Bilateral homogeneous brown to black pigmentation is the hallmark of periorbital hyperpigmentation (POH), a frequent condition that mainly affects the lower eyelids but can also occasionally spread to the eyebrows, temporal regions, malar regions, lateral nasal root [1,2], and upper eyelids. It has a complex origin, is frequent in females, and begins in early adulthood [3]. POH is a dermatological disorder that is aesthetically noticeable, psychologically upsetting, and can have an impact on a person's quality of life (QoL).

By displaying subtle clinical patterns of skin lesions and subsurface skin structures that are invisible to the human eye, dermoscopy is a non-invasive diagnostic method [4]. POH is essentially a clinical diagnostic, and dermoscopy can be used as an extra tool to categorize the various POH patterns.

AIM OF THE STUDY: To study clinical and dermoscopic evaluation of periorbital hyperpigmentation in teaching hospital.

After approval from the institute ethical committee and written informed consent was taken from each patient before the start of the study.

Type of study: Prospective study

Duration of study: 2 years i.e., from to 2022 to 2024

Place of study: Department of Dermatology, VRK teaching hospital and Research hospital for duration of 2 years.

Sample size: Calculation was done using prevalence 84%13, confidence interval = 95% and margin of error=5%. A total of 85 patients were enrolled in this study.

Inclusion criteria

• Aged between 17 to 60 years.
• Patients with history of POH.

Exclusion criteria

• Those patients who were on topical medication for POH in the past four weeks.

METHODOLOGY

Following informed consent, the patient's demographic information, medical history, and disease-related clinical examination were recorded. Risk variables such as family history, sleep duration <6 hours, TV viewing <8 hours, stress, and eye-rubbing behavior were evaluated in all cases and controls. Comprehensive clinical examination to identify involvement of the upper, lower, or both eyelids and extension beyond the periorbital region; color of hyperpigmented areas (light brown, dark brown, red, or blue); presence of any ermatological disease or scar in the periorbital region; presence of any visible bulging; shadow effect; superficial visible vasculature (i.e., capillaries or veins) in the infraorbital region; pallor in the face, nails, and palms; any makeup on the face; and pigmentation in other facial features, such as freckles or melasma.

The diagnosis of periorbital melanosis was done clinically and the patients were classified according to the classification proposed by Ranuetal grading of POM [5] was done in comparison to surrounding skin as follows:

0 - Skin colour comparable to other facial skin areas,

1 - Faint pigmentation of infraorbital fold,

2 - Pigmentation more pronounced,

3 - Deep dark colour, all four lids involved,

4 - Grade 3+ pigmentation spreading beyond infraorbital fold.

All patients were examined with Wood's lamp to determine whether pigmentation is epidermal or dermal.

Eyelid stretch test was done to rule out the shadow effect.

Baseline investigations like complete blood count, serum TSH, SGPT, serum cholesterol, random blood sugar was done for all patients to identify the concomitant illnesses.

A Dermlite DL4 (3Gen, Inc., USA) dermoscope was used to do a dermoscopic examination of the periorbital region. There are no recognized tests or surveys to evaluate POH patients' quality of life. However, we utilized the MELASQOL scale 6 because this condition is similar to melasma in many ways.

Statistical analysis

SPSS version 20 was used to enter and analyze all of the data. All parametric variables had their mean and standard deviation determined, while all non-parametric variables had their frequencies and percentages determined. Multinomial logistic regression was used to examine the relationship between POM and other factors. The threshold for statistical significance was set at P<0.05

Table 1 : Age distribution

Figure-1: Bar diagram showing age distribution

In the present study  Of the 85 patients included in our study, The age of patients presenting with POH ranged from 17 to 70  years. The mean age of onset was 32.86 years. Most patients belonged to the 31-40 years age group (43.5%).

Figure-2: Pie diagram showing gender distribution

Females were predominant constituting 76.4% (65/85). Males 23.5%(20/85). Majority of the patients were housewives constituting 61.1% (52//85), followed by students 23.5% (20/85) , while  3.5% were businessmen(3/85) , 9.4%   were security guards(8/85)  and  2.3% (2/85)  were  teachers. 64.7% (55/85) Patients had a positive family history of POH.

According to   duration of periorbital pigmentation 58.8% (50/85) had  the complaint for more than 1 – 3 years, 41.1% (35/85%)had complaints 3-5 years.

According to   distribution of systemic illness: History of systemic illness (anemia, atopy, thyroid dysfunction, diabetes, or hypertension) was seen in 52.9% (45/85)  of cases (P = 0.0001). Atopy (P = 0.002) and anemia (P = 0.013) were most significantly associated with POH.

According to   distribution of site: The most common site involved were lower eyelids constituting 80% (68/85) followed by 20% involvement of both upper and lower eyelids (17/85)

Table 2: Distribution of clinical features.

Figure- 2: Bar diagram showing distribution of clinical features.

In our study Vascular POM (51.7%)  was found to be the most common type followed by constitutional (25.8%) , post-inflammatory (11.7%) and shadow type (9.4%) .

POH was not limited to the periocular area and extended to the cheeks. The patients had a linear extension of their hyperpigmentation of lower eyelids extending from the medial aspect of the eye along the nasojugal groove (a dividing line between the lower eyelid and cheek) toward the malar area and thus could be differentiated from the pigmentary demarcation lines.

