Treatment of Periorbital Hyperpigmentation: A Narrative Review of the Evidence and an Etiology-Guided Framework

Ribhav Walia

doi:10.20944/preprints202609.1609.v1

Submitted:

18 September 2026

Posted:

18 September 2026

You are already at the latest version

Abstract

Periorbital hyperpigmentation (POH), commonly known as dark circles, is a highly prevalent, benign cosmetic concern with a heterogeneous etiology spanning constitutional (pigmentary), vascular, post-inflammatory, and structural (shadow/volume-loss) subtypes, which frequently coexist in the same patient. This narrative review draws on a literature search (PubMed, Cochrane Central and Google Scholar, conducted in September 2026) identifying 102 relevant sources spanning 1995–2026, of which 66 are directly cited, summarizing the evidence for each major treatment category, topical/cosmeceutical agents, chemical peels, laser and light-based devices, micro-needling, platelet-rich plasma (PRP), platelet-rich fibrin, carboxytherapy, dermal fillers, and autologous fat/nanofat grafting, organized around the presumed etiological subtype being treated. This review is an etiology-based framework to critically synthesize the treatment literature and distinguish replicated comparative evidence from isolated comparisons. Although improvement has been reported with many modalities, certainty remains limited by small samples, heterogeneous outcomes, inconsistent etiological classification, and short follow-up. We highlight replication of comparative trials with standardized outcome measures as the field's most pressing need.

Keywords:

periorbital hyperpigmentation

;

dark circles

;

infraorbital melanosis

;

periorbital rejuvenation

;

tear trough

;

skin pigmentation

;

etiology

;

treatment

Subject:

Medicine and Pharmacology - Dermatology

Introduction

Periorbital hyperpigmentation (POH) refers to increased pigmentation of the skin surrounding the eyes relative to the surrounding facial skin, most often affecting the lower eyelid (infraorbital) region, with a supraorbital (upper eyelid) variant also described.¹⁻³ It is extremely common, disproportionately reported by women, and although medically benign, it is a persistent source of cosmetic dissatisfaction that sustains a large commercial and clinical market, from over-the-counter eye creams to laser platforms, injectables, and surgical correction.¹·⁴

The term “periorbital hyperpigmentation” is used broadly in this literature to describe a visual phenotype of infraorbital darkness, but this phenotype is not always caused by true excess melanin. It is useful to distinguish periorbital darkness, the broader clinical appearance patients present with, from true hyperpigmentation or melanosis, which is one specific contributor to that appearance; visible vascular congestion and structural shadowing from volume loss can produce a similar visual effect without any true increase in pigment. Most classification schemes distinguish four broad mechanisms underlying this phenotype: constitutional (excess epidermal or dermal melanin, often with a genetic and ethnic predisposition), vascular (visible dilated or congested periorbital venous plexuses seen through thin eyelid skin), post-inflammatory (hyperpigmentation following eczema, allergic contact dermatitis, or eye rubbing), and structural or shadow-type (volume loss, tear trough deformity, or skin laxity that casts a shadow rather than reflecting true pigment change).¹⁻⁵ We use this four-category, mechanism-based framework here as a pragmatic organizing tool for treatment synthesis; classification systems for this condition differ across the literature, and this framework is not universally standardized.

Most patients present with a mixed picture rather than a single pure mechanism, which is a plausible contributor to why no single treatment reliably satisfies all patients.

This heterogeneity has not gone unnoticed: at least twelve reviews or consensus statements addressing POH treatment have been published since 2013^{1,2,3,4,6,7,8,49,50,51,52,53}, including a 2024 systematic review focused specifically on Fitzpatrick skin types IV–VI⁴⁹, a 2025 systematic review with meta-analysis pooling improvement rates across 33 studies⁵⁰, a 2025 systematic review focused specifically on PRP versus PRF for periorbital rejuvenation⁵², a 2026 multispecialty systematic review organized by anatomy-driven treatment selection⁵¹, and a 2026 global Delphi consensus statement on melanin hyperpigmentation disorders that includes dedicated POH treatment algorithms.⁵³

This article aims to use an etiology-based framework to critically synthesize the treatment literature and to distinguish replicated comparative evidence from isolated, single-trial comparisons, a question distinct from the pooled improvement-rate meta-analysis in reference⁵⁰ and complementary to, rather than competing with, the anatomy/modality-first organization used in references 50 and 51. Concretely, this review also (1) incorporates treatment-specific evidence published through 2026 that postdates most of the reviews above and (2) examines specifically whether individual head-to-head treatment comparisons have been replicated across more than one study, since this determines what can be said with any confidence about relative efficacy. Table 1 summarizes how this review relates to the existing review literature on POH treatment.

