CASE REPORT
Fractionated 1550-nm Erbium-Doped Fiber Laser for the
Treatment of Periorbital Hyperpigmentation
MEGAN NICOLE MOODY, MD, MPH,* JENNIFER M. LANDAU, BS,* LEONARD H. GOLDBERG, MD,*†‡§
AND PAUL M. FRIEDMAN, MD†‡§¶
The authors have indicated no significant interest with commercial supporters.
Periorbital hyperpigmentation is a commoncondition that involves darkening of the upper
and lower eyelid skin; it is often refractory to treat-
ment. Multiple treatment modalities have been
used for periorbital hyperpigmentation, including
bleaching creams, topical retinoic acid, chemical
peels, laser therapy, and surgical correction. Lasers
that have been used successfully include the
Q-switched ruby laser1,2 and an ablative carbon
dioxide (CO2) resurfacing laser,
3 yet they carry a
risk of postinflammatory hyperpigmentation (PIH).
Because of the complex etiology of the condition, a
combination treatment approach may be most
effective for targeting the contributing factors, such
as dermal melanosis, PIH from atopic or allergic
contact dermatitis, superficial vasculature, and skin
laxity.
Case Report
A 44-year-old Caucasian woman (Fitzpatrick skin
type II) with no significant past medical history pre-
sented for evaluation of acne scars and periorbital
irritation. According to the patient, she had under-
gone two courses of oral isotretinoin (Accutane)
6 years before presentation for acne; after finishing
the second course, she noted improvement of her
acne, accompanied by gradual and unremitting
swelling of her eyelids (facial swelling has been pre-
viously reported as a side effect of isotretinoin4).
She reported a prolonged history of “puffy eyelids”
and progressive darkening of the skin around her
eyes. She also reported multiple severe sunburns of
her eyelids when she was younger. On presentation,
she had significant bilateral periorbital splotchy
hyperpigmented macules involving her upper and
lower eyelids and her medial and lateral canthi. The
hyperpigmentation extended to a level of approxi-
mately 1 inch below her eyes (Figures 1 and 2A).
After a thorough evaluation, we decided on a series
of treatment sessions using a 1550-nm fractionated
erbium-doped fiber laser (Fraxel re:store, Solta
Medical, Haywood, CA). Over 4 months, she
received four treatments with the laser for her
eyelids and for acne scarring on her bilateral
cheeks. Before each treatment, the area was
cleansed with a mild soap (Cetaphil Gentle Skin
Cleanser; Galderma Laboratories, L.P.). Triple
anesthetic cream (benzacaine 10%, lidocaine 6%,
tetracaine 4%; New England Compounding Cen-
ter, Framington, MA) was applied to the treated
area for 1 hour before treatment with the1550-nm
fractionated erbium doped fiber laser (Fraxel re:
*Derm Surgery Associates, Houston, Texas; †Department of Dermatology, Weill Cornell Medical College, New York,
New York; ‡Department of Dermatology, Methodist Hospital, Houston, Texas; §Department of Dermatology,
University of Texas, Houston, Texas; ¶Dermatology and Laser Surgery Center, Houston, Texas
© 2011 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �
ISSN: 1076-0512 � Dermatol Surg 2011;1–4 � DOI: 10.1111/j.1524-4725.2011.02216.x
1
store). Eye shields were not used during the treat-
ment sessions. The technique used for the upper
eyelid skin was the same as that reported by Sukal
and colleagues5 for eyelid tightening; we instructed
the patient to keep her eyes closed while simulta-
neously retracting the eyelid skin over the orbital
rim for treatment.
Treatments sessions using the 1550-nm fractionated
erbium doped fiber laser used a 15-mm spot size
and four passes, for a total of 4.67–5.51 kJ (includ-
ing treatment of the entire face) at an energy fluence
of 70 J/cm2 (Table 1). Treatment levels ranged
from 10 to 11, corresponding to surface area cover-
age of 29–32%. The treatments were spaced at an
average of 4.8 weeks (range 3–6 weeks). A cooling
device (Zimmer Elektromedizin Cryo 5; Zimmer
Medizin Systems, Irvine, CA) was concomitantly
used to protect the epidermis and minimize patient
discomfort. After each treatment session, the
patient was counseled on strict broad-spectrum sun
protection using at least SPF 30 at all times and sun
avoidance if possible. Two months after the fourth
treatment, physician and patient noted significant
improvement of the periorbital hyperpigmentation
bilaterally (Figures 1B and 2B).
Discussion
Periorbital hyperpigmentation is a common prob-
lem that has multiple etiologies (Table 2), includ-
ing dermal melanosis, PIH from atopic or allergic
contact dermatitis (people with allergies tend to
(A)
(B)
Figure 1. Patient at baseline with periorbital postinflamma-
tory hyperpigmentation (PIH) (A) and at 2 months after
four treatments using a fractionated 1550-nm erbium-
doped fiber laser with significant improvement of the peri-
orbital PIH (B).