Table 3: Distribution of Grading

In our study  25.8% (22/85) were classified as Grade I (light brown), 41.1%  patients (35/85) as Grade II (brown/dark brown color) and 27.0% patients (23/85) as Grade III (black color) of periocular skin  and Grade IV 5.8% (5/85).

Table 4 : Distribution of Dermoscopic examination

Figure-3: Bar diagram showing distribution of Dermoscopic examination

Dermoscopic patterns observed in POH include pseudoreticular (31.7%), blotchy (29.4%), superficial dilated veins (21.1%), speckled (12.9%), telangiectasia (3.5%) and reticulate (1.1%) patterns.

Figure-5: Dermoscopic examination images in cases of present study

Comparative studies related to age and gender distribution

In the present study, Patients who presented with POH ranged in age from 17 to 70. 32.86 years old was the average age at onset. The majority of patients (43.5%) were between the ages of 31 and 40.The majority were women, making up 76.4% (65/85) and men, 23.5% (20/85).

This is consistent with a study by Mostafa et al. [6], which found that the most prevalent age group affected was between 21 and 40 years old for both males and females. This is comparable to a study conducted in India by Sheth et al. [7], which found that the mean age affected was 28.18 years old (range = 8–50 years). The mean age impacted was 26.63 years for males and 28.61 years for females.

The majority of patients (76) in the Ashwini Mahesh et al. [8] study were female, and the typical age range was 16–25 years old. The average age in the Anu et al. [9] study was 29.03 years (SD +/- 7.9). The age group of 26 to 35 years old accounted for the bulk of cases (43%). In these instances, the male to female ratio is 1:3.34. The cases (n = 77) showed a female preponderance. Eleven males and 39 females participated in the Mithali et al. study [10]. It was discovered that POH was more prevalent in females than in males.

Comparative studies related to distribution of site of POH

In our study 20% of both the upper and lower eyelids were implicated, with the lower eyelids accounting for 80% of the involvement (68/85). These results contrasted with the Ashwini Mahesh et al. study [8], which found that the majority of patients had involvement in both eyelids (58%), with lower eyelids coming in second (28%).

Comparative studies related to distribution of family history of POH

A positive family history of POH was present in 64.7% (55/85) of the patients. A familial trait with variable gene expression and dominant autosomal inheritance has been noted in a small number of research. [11, 12]. Many workers have reported a comparable incidence of positive family history [13].

Comparative studies related to distribution of systemic illness

In the present study 52.9% (45/85) of cases had a history of systemic illness, such as anemia, atopy, thyroid dysfunction, diabetes, or hypertension (P = 0.0001). The two conditions most substantially linked to POH were atopy (P = 0.002) and anemia (P = 0.013). A research by Anu et al. found similar results [9].

Comparative studies related to distribution of clinical symptoms

The most prevalent type in our study was vascular POM (51.7%), which was followed by constitutional (25.8%), post-inflammatory (11.7%), and shadow type (9.4%).Similar results with constitutional type (77) and postinflammatory type (12) were noted in the Ashwini Mahesh et al. study [8]. In contrast, vascular POH (44%) was the most prevalent form in the Brinda et al. [14] investigation, followed by constitutional (33.2%), post-inflammatory (13.6%), and shadow type (9.2%).

Comparative studies related to distribution of grading of POH

Anu et al study Grade 4 was found to be the predominant grade, followed by grade 3 and grade 2, This was in contrast to  Ashwini mahesh et al [8] and Brinda et al study [14]  where majority of the patients had grade II  2 (47%) and (48.4%) POH respectively.

Comparative studies related to distribution of Dermoscopic pattern of POH

Pseudoreticular (31.7%), blotchy (29.4%), superficially dilated veins (21.1%), speckled (12.9%), telangiectasia (3.5%), and reticulate (1.1%) patterns were observed in our study's dermoscopic pattern.    pseudoreticular (74%), blotchy (71%), superficially dilated veins (46%), speckled (27%), zelangiectasia (7%), and reticulate (2%) patterns were seen in the study by Anu Geoge et al. [9]. We saw blotchy (19%), superficially dilated veins (72%), and pseudoreticular (100%) patterns in controls.

In the study by Ashwini Mahesh et al. [8] Of the 100 patients, 33 exhibited a mixed pigmentary-vascular pattern, 15 had vascular, and 52 had pigmentary. There were three subcategories of the pigmentation patterns: mixed (17%), dermal (14%), and epidermal (54%). The most prevalent vascular pattern (65%) was the reticular pattern.

The majority of patients (64%), in the study by Mithali et al. [14], exhibited multicomponent patterns, which comprised multiple patterns of skin alterations, pigmentation, and vascular. Blotches (30%), an enhanced pigment network (28%), coarse speckles (24%), fine speckles (20%), and globules (16%) were among the pigmentation patterns displayed by the dermoscopy.

A prevalent dermatological condition, especially in women, is peri-orbital hyperpigmentation. It is a complex problem that includes lifestyle choices, genetics, and some coexisting medical conditions. Classifying and grading the peri-orbital hyperpigmentation is crucial. Whether the pigment originates from melanin or the underlying vasculature, a dermoscope can assist identify its source? Because melanin-based pigment can react to pigment reduction drugs and laxity can be controlled with lasers and radiofrequency, this can also assist in tailoring the treatment to the etiology.

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