Literature Search

A literature search was originally conducted in PubMed, Cochrane Central, and Google Scholar in September 2026, using combinations of the terms “periorbital hyperpigmentation,” “dark circles,” “infraorbital hyperpigmentation,” “treatment,” and names of specific modalities (e.g., “laser,” “platelet-rich plasma,” “carboxytherapy,” “filler”), supplemented by hand-searching the reference lists of retrieved articles and citing articles. This yields a combined total of 102 sources identified as relevant, spanning 1995–2026 (Figure 1); of these, 66 are cited directly in this narrative synthesis, with the remainder consisting of additional case reports, conference proceedings, or sources whose findings substantially overlapped with an already-cited source on the same intervention. Given the heterogeneity of designs and outcome measures identified, this article synthesizes the evidence narratively by treatment category rather than through pooled statistical analysis; where a specific treatment comparison has been tested in more than one trial, this is noted explicitly, since this is where the evidence permits the strongest conclusions.

Topical and Cosmeceutical Agents

Topical agents are generally less invasive and are associated with fewer procedural risks than injectable or energy-based treatments, though they are not risk-free, allergic or irritant contact dermatitis and paradoxical pigmentation can occur, particularly in the thin periorbital skin. They are typically directed at constitutional (pigmentary) or mild vascular POH. A Brazilian herbal eyecare compound produced measurable reduction in periorbital hyperchromia and puffiness over 30 days in a controlled cosmetic trial.¹⁰ A topical eye cream containing low molecular weight heparan sulfate produced global periorbital rejuvenation, including pigmentation improvement, over 12 weeks.¹¹ A formulation derived from mesenchymal stromal cell conditioned medium reduced under-eye dark circles on both instrumental and investigator assessment in human volunteers.¹² A three-polymer interpenetrating humectant network improved periorbital skin hydration, evidence of a cosmetic hydration benefit rather than direct evidence of pigment reduction, though it may indirectly improve the appearance of fine lines that can accentuate shadow-type POH.¹³ A review of caffeine-containing cosmetic products concluded that, despite the marketing volume surrounding caffeine as an anti-dark-circle ingredient, direct evidence for a clinically meaningful pigment-reduction effect is more limited than for its decongestant/anti-puffiness action, illustrating that not every widely marketed topical claim is equally well supported.¹⁴ More recently, an exploratory single-arm trial of topical castor oil cream reported improvement in infraorbital hyperpigmentation, though as a single-arm, unblinded study this evidence is preliminary,⁵⁸ and a vitamin K (menadione)-incorporated chitosan/alginate hydrogel was proposed as a novel topical delivery vehicle for POH, with early formulation and small-scale efficacy data.⁶³ As a category, topical agents may reasonably be considered a first-line, adjunctive option for mild constitutional or vascular POH rather than a primary treatment for structural or deeply pigmented presentations. Nearly all supporting studies in this category are small, single-arm, and industry- or manufacturer-associated, without an untreated or vehicle-controlled comparison group, which limits how much weight these findings can bear.

Chemical Peels

Superficial chemical peels are directed primarily at constitutional (pigmentary) POH. In a three-arm randomized comparison, 20% glycolic acid peel produced greater improvement than 15% lactic acid peel or topical 20% vitamin C, but with a correspondingly higher rate of erythema and irritation.¹⁵ A follow-up trial by the same group comparing 12% ferulic acid peel against the same glycolic and lactic acid concentrations again found glycolic acid most effective, with ferulic acid offering a more favorable tolerability profile, positioning it as a reasonable option for patients unable to tolerate glycolic acid’s side-effect burden, particularly relevant in darker Fitzpatrick phototypes, where more aggressive peels carry a higher risk of post-inflammatory hyperpigmentation.¹⁶ Combined trichloroacetic acid (TCA) and lactic acid peeling produced favorable improvement in infraorbital dark circles across four weekly sessions in a case series.¹⁷ At the deeper end of the spectrum, a large multi-institutional retrospective series from the International Peeling Society reported durable improvement in constitutional periorbital dark circles following phenol-croton oil peeling, a medium/deep peel with a materially different downtime and risk profile than the superficial peels above, and one that requires more caution in darker phototypes.¹⁸ A light-device-based adjunctive approach was also reported effective for POH in a 2023 series.¹⁹ A more recent randomized comparison found mandelic acid peel produced greater improvement than topical 2% kojic acid for periorbital melanosis, with a more favorable tolerability profile than typically reported for glycolic acid, suggesting mandelic acid may offer a useful lower-irritation alternative within the peel category.⁵⁷ The head-to-head peel comparisons provide relatively stronger comparative evidence, being randomized and controlled, whereas the deeper phenol-croton and light-device-adjunctive approaches remain supported mainly by retrospective series without a comparator arm.

