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| ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 4
| Issue : 1 | Page : 29-34 |
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A study of dermatoscopic pattern of periorbital hypermelanosis
Sonal K Ahuja, Ashish R Deshmukh, Shweta R Khushalani
Department of Skin & V.D, MGM Medical College & Hospital, Aurangabad, Maharashtra, India
| Date of Web Publication | 19-Jun-2017 |
Correspondence Address:
Ashish R Deshmukh
Department of Skin & V.D MGM Medical College & Hospital, N-6, CIDCO, Aurangabad, Maharashtra - 431 003
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2349-5847.208295
Background: Periorbital hypermelanosis is a condition characterised by bilateral homogenous, hyperchromic macules and patches, primarily involving the upper and the lower eyelids.
Aim: To study dermoscopic patterns of periorbital hypermelanosis.
Materials and Methods: The study comprised 200 patients, of age above 18 years, attending the Skin and V.D. Out Patient Department. Detailed history was noted in the proformas, and the dermoscopic finding in view of colour of pigment, pattern of pigment and pattern of blood vessel was noted with a Dermlite-3 model.
Result: Out of 200 patients, 78 (39%) had epidermal type of pigmentation, that is, light brown, 18 (9%) had dermal, that is, dark brown to grey and 104 (52%) had mixed type, that is, visible vascularity with epidermal type of pigmentation. Reticular pattern was the only type of vascular pattern which was observed in all mixed type of pigmentation.
Conclusion: Patients with periorbital hypermelanosis showed brown circles, with colours on dermoscopy from brown to grey based on the level of pigmentation and reticular type of vessel arrangement.
Keywords: Dermoscopy, hypermelanosis, hyperpigmentation, periorbital
How to cite this article:
Ahuja SK, Deshmukh AR, Khushalani SR. A study of dermatoscopic pattern of periorbital hypermelanosis. Pigment Int 2017;4:29-34 |
| Introduction | |  |
This study depicts the dermoscopic pattern of periorbital hypermelanosis. Periorbital hypermelanosis, also known as dark circles or idiopathic cutaneous hyperchromia of the orbital region, is characterised by bilateral homogenous, hyperchromic macules and patches, primarily involving the upper and the lower eyelids but also sometimes extending towards eyebrows, malar region and lateral nasal root, also defined as extension of the pigmentary demarcation lines-F of the face.[1] Females are more affected than males.[2] The pigmentation of the periorbital region depends on multiple factors: the amount of melanin deposited in the epidermis and dermis, the presence of periorbital blood vessels, reduced thickness of the epidermis (creating a translucent appearance that leaves deep structures visible − the thinnest epidermis of the human body is located in this region) and the genetic factors.[3] There are various etiological factors such as ageing, lifestyle, medications, hormonal, refractive errors, excessive subcutaneous vascularity, shadowing due to skin laxity, genetic,[4] atopy, exposure to irritants, recurrent and chronic factors (contact dermatitis, blepharitis, etc.)[3] or association with major or chronic illnesses.
Dermoscope is a non-invasive, diagnostic tool which visualises subtle clinical patterns of skin lesions and subsurface skin structures not normally visible to an unaided eye.
The basic principle of dermoscopy is trans-illumination of a lesion. A dermoscope consists of an achromatic lens. When incident light falls on skin, it undergoes reflection, refraction, diffraction and absorption. This principle has been harnessed to improve the visibility of subsurface skin structures by employing application of linkage fluids over the lesion to improve the translucency of the skin.
Dermoscope has been largely used in white-skinned individuals for the study of melanocytic nevi and melanoma.[5]
Dermoscopy[6] has been used as a tool in diagnosis of level of pigmentation, that is, epidermal or dermal in melasma. Its use in periorbital hypermelanosis has not been demonstrated yet.
