Three readings were recorded on the same site for both affected and unaffected skin, and the average of the three readings was recorded. The difference between the mean melanin measurements of the affected and nearby unaffected skin was recorded as the melanin index. The same was done for erythema readings.
A 2 mm punch biopsy was taken from affected skin as well as nearby unaffected skin in the temple region for histologic evaluation. Skin specimens were stained with hematoxylin and eosin as well as Fontana–Masson stain and rated by a dermatopathologist. Using the Fontana–Masson stained slides, a qualitative rating of epidermal and dermal melanin was conducted in a blinded fashion for both affected and unaffected skin with scores of 0 (absent), 1 (mild), 2 (moderate), or 3 (severe). The difference in scores of affected and unaffected skin was recorded for both epidermis and dermis.
| Results|| |
A total of 50 subjects were screened, of which 16 (nine males and seven females, mean age 40 years) matched the inclusion/exclusion criteria and consented to be in the study [Table 1]. The average age of onset of dark circles was 22 years and 81% (13/16) reported a family history of dark circles as well. The majority did not have any comorbidities and did not practice regular sun protection. None of the subjects reported present or past history of atopic dermatitis, any other form of dermatitis, or symptoms associated with the dark circles. None of the subjects had a history of lichen planus, lichen planus pigmentosus, or medication-induced pigmentation.
There was a spectrum of severity of dark circles among the enrolled subjects. Fourteen of 16 also had varying degrees of erythema. [Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7] are examples of various clinical presentations. One subject was noted to have prominent underlying blood vessels, which gave a blue-green color to the skin. Subjects with severe dark circles appeared to have lichenification of the eyelid skin on examination but there was no histologic correlation of this finding on microscopic examination. Nonpigmentary causes of dark circles included three subjects with exaggerated tear trough depression and six with translucent skin. No subject had herniation of the infraorbital fat pad. One subject showed extension of the dark circles coalescing with pigmentary demarcation line F on the cheeks.
|Figure 4 Periorbital dark circles in a South Asian male with underlying erythema.|
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|Figure 5 Periorbital dark circles in a South Asian male with prominent underlying vessels, giving a blue-green color to the skin.|
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|Figure 6 Periorbital dark circles in a South Asian male accentuated by exaggerated tear trough depression and appearance of lichenification.|
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|Figure 7 Periorbital dark circles in a South Asian male with extension to pigmentary demarcation line F on the zygoma.|
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The melanin index correlated with global clinical severity ratings of mild, moderate, and severe pigmentation. There was no correlation between the clinical severity of dark circles and the difference in erythema readings of the Mexameter between involved and uninvolved skin.
Histopathological evaluation showed varying degrees of melanin in both the epidermis and dermis. One-half of the subjects had no difference in qualitative evaluation of epidermal melanin between affected and unaffected skin. Of the remaining, seven had more epidermal melanin in the affected skin and one subject had less epidermal melanin. Fourteen (88%) had more dermal melanin in the affected skin compared to unaffected skin [Figure 8]. There was no evidence of acanthosis nigricans, vacuolar interface dermatitis, lichenoid changes, lymphocytic infiltration, spongiosis, or deposition of a drug or foreign body.
|Figure 8 Periorbital dark circle. Photomicrograph showing increased melanin in the dermis (Fontana–Masson stain, original magnification ×400).|
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Eleven of 16 subjects felt embarrassed or self-conscious in the past week because of dark circles. Nine subjects reported that dark circles affected their social or leisure activities. Furthermore, four of 16 subjects reported that dark circles created problems with partners or close friends. One subject stated, “I feel bad and aged. Also, people think that I am tired and stressed out.”
| Discussion|| |
Many causes of periorbital dark circles have been reported. However, only a few studies have sought to measure the degree of pigmentation in dark circles in subjects with skin of color to determine severity and location of increased pigmentation. In a previous study of Asian Indian patients with dark circles by Malakar et al., 17 of 100 patients underwent 2 mm punch biopsies of the dark circles. The specimens were qualitatively evaluated and reported to have variable degrees of melanophages in the upper dermis. A study of 82 patients with dark circles by Chatterjee et al. showed mixed dermoepidermal pigmentation being present in the majority (70.73%) and clinicopathological concordance for dermal pigmentation. A study by Watanabe et al. described the result of punch biopsies performed on 12 Japanese patients with dark circles. Biopsies were stained with S100 and Fontana–Masson, and all 12 cases showed dermal melanocytosis. Momosawa et al. examined the skin of 18 Japanese patients enrolled in a treatment study with a topical depigmenting cream and Q-switched ruby laser treatments for dark circles. Fontana–Masson staining showed epidermal and dermal pigment in all patients. In our study, Mexameter readings of melanin content correlated with ratings of clinical severity of the dark circles, confirming melanin as the cause of dark circles in our patients. Furthermore, dermal melanin was rated higher than epidermal melanin, suggesting the appearance of dark circles is predominantly due to dermal melanin.
The strong family history of dark circles in our subjects suggests a genetic component in the development of this disorder in many South Asians. Pigmentary demarcation lines, A–D, which are located on the on upper arms, lower limbs, and chest, respectively, are well described. Facial pigmentary demarcation lines F, G, and H have been described in Indian patients and also have a genetic component in their pathogenesis. Pigmentary demarcation line F causes darkening of the lateral cheek and periorbital skin and often occurs in conjunction with dark circles. In a study of 100 Asian Indian patients, aged 11 to 22 years with dark circles, 92% were found to have periorbital dark circles that were continuous with facial pigmentary demarcation lines on the side of the face. In our study, one subject had pigmentary demarcation line F contributing to his dark circles. Other pigmentary causes of dark circles include post-inflammatory hyperpigmentation due to atopic dermatitis and contact dermatitis, erythema dyschromicum perstans, and drug or heavy metal deposition.,, None of our subjects had spongiosis or changes of lichenification on histologic evaluation, helping to rule out these disorders.