Laser and Light-Based Therapy

Laser and light-based devices constitute the largest and most heterogeneous evidence category. They can be grouped by their intended target: melanin-targeting devices for pigmentary POH, and vascular-targeting devices for vascular POH, with a separate group of resurfacing/remodeling devices acting through a less chromophore-specific mechanism. Among melanin-targeting devices, Q-switched ruby laser combined with topical tretinoin/hydroquinone bleaching produced excellent-to-good clearing of periorbital pigmentation in the majority of Japanese patients treated, with a low incidence of post-inflammatory hyperpigmentation.²⁰ A 694-nm fractional Q-switched ruby laser produced significant biometric improvement in infraorbital dark circles over three sessions.²¹ Dermal melanocytosis-type dark rings, a constitutional subtype more common in East Asian populations, responded well to Q-switched ruby laser in a dedicated Japanese case series, underscoring that Fitzpatrick phototype and pigment-cell distribution matter when selecting laser wavelength and fluence, more pigmented skin carries greater risk of post-treatment dyspigmentation and generally warrants more conservative settings.²² Low-fluence Q-switched 1064-nm Nd:YAG laser produced statistically significant improvement in melanin-index and skin-lightness parameters in a dedicated efficacy and safety study.²³ Among vascular-targeting devices, long-pulsed 1064-nm Nd:YAG laser, which targets hemoglobin rather than melanin, was reported effective specifically for venous-type infraorbital dark circles, illustrating the importance of matching device and target chromophore to the presumed etiological mechanism rather than defaulting to a single laser platform for all POH.²⁴ A non-ablative long-pulse 2940-nm Er:YAG laser was reported effective for broader periocular rejuvenation, including a pigmentary component.²⁵ Among resurfacing/remodeling approaches, fractional CO2 laser combined with topical tranexamic acid produced comparable physician-rated improvement to micro-needling with tranexamic acid in a randomized split-face trial,²⁶ and fractional CO2 laser combined with micro-needling and topical TCA produced a numerically greater complete-response rate than fractional CO2 laser alone in a comparative Iranian trial, though not all between-group differences reached statistical significance at every visit.²⁷ Fractional CO2 laser also produced greater physician- and patient-rated satisfaction than carboxytherapy in a randomized trial discussed further below.²⁸ More recently, combining Q-switched 1064-nm Nd:YAG laser with radiofrequency-assisted topical vitamin C delivery produced significant improvement in pigmented infraorbital dark circles in a 2024 prospective study,⁵⁴ a novel 1064-nm Nd:YAG laser using a 650-microsecond pulse duration was reported to provide a painless, downtime-free option for lower eyelid rejuvenation in a 2025 study,⁵⁵ and sublative fractional radiofrequency (a resurfacing modality using ablative micro-channels similar in principle to fractional laser) was reported to improve periorbital hyperpigmentation in a dedicated study, positioning it alongside fractional CO2 as a further resurfacing-based option. As with topical agents, the strength of evidence varies considerably by device: the randomized split-face comparisons (e.g., laser vs. micro-needling, laser vs. carboxytherapy) rest on controlled, comparative designs, while single-arm device series, including most of the newer 2024–2025 laser reports above, remain hypothesis-generating rather than confirmatory.⁵⁶