Blood vessels are visible dermoscopically due to the haemoglobin they contain. Analysis of vessel pattern often serves as an additional clue to diagnosis, though the pattern of vessels is less specific than the pattern of melanin. The pattern of vessels is based on two things: type and arrangement of vessels in the lesion. Vessels may be seen as dots, clods, lines, looped, curved or serpentine, helical or coiled, whereas vessel arrangement can be appreciated as clustered, linear, centred, radial, reticular and branched [Figure 1],[Figure 2],[Figure 3]. | Figure 1: Pie chart explaining prevalence of epidermal, dermal and mixed type of pigmentation
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 | Figure 2: Diagrammatic representation of types of vessel in periorbital hyperpigmentation
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 | Figure 3: Diagrammatic representation of arrangement of vessels in periorbital hyperpigmentation
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We undertook a study to find out the dermoscopic patterns of periorbital hypermelanosis.
| Materials And Methods | | |
This was a single-centred, cross-sectional descriptive study aimed at studying the dermoscopic pattern of periorbital hypermelanosis in patients attending the Skin Out Patient Department. Ethical clearance of this study was obtained from the local review board, and informed consent of every patient was obtained. A total of 200 patients were enrolled for the study. Detailed information of each patient was taken based on history of chronic illness, occupational history, sleep habits, reading habits, drug history, family history, refractive errors, menstrual history and genetic history. All patients with periorbital hypermelanosis (POH) above the age of 18 were included in the study.
Grading of POH (done in comparison to surrounding skin) was done as follows:- 0–Skin colour comparable to other facial skin areas
- 1–Faint pigmentation of infra-orbital fold
- 2–Pigmentation more pronounced
- 3–Deep dark colour, all four lids involved
- 4–Grade 3+ pigmentation spreading beyond infra-orbital fold.
Digital photographs of the patient from forehead till the malar area of the face were taken without flash, keeping the place constant with a white background.
Dermlite-3 (DL3N; 3 Gen. Inc., 31521 Rancho Viejo road Suite 104, San Juan Capistrano, CA 92675, USA) was used for studying the pigment level and vascular cause of periorbital hypermelanosis. Dermlite-3 is a camera-compatible dermoscope designed to view skin lesions with higher magnification and clarity. A high quality, four-element, 25 mm, 10× lens with colour correction and reduced image distortion helps in giving an image rich in surface detail.
Dermoscopy was performed on all patients. Pictures of the patients of the periorbital region − left upper eyelid, left lower eyelid, right upper eyelid and right lower eyelid were taken with cross-polarised light with pigment boost to study the level of pigment, that is, whether it is epidermal, dermal or mixed type (i.e. epidermal or dermal with visible vasculature).
| Results | | |
A total of 104 (52%) patients had mixed type of pigmentation, that is, visible vascularity in reticular pattern arrangement and epidermal type of pigmentation [Table 1]; [Figure 1], [Figure 4],[Figure 5],[Figure 6],[Figure 7]], while 78 (39%) patients had epidermal type of pigmentation of homogenous and cobble stone type [[Figure 8],[Figure 9],[Figure 10],[Figure 11]] and 18 (9%) patients had dermal type of pigmentation, as multicomponent and pigment blotch pattern of pigmentation [[Figure 12],[Figure 13],[Figure 14]]. In the present study, 200 patients with periorbital hypermelanosis were included with detailed history and examination. Dermoscopic examination was done based on the proforma prepared, and pattern evaluation was done based on three factors: colour of pigment, pattern of pigment and pattern of blood vessel. Reticular pattern was the only type of vascular arrangement observed in all mixed type of pigmentation. | Figure 4: Dermoscopic picture of mixed type of pigmentation: epidermal pigmentation along with visible reticular arrangement of vessels seen
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 | Figure 5: Straight type of vessels with reticular pattern of vascular arrangement
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 | Figure 7: Dermoscopic picture of mixed type of pigmentation: epidermal pigmentation along with slightly visible reticular arrangement of vessels seen
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 | Figure 8: Dermoscopy picture of epidermal pigmentation showing homogenous type of light brown colour pigment of melanin in epidermis
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 | Figure 9: Epidermal pigmentation with cobble stone type of brown macules with central hypopigmentation showing melanin in epidermis around the infundibula
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 | Figure 10: Epidermal pigmentation with cobble stone type of brown macules showing melanin in epidermis
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 | Figure 11: Brown colour pigment with central hypopigmentation showing melanin in epidermis, homogenous and cobble stone type
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 | Figure 12: Dermoscopy picture of dermal pigmentation with speckled type of dark brown pigmentation, as multicomponent and pigment blotch pattern of pigmentation
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 | Figure 13: Dermal pigmentation with speckled type of dark brown and grey pigmentation, as pigment blotch pattern of pigmentation
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 | Figure 14: Dermal pigmentation with speckled type of dark brown pigmentation, as pigment blotch pattern of pigmentation
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Among the 200 patients, the prevalence of periorbital hyperpigmentation was seen in 169 females (84.5%) and 31 males (15.5%) [Table 2]. In addition, positive family history was seen in 163 (81.5%) patients, and negative family history was present in 37 (18.5%) patients [Table 3].
