Periorbital hyperpigmentation: Current treatment modalities with a spotlight on tranexamic acid

Abstract

Periorbital hyperpigmentation (POH) is a frequent, multifactorial dermatological state known by discoloration of the skin around the eyes, often resulting from dermal melanin deposition, hypermelanized basal layers, and vascular or structural factors. It affects both sexes, with a higher prevalence in females, possibly due to hormonal influences. Clinically, POH presents as brown-black pigmentation of the lower eyelids, giving a fatigued appearance, and careful examination is essential to differentiate true pigmentation from shadowing effects. A wide range of treatment modalities exists, including topically applied depigmenting agents (hydroquinone, tretinoin, kojic acid, azelaic acid, vitamin-derived agents), chemical peels, intralesional injections (fat grafting, soft tissue fillers, platelet-rich plasma, mesotherapy, botulinum toxin, tranexamic acid), and laser or microneedling therapies. The selection of treatment is determined by the underlying pathophysiology, skin type, patient tolerance, and desired outcomes. Combination therapies, targeting multiple mechanisms such as pigmentation, vascularity, and structural volume loss, often yield the most effective results.