The First Systematic Review and Meta-Analysis of Pharmacological and Nonpharmacological Procedural Treatments of Dark Eye Circles (Periorbital Hyperpigmentations): One of the Most Common Cosmetic Concerns

Abstract

Background: A notable trend has been observed toward procedural interventions for periorbital hyperpigmentation (POH), with a variety of pharmacological and nonpharmacological treatment modalities being introduced. This systematic review aims to provide a comprehensive evaluation of these diverse procedural treatments for POH in the medical literature.

Method: A systematic search was performed in major databases up to 2023, and studies were evaluated for clinical improvement, patient satisfaction, and adverse events. The retrieved studies were categorized as lasers and light therapies, chemical peels, PRP, carboxytherapy, fillers and injections, microneedling, and combination therapies.

Results: A total of 33 studies involving 1320 patients were evaluated. The meta-analysis of improvement rates revealed that lasers (fractional CO₂ and Q-switched or long-pulsed Nd: YAG) and combination treatments (microneedling + chemical peels or fillers + lasers) demonstrated the highest efficacy, with 82% and 75% of patients experiencing excellent or good (> 50%) improvement, respectively. Chemical peels, carboxytherapy, and PRP were less effective, benefiting 63%, 54%, and 44% of patients in the same category, respectively. Although fillers and autologous fat injections showed marked improvement in 94% and 74% of patients, the comparison of their results was limited due to their representation by a single study in each category. Considering the meta-analysis of satisfaction rates, lasers and combination treatments also led, with 82% and 75% of patients expressing over 50% satisfaction with treatment, respectively. Adverse events were generally mild and transient across treatments. Common side effects of lasers included transient burning and erythema. The fractional CO₂ laser was associated with discomfort, pain, and edema, with a shorter duration of swelling and erythema when combined with PRP. Q-switched and picosecond Nd:YAG lasers had higher postinflammatory hyperpigmentation rates compared to carboxytherapy and the picosecond 755-nm laser. The most common adverse effect of chemical peeling was erythema, with glycolic acid showing the maximum incidence.

Conclusion: This systematic review reveals that lasers and combination therapies are the most effective and satisfactory treatments for POH, with generally mild and transient adverse events. However, further studies comprising larger sample sizes, multiple-arm designs, and longer follow-ups are needed to enable more robust comparisons.