Under Wood’s lamp examination, dermal pigmentation was present in 140 (70%) patients, and epidermal pigmentation was seen in 60 (30%) patients [Table 4].
| Discussion | | |
In the present study, 200 patients of POH were included. Each patient had undergone dermoscopic examination, and it was observed that 78 (39%) patients had epidermal, that is, light brown colour of pigmentation, 18 (9%) patients had dark brown to grey colour of pigmentation and 104 (52%) patients had mixed type of pigmentation, that is, visible vascularity and epidermal type of pigmentation.
A study conducted by Gaón and Romero[3] examined 48 patients (40 women and 8 men) between 25 and 53 years old whose reason for consultation was periorbital hyperpigmentation. They performed clinical examinations with the naked eye under slight local traction, in addition to dermoscopic examination, finding 12 (25%) vascular type patients, 15 (31%) pigmented type patients and 21 (44%) mixed-type patients in the studied series. In the dermoscopic examination of patients with the vascular type, the authors found a diffuse erythema pattern or multiple thin blood vessels or a diffuse vascular network. In the pigmented type, it was possible to observe a pattern of multiple dots with different sizes and colours or a diffuse network of pigment. The mixed type was characterised by the combination of the patterns described above. Kittler[7] in his book on dermoscopy has mentioned pattern analysis for pigmented lesions. On that basis, we did a pattern analysis and observed that our patient with POH showed brown circles which correspond to melanin in the epidermis around infundibula, colours on dermoscopy like light brown and grey based on the level of pigmentation and reticular type of vessel arrangement.
A study was conducted by Sarkar et al.[8] on melasma update on the use of dermoscopy for the diagnosis of melasma. Lesions of melasma show diffuse reticular pigmentation in various shades of brown with sparing of follicular openings and depict the dermoscopic appearance of a patient with epidermal melasma. Dermal melasma shows diffuse dark brown to greyish pseudo-reticular pigmentation. Annular, honeycomb and arcuate structures may be seen.
Dermoscope can be used as a diagnostic modality and as a non-invasive tool for determining the level of pigmentation along with the estimation of presence of pigmentation whether it is due to melanin or vasculature. And therefore, the treatment of periorbital hypermelanosis depends upon the aetiology, with pigment managed by pigment reducing agents, laxity managed by lasers and radiofrequency. As in the case of vascular aetiology, depigmenting agents may not show a result.
The strength of this study is that, to the best of our knowledge, it is the first Indian study of dermoscopic pattern of periorbital hypermelanosis, with the limitation being that the histopathological correlation was not performed because of the aesthetic concerns.
As this is a pure clinical and non-invasive study which carries diagnostic and prognostic value for management of periorbital hypermelnosis, it can be included as a routine investigation for patients with periorbital hypermelanosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 3. | Gaón NQ, Romero W. Dermoscopy in periorbital hyperpigmentation: An aid in the clinical type diagnosis. Surg Cosmet Dermatol 2014;6:171-2. |
| 4. | Goodman RM, Belcher RW. Periorbital hyperpigmentation. An overlooked genetic disorder of pigmentation. Arch Dermatol 1969;100:169-74. |
| 5. | Hirmand H. Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg 2010;125:699-708. |
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| 7. | Kittler H. Dermatoscopy: An Algorithmic Method Based on Pattern Analysis. Vienna, Austria: Facultas WUV/Maudrich; 2011. |
| 8. | Sarkar R, Arora P, Garg VK, Sonthalia S, Gokhale N. Melasma update. Indian Dermatol Online J 2014;5:426-35. [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1], [Table 2], [Table 3], [Table 4]
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