Micro-Needling, with or Without Radiofrequency or Trichloroacetic Acid

Micro-needling, alone or combined with radiofrequency (microneedle fractional radiofrequency, MRF) or topical TCA, is proposed to act through both direct pigment clearance and stimulation of dermal collagen and vascular remodeling, a proposed rather than directly demonstrated mechanism in the POH-specific studies below, potentially suiting it to mixed pigmentary-and-structural presentations. In a series of nine patients treated with three MRF sessions, colorimeter-assessed skin lightness improved significantly, alongside improvements in dermal density and elasticity on ultrasound and cutometer assessment.²⁹ Combined micro-needling with 10% TCA produced a fair-to-excellent response in the large majority of patients treated (92.3%), with only minor, transient side effects.³⁰ As noted above, micro-needling with tranexamic acid produced comparable physician-rated improvement to fractional CO2 laser with tranexamic acid in a randomized split-face comparison, suggesting micro-needling-based protocols may offer a lower-cost alternative to laser platforms for this specific indication.²⁶

Platelet-Rich Plasma, Plasma Gel, and Carboxytherapy

Autologous platelet-rich plasma (PRP), plasma gel, and subcutaneous carbon dioxide injection (carboxytherapy) are grouped together here because they have been directly compared against one another more often than any other pair of modalities in this literature, making this the category where the strongest comparative statements are possible. PRP produced significant improvement in infraorbital dark circles and crow’s feet wrinkles in an early dedicated efficacy study.³¹ Carboxytherapy alone, delivered as a three-session subcutaneous carbon dioxide protocol, was reported effective and well tolerated in a dedicated case series.³² Three separate split-face trials have directly compared PRP against carboxytherapy, with inconsistent rankings: one found carboxytherapy produced greater physician-graded improvement,³³ a second found PRP produced greater improvement on patient-rated vascularity/pigmentation scores,³⁴ and a third found PRP produced significantly greater histopathological melanin clearance, while patient-rated outcomes did not differ significantly between arms.³⁵ Across these three comparative studies, no consistent superiority of either PRP or carboxytherapy has been demonstrated, the direction of benefit differs by which outcome measure (physician grading, patient rating, or histopathology) each trial emphasized. Accordingly, current evidence does not support a confident efficacy-based preference between the two, and the practical choice between them may be more reasonably informed by tolerability: carboxytherapy is more consistently associated with transient inflammation/edema, while PRP is more consistently associated with pain, ecchymosis, and, in one series, a meaningful treatment discontinuation rate. Plasma gel produced greater improvement than standard PRP on both subjective and Antera 3D objective assessment in a comparative split-face study, though improvement was not maintained for either modality at three months,³⁶ while platelet-poor plasma gel produced greater improvement than standard PRP in a separate comparative dermoscopic study, a result that runs counter to the general assumption that higher platelet concentration confers greater benefit, and suggests the mechanism of these plasma-derived treatments for POH specifically may not be purely platelet-driven.³⁷ Chemical peeling produced significantly greater improvement than PRP for POH in a further comparative trial, reinforcing that relative efficacy between ostensibly similar minimally invasive categories should not be assumed without direct comparison.³⁸ Carboxytherapy has also been compared against laser platforms: fractional CO2 laser produced greater satisfaction than carboxytherapy in one randomized trial,²⁸ while carboxytherapy produced greater improvement than fractional Q-switched Nd:YAG laser, with fewer side effects and lower cost, in a separate trial, these two carboxytherapy-vs-laser comparisons used different laser platforms and are not directly reconcilable with one another, illustrating a broader pattern in this literature in which single trials of superficially similar comparisons (“carboxytherapy vs. laser”) in fact test different, non-interchangeable technologies.³⁹ Finally, in a three-arm comparison, mesotherapy produced significantly greater improvement than carboxytherapy or chemical peeling.⁴⁰ This category has also expanded to include platelet-rich fibrin (PRF), a related but distinct autologous platelet-derived product. A 2026 randomized split-face trial comparing PRP against PRF on periorbital skin quality found generally comparable outcomes between the two, mirroring the inconsistent-but-comparable pattern already seen for PRP versus carboxytherapy,⁶⁰ a finding a dedicated 2025 systematic review of PRP versus PRF for periorbital rejuvenation reached similarly, without identifying a consistent advantage for either.⁵² PRP has also been compared against non-plasma injectable protocols: PRP produced significantly greater improvement than combined tranexamic acid plus vitamin C mesotherapy in a 2024 split-site randomized trial,⁶¹ while a biofiller was reported superior to PRP mesotherapy in a separate comparative trial — together suggesting that PRP's relative standing depends heavily on which specific comparator and outcome measure a given trial selects, consistent with the broader pattern described above.⁶² Additional single-arm evidence for carboxytherapy specifically was reported in a 2024 study, consistent with the modality's established but comparator-dependent efficacy profile above.⁵⁹