Tear trough depression, pseudo-herniation of orbital fat, and translucent lower eyelid skin are nonpigmentary causes of dark circles. A deep tear trough, which is a hollowed area on the medial aspect of the inferior orbital rim, can give the appearance of a dark circle under the eyes. The tear trough deepens with loss of fat and cheek descent that occurs with age. Another nonpigmentary cause of dark circles is herniation of an orbital fat pad beneath the eye due to weakening of the surrounding muscle structures. This finding also was not seen in our cohort. Thin, translucent skin overlying the orbicularis oculi allows visibility of the subcutaneous vasculature and can give the appearance of dark circles. Only one subject in our study had this finding.
The impact of dark circles on quality of life (QOL) has yet to be determined. QOL studies in patients with other facial pigmentation issues, such as melasma and vitiligo have shown a significant, negative impact on QOL, including social life, recreation, and leisure activities., In our study, the patients reported a significant effect of dark circles on QOL, including embarrassment and feeling self-conscious in the past week due to dark circles. Nearly half of the subjects reported that dark circles affected their social or leisure activities. Not only did subjects feel “bad and aged,” but they also struggled with the perception of being “tired and stressed out,” all of which negatively affected their QOL.
Generally, treatments for dark circles include depigmenting creams and procedural interventions such as trans-conjunctival blepharoplasty, autologous fat transplantation, resurfacing lasers, and fillers. Home remedies abound as seen in a simple Internet search for “dark circles.” Of note, there is not one consistent treatment that offers complete resolution of dark circles in South Asians. This speaks to the largely epidermal nature of the aforementioned interventions whereas our findings show the major cause of dark circles may be increased melanin in the dermis, which is difficult to resolve with depigmenting agents. It also speaks to the multifactorial nature of the problem in affected patients. Clearly, better treatments for dermal pigmentation need to be developed.
A limitation of our study is the fact we used hematoxylin and eosin and Fontana–Masson stains, which can only show the pigment concentration due to free melanin inside melanophages and melanocytes, and was unable to determine if the dermal pigment increase is due to melanosis or melanocytosis. Future studies should use stains such as S-100 to further characterize melanocyte concentration, consider using dermoscopy to assess the depth of melanin deposition, and to find optimal methods to prevent and treat dark circles.
In summary, our study adds to the body of understanding of this common patient complaint in South Asian patients. As discussed, periorbital dark circles can occur for a wide range of reasons, and those reasons likely vary, depending on a patient’s exposure to UV light and racial/ethnic background. This understanding should help clinicians diagnose, counsel, and manage their patients who complain of dark circles, particularly South Asians.
This study was funded by an unrestricted grant from Mary Kay Incorporated.
Financial support and sponsorship
Conflicts of interest
The authors reported no conflicts of interest.
| References|| |
Epstein J. Management of infraorbital dark circles. Arch Fac Plast Surg 1999;1:303-7.
Ranu H, Thng S, Hog B, Burger A, Hog C. Periorbital hyperpigmentation in Asians: an epidemiological study and a proposed classification. Dermatol Surg 2011;37:1-7.
Clarys P, Alewaeters K, Lambrecht R, Barel A. Skin color measurements: comparison between three instruments: the Chromameter, the Derma Spectrometer and the Mexameter. Skin Res Technol 2000;6:230-8.
Malakar S, Lahiri K, Banerjee U, Mondal S, Sarangi S. Periorbital melanosis is an extension of pigmentary demarcation line-F on the face. Ind J Venerol Leprol 2007;73:323-5.
Chatterjee M, Suwal B, Malik A, Vasudevan B. A study of epidemiological, etiological, and clinicopathological factors in periocular hyperpigmentation. Pigment Int 2018;5:34-42. [Full text]
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 be successfully treated by Q-switched ruby laser. Dermatol Surg 2006;32:785-9.
Momosawa A, Kurita M, Ozaki M et al.
Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for periorbital skin hyperpigmentation in Asians. Plastic Reconstr Surg 2007;121:282-8.
Somani V, Razvi F, Sita V. Pigmentary demarcation lines over the face. Indian J Dermatol Venereol Lepro 2004;70:336-41.
Sardana K, Rajpal M, Garg V, Mishra D. Periorbital hyperpigmentation mimicking fixed drug eruption: a rare presentation of erythema dyschromicum perstans in a paediatric patient. J Eur Acad Dermatol Venereol 2006;20:1328-99.
Freitag F, Cestari T. What causes dark circles under the eyes? J Cosmetic Derm 2007;6:211-5.
Goldberg R, McCann J, Fiaschetti D. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstru Surg 2005;115:1395-1402.
Balkrishnan R, McMichael A, Camacho F, Saltxberg F. Development and validation of a health-related quality of life instrument for women with melasma. Br J Dermatol 2003;149:572-7.
Thompson A, Clarke S, Newell R, Gawkrodger D. Vitiligo linked to stigmatization in British South Asian women: a qualitative study of the experiences of living with vitiligo. Br J Dermatol 2010;163:481-6.
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