(A) (B)
Figure 2. Patient at baseline with periorbital postinflamma-
tory hyperpigmentation (PIH) (A) and at 11 months after
four treatments using a fractionated 1550-nm erbium-
doped fiber laser with significant improvement of the peri-
orbital PIH (B).
TABLE 1. Treatment Parameters
Session
Energy,
mJ
Treatment
Level Coverage,%
1 70 10 29
2 70 10 29
3 70 11 32
4 70 11 32
1550-NM ERBIUM-DOPED FIBER LASER FOR PIH
DERMATOLOGIC SURGERY2
rub and scratch the periocular region and may sub-
sequently develop an accumulation of fluid), super-
ficial location of vasculature, and skin laxity.6 The
condition may worsen with exhaustion and lack of
sleep.6 The complex nature of periorbital hyperpig-
mentation and lack of a clearly defined treatment
regimen creates a challenge for the treating physi-
cian. Multiple modalities have been used separately
and in combination to treat dark circles under the
eyes, with varying degrees of success, including
bleaching creams, topical retinoic acid, chemical
peels, lasers, and surgical excision. Because of the
complex etiology of the condition, many suggest a
combination treatment approach to target the vary-
ing causes.7 For example, one group recommends
the use of topical hydroquinone and tretinoin in
addition to Q-switched ruby laser sessions; they
postulate that these topical treatments not only
enhance treatment efficacy, but also lower the risk
for PIH secondary to laser treatments.8 Another
study used a CO2 laser followed by a Q-switched
alexandrite laser, effectively targeting pigmentation
in the dermis and epidermis.9
Because a multitude of factors cause periorbital
hyperpigmentation, the chosen treatment regimen
should encompass as many of these factors as
possible. The nonablative fractionated 1550-nm
erbium-doped fiber laser preserves the stratum
corneum while creating microscopic treatment
zones (MTZs) of thermal injury in the epidermis
and dermis. This modality has been proven to treat
a variety of conditions effectively, including photo-
aging, melasma, and acne scars. The laser functions
to eliminate melanin pigment from the epidermis
and dermis through a “melanin shuttle,” which
exudes the pigment from the skin through the
MTZs.10–12 Because dermal melanin deposition is
recognized as one of the main factors contributing
to periorbital hyperpigmentation, the 1550-nm
erbium-doped fiber laser is an excellent treatment
option because of its ability to reduce the overall
dermal melanin content. A second contributing
factor to periorbital hyperpigmentation is PIH from
trauma (rubbing or scratching) of the skin around
the eyes. Many lasers used today in dermatologic
procedures are highly successful for treatment of
dyschromia, yet they have the risk of causing new-
onset PIH or the exacerbation of existing PIH.
When considering this risk, laser therapy for PIH
must be approached with caution. Again, the 1550-
nm erbium-doped fiber laser remains an excellent
option, for it not only has a low risk for new-onset
PIH (0.73%),13 but it has also been used in the
treatment of existing PIH.14 A final factor to con-
sider when treating this multifaceted condition is
skin laxity, which has been reported to contribute
to the appearance of periorbital hyperpigmentation.
The 1550-nm erbium-doped fiber laser has been
shown to improve various aspects of photoaging
through stimulation of collagen formation, decreas-
ing skin laxity and diminishing the shadowing
effect that exacerbates the appearance of dark skin
around the eyes.11,12 We attribute the success of
nonablative fractional photothermolysis for treat-
ment of periorbital hyperpigmentation not only to
the ability to target dermal and epidermal melanin,
but also to its ability to tighten eyelid skin.
TABLE 2. Etiologic Factors of Periorbital Postinflammatory Hyperpigmentation
Dermal melanin deposition Shown histologically in multiple studies1,2,5
Postinflammatory
hyperpigmentation
Occurs secondarily to many inflammation-causing conditions that disrupt
the dermo-epidermal junction, including atopic dermatitis and contact
allergic dermatitis
Vascular pigmentation Occurs because of the superficial location of periorbital vessels
Skin laxity and
periocular rhytides
Photodamage and aging cause skin sagging and wrinkles, which create
a shadowing effect that heightens the appearance of darkened periorbital
skin
Periorbital edema Periorbital edema ? thickening of the dermis ? light diffusion alterations,
enhancing appearance of darked periorbital skin
MOODY ET AL
2011 3
The 1550-nm fractionated erbium-doped fiber
laser safely and effectively treated our patient’s
bilateral periorbital hyperpigmentation without
any complications. Larger prospective studies are
indicated to better determine the efficacy rate and
ideal treatment parameters for using this treat-
ment modality for periorbital hyperpigmentation.
References
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Address correspondence and reprint requests to:
Paul M. Friedman, MD, Dermatology & Laser Surgery
Center, 6400 Fannin St, Suite 2720, Houston, Texas
77030, or e-mail: drpaul@dermlasersurgery.com
1550-NM ERBIUM-DOPED FIBER LASER FOR PIH
DERMATOLOGIC SURGERY4