Dermal Fillers and Volumizing Injectables

Fillers and other volumizers are directed specifically at structural (shadow/volume-loss) POH, where the visual darkness arises from tissue contour rather than true pigment excess; that is, they treat periorbital darkness rather than hyperpigmentation itself, and accordingly act through a fundamentally different mechanism than the pigment- or vessel-targeted treatments above. Hyaluronic acid filler placed in the tear trough is among the most extensively described interventions for structural POH: a large retrospective series of 303 consecutive treatments reported consistent temporary correction of the naso-jugal groove,⁴¹ and a further series describing an etiopathogenic-classification-guided cannula filling technique reported high patient satisfaction when filler selection was matched to the specific structural pattern present.⁴² A dedicated series on hyaluronic acid filler for tear-trough-deformity-induced periorbital melanosis similarly reported favorable outcomes, while also detailing management of filler-specific complications such as the Tyndall effect (a blue-grey discoloration from superficially placed product) and lump formation.⁴³ Beyond these two commonly reported complications, tear-trough filler carries a broader recognized risk profile that includes edema, contour irregularity, delayed-onset swelling, and, rarely, vascular occlusion with a risk of vision-threatening complications given the region's vascular anatomy; these risks warrant discussion with patients regardless of how well-tolerated most treatments are in practice. Injectable porcine collagen produced quantifiable, immediate correction of structural dark circles, with effect partially regressing over the following weeks, consistent with the expected resorption profile of a non-permanent volumizing agent.⁴⁴ The strongest single piece of evidence in this category is a prospective, multicenter, single-blind, randomized, controlled trial of a specific hyaluronic acid filler (VYC-15L) for infraorbital hollowing, which found significant improvement in both investigator- and patient-assessed Global Aesthetic Improvement Scale scores and patient-reported satisfaction relative to a no-treatment control group, a materially higher level of evidence than the retrospective and single-arm designs that otherwise dominate this category.⁶⁶ A cross-linked porcine collagen filler was similarly reported effective for combined dermatochalasis and POH in a 2025 quantitative assessment study,⁶⁵ and an injectable combining sodium hyaluronate with vitamin C, tranexamic acid, and glutathione was reported effective and well tolerated for pigmented dark circles in a 2025 study, illustrating a trend toward combining a volumizing vehicle with pigment-directed active ingredients in a single injectable.⁶⁴ As a category, fillers offer rapid correction of true volume-loss POH but carry technique-dependent risks that are largely distinct from those of the pigment- or vessel-targeted categories above, reinforcing that filler selection should be reserved for cases in which a structural, rather than purely pigmentary, component is clinically evident. The Volbella trial aside, this category rests mainly on retrospective series and complication reports rather than controlled comparative data.

Autologous Fat and Nanofat Grafting

Autologous fat grafting, and its mechanically emulsified derivative “nanofat,” combine volumization with proposed regenerative effects related to adipose-derived cellular and stromal components, a mechanism that remains largely theoretical in the POH-specific studies cited here rather than directly demonstrated, positioning this category between the purely volumizing fillers above and the purely pigment-directed treatments discussed earlier. Standard autologous fat transplantation was reported effective for infraorbital dark circles in an early pilot study, establishing proof of concept for this approach.⁴⁵ Nanofat injection specifically produced significant or moderate improvement in the majority of treated patients (70%) in a dedicated case series, with 80% patient satisfaction.⁴⁶ A short review of emulsified fat and nanofat concluded that, relative to conventional fat grafting, the finer particle size of nanofat reduces the visible lumping that can complicate structural correction of the thin infraorbital skin.⁴⁷ In a randomized single-blinded comparison, autologous nanofat transfer produced significantly greater improvement and satisfaction than PRP, suggesting that where a genuine volume-loss component is present, fat-based approaches may offer an advantage over purely regenerative injectables like PRP that lack a volumizing effect.⁴⁸

Etiology-Guided Treatment Selection

Synthesizing across the categories above, the evidence is broadly consistent with the mechanism-guided pattern summarized in Table 2. This framework is broadly consistent with, though independently derived from, the treatment algorithms in the 2026 global consensus statement on melanin hyperpigmentation disorders, which addresses POH as part of a broader classification of pigmentary conditions.⁵³ Because most treatment studies did not prospectively stratify participants according to a standardized etiological classification before assigning treatment, this framework should be regarded as an evidence-informed clinical synthesis rather than a validated treatment algorithm.

Evidence Gaps and Directions for Future Research

Several gaps remain apparent despite the volume of literature on this topic. First, formal etiological stratification before treatment assignment is rare; most studies enroll patients with POH broadly defined, limiting the strength of mechanism-specific conclusions such as those in Table 2. Second, direct head-to-head comparisons exist for only a handful of treatment pairs, principally PRP versus carboxytherapy and glycolic-versus-lactic-acid peel, and even within these, results are not consistent across trials, as detailed above. Third, outcome measures vary widely across studies (colorimetric indices, physician and patient global assessment scales, digital photography-based scoring, and histopathological melanin quantification), and these outcomes are not interchangeable: a treatment that produces greater physician-rated improvement is not necessarily the treatment patients rate as more satisfying, and studies that report a modality as “superior” should be read with the specific outcome measure in mind rather than as a general efficacy statement. Fourth, durability of improvement is inconsistently characterized: follow-up beyond six months is uncommon across all modalities, including PRP, carboxytherapy, fillers, fat grafting, laser, and peels, so it is often unclear whether reported improvement represents a lasting correction or a temporary effect. Finally, skin phototype is inconsistently addressed as a treatment-selection variable, despite its direct relevance to the risk of post-inflammatory hyperpigmentation with more aggressive peels and lasers in darker-skinned patients. Future research using a validated POH grading scale, standardized photography and colorimetry, predefined follow-up beyond six months, and stratification by both etiological mechanism and Fitzpatrick phototype would meaningfully strengthen this evidence base.

Ethics Statement

This is a narrative literature review; the author collected and analyzed no new human or animal data. Ethical oversight, institutional review board approval, and informed consent for the individual studies discussed herein are the responsibility of, and were addressed by, the original investigators of each cited study.

Limitations

This review has several limitations. The search was restricted to 3 databases (PubMed, Cochrane Central, and Google Scholar), supplemented by hand-searching, and was not designed to be exhaustive or independently reproducible as a systematic review, consistent with narrative review methodology. Only English-language sources were considered. The heterogeneity of POH definitions and outcome measures across the underlying literature precluded quantitative synthesis. The evidence base is dominated by small, often uncontrolled studies, and formal etiological stratification before treatment was rare, which limits the strength of the etiology-guided framework proposed here. Publication bias favoring positive results cannot be excluded. Finally, as with any narrative review, study selection and emphasis reflect the author's judgment rather than a pre-specified, reproducible selection algorithm.

Conclusion

Periorbital hyperpigmentation is addressed through a wide range of modalities, topical agents, chemical peels, laser and light-based devices, micro-needling, PRP and carboxytherapy, fillers, and autologous fat/nanofat grafting. Although improvement has been reported with many of these modalities, certainty remains limited by small samples, heterogeneous outcomes, inconsistent etiological classification, and short follow-up. Building on, and updating, at least twelve prior reviews and consensus statements on this topic, this review's contribution is not to propose a novel etiological classification, the 2026 global consensus statement now offers POH-specific subtype recommendations of its own, but to use an etiology-based framework to critically synthesize the treatment literature and to distinguish replicated comparative evidence from isolated, single-trial comparisons. Where comparative evidence exists, notably for PRP versus carboxytherapy, no consistent superiority of either approach has been demonstrated, and the practical choice between them is more reasonably informed by tolerability than by a confidently superior option. For most other comparisons in this literature, the evidence remains limited to a single trial. An etiology-informed approach is a clinically rational framework for treatment selection, although its effectiveness as a formal treatment algorithm remains to be validated in comparative, phenotype-stratified studies.

Declaration of the Use of Generative AI and AI-Assisted Technologies in the Research and Writing Process

During the preparation of this work, the author used Claude (Anthropic) in order to assist with literature synthesis, drafting, and organization of the manuscript text and tables. Following the use of this tool/service, the author reviewed and edited the content thoroughly and hereby declares full responsibility for the authenticity of the contents of this publication.

Funding

This work received no funding.

Conflicts of interest

The author declares no conflicts of interest.

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Figure 1. Distribution of sources identified during the narrative literature search and hand-search update, by treatment category (n=102 identified; 66 cited directly in this review). This figure is descriptive of the search yield and is not a systematic evidence map or quality-weighted synthesis. “Other” includes etiology-focused reviews, consensus statements, case reports, and combination-therapy studies not attributable to a single category.

Table 1. Prior reviews and consensus statements on periorbital hyperpigmentation treatment and how this review differs.

Review (first author, year)	Scope	What this review adds
Alsaad & Mikhail, 2013³	Etiology and treatment overview	Search extended over a decade further; adds comparative-trial evidence published since
Roberts, 2014²	Etiology, evaluation, and aesthetic treatment overview	Adds laser, PRP/carboxytherapy, and filler trials published 2015–2026
Sarkar et al., 2016¹	Comprehensive review, skin-of-color focus	Broader geographic/ethnic evidence base; explicit mechanism–treatment mapping
Taskin, 2015⁸	Etiology and difficulties in management	Adds a decade of subsequent device- and injectable-specific evidence
Agrawal, 2018⁷	Overview of management challenges	Adds comparative trials (PRP vs. carboxytherapy, peel-vs-peel, PRP vs. PRF) published after 2018
Michelle et al., 2021⁶	Systematic review of POH treatment (39 studies)	Adds 2021–2026 literature; examines which comparisons have been replicated more than once
Samaan & Cartee, 2023⁹	Periorbital vascularity, erythema, and hyperpigmentation	Broader scope across all POH mechanisms, not vascular/erythema alone
Park et al., 2024⁴⁹	Systematic review restricted to Fitzpatrick skin types IV–VI	Broader phototype range; not restricted to darker skin types alone
Pour Mohammad et al., 2025⁵⁰	First systematic review with meta-analysis (33 studies, pooled improvement rates by modality)	Organizes evidence by etiological mechanism rather than pooled improvement rate; examines replication of specific head-to-head comparisons, which meta-analytic pooling does not address
Sollitto et al., 2025⁵²	Systematic review restricted to PRP vs. PRF for periorbital rejuvenation	Places the PRP/PRF comparison within a broader etiology-guided framework across all treatment categories, not as its central focus
Beer et al., 2026⁵¹	Multispecialty systematic review (50 studies), anatomy-driven, modality-first organization	Organizes evidence by presumed etiological mechanism rather than by anatomic/modality category; a complementary rather than competing framework
Passeron et al., 2026⁵³	Global Delphi consensus across all melanin hyperpigmentation disorders, including a POH section	Focused specifically on POH rather than melanin hyperpigmentation disorders broadly; narrative literature synthesis rather than consensus methodology

Table 2. Etiology-guided approach to treatment selection in periorbital hyperpigmentation (evidence-informed conceptual framework, not a validated algorithm).

POH mechanism	Underlying process	Treatment options and evidence basis
Constitutional (pigmentary)	Excess epidermal/dermal melanin, often genetic/ethnic predisposition	Chemical peels — comparative RCT evidence (glycolic vs. lactic vs. ferulic/vitamin C/mandelic/kojic); Q-switched/fractional laser — mostly single-arm series; topical agents — mostly single-arm/mechanistic support
Vascular	Visible, congested periorbital venous plexus through thin skin	Long-pulsed Nd:YAG laser — single-arm series; carboxytherapy — comparative RCT evidence (mixed direction); topical vasoconstrictive agents — mechanistic/indirect support
Post-inflammatory	Prior eczema, allergic contact dermatitis, or chronic rubbing	Treat underlying dermatitis first — mechanistic/extrapolated; gentle peels — indirect evidence; cautious laser — indirect evidence with recognized risk of further post-inflammatory pigmentation
Structural (shadow/volume-loss)	Tear trough deformity, volume loss, skin laxity casting a shadow	Hyaluronic acid filler — multicenter RCT evidence for at least one product; calcium hydroxylapatite/porcine collagen — single-arm series; autologous fat/nanofat — comparative trial evidence vs. PRP; surgical blepharoplasty — mechanistic/extrapolated
Mixed (most patients)	Combination of the above	Combination therapy (e.g., laser + filler, or peel + micro-needling) — predominantly single-arm/comparative case series, individualized to the dominant component(s) present

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