|Year : 2021 | Volume
| Issue : 2 | Page : 153-160
A study on pattern of dermatoses affecting periorbital region and its clinicodermoscopic correlation
Namrata Bhavsar, Pragya Ashok Nair
Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad, Gujarat, India
|Date of Submission||21-May-2020|
|Date of Decision||07-Sep-2020|
|Date of Acceptance||23-Nov-2020|
|Date of Web Publication||26-Aug-2021|
Pragya Ashok Nair
Department of Dermatology and Venereology, Pramukhswami Medical College, Karamsad - 388 325, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The periorbital area may be affected by a vast number of dermatoses such as infectious or noninfectious diseases, inflammatory dermatoses, systemic diseases, drug reactions, benign and malignant lesions, and traumatic lesions, thus poses both diagnostic and therapeutic challenge. Objectives: To study the pattern of dermatoses involving periorbital region and to correlate its clinical and dermoscopic findings. Materials and Methods: A cross-sectional study was carried out in patients with periorbital dermatoses (PODs) attending the Department of Dermatology during April 2018–March 2019 after approval from the ethical committee. A detailed history was taken and investigations including hemoglobin levels, Vitamin B12, serum cholesterol, and wood's lamp examination were done as and when required. A prestructured pro forma was used to collect the data. Data were entered into Microsoft Excel 2010 and analyzed using EPI INFO. Ver7 software (Developed by united states of America centre for disease control. Results: A total of 275 patients were studied of which majority of patients belonged to the age group of 41–60 years (38.5%) with a female-to-male ratio of 1.16:1. The most common group of PODs was skin tumors (25.1%), followed by disorders of pigmentation (17.4%), infections (13.1%), and periorbital dermatitis (11.6%). Most common dermoscopy findings of PODs were as follows: (a) common seborrhoeic keratosis (CSK): comedone-like opening, fissures and ridges, and sharp demarcation; (b) verruca vulgaris: finger-like papilla, red brown dots in center of papilla; (c) periorbital hyperpigmentation: blotches, globules, exaggerated pigment network, and reticular vessels; (d) allergic dermatitis: patchy red dots, pinkish hue, and patchy scale; (e) senile comedone: comedone-like opening; and (f) xeroderma pigmentosus: orange–yellow homogenous structures. Conclusion: Periorbital region is an area of cosmetic concern. Dermoscopy improves the differential diagnosis of common PODs and its knowledge may aid to reduce unnecessary invasive procedures such as shaving or incisional biopsies which may lead to scarring.
Keywords: Blotches, common seborrheic keratosis, globules, periorbital dermatosis, periorbital pigmentation
|How to cite this article:|
Bhavsar N, Nair PA. A study on pattern of dermatoses affecting periorbital region and its clinicodermoscopic correlation. Clin Dermatol Rev 2021;5:153-60
|How to cite this URL:|
Bhavsar N, Nair PA. A study on pattern of dermatoses affecting periorbital region and its clinicodermoscopic correlation. Clin Dermatol Rev [serial online] 2021 [cited 2022 Aug 8];5:153-60. Available from: https://www.cdriadvlkn.org/text.asp?2021/5/2/153/324576
| Introduction|| |
The eyes along with periocular area are the focal point of facial expression. It not only conveys full range of human emotion but also has a significant impact on how one is perceived in terms of health and beauty. The periorbital area is also a very relevant esthetic unit of the face and is one of the first to show signs of aging, so it is frequently treated with cosmetic intentions. Periorbital dermatoses (PODs) are dermatological manifestations around the eyes, posing both diagnostic and therapeutic challenge for dermatologists. The similarity of symptoms in this area causes diagnostic dilemma and the anatomic features like thin skin of the eyelids and its proximity to the eyeball results in a therapeutic challenge. Although it does not cause morbidity, it can influence the quality of life due to easy visibility of the region which is cosmetically distressing. Some PODs are heralding features of underlying systemic diseases, so it helps in early diagnosis and treatment of underlying systemic conditions. Dermoscopy is a noninvasive, in vivo diagnostic technique which may confirm clinical diagnosis and avoid the need of biopsy. It helps to differentiate benign from malignant lesions and melanocytic from nonmelanocytic lesions. It can also be used to evaluate disease activity and treatment efficacy. As there is a lack of adequate data on the frequency and distribution of POD in India, this study was undertaken in our institute with the aim of characterizing the spectrum of POD and to correlate the clinical and dermoscopic findings.
| Materials and Methods|| |
The present study was a cross-sectional study carried out after Institutional ethical committee (IEC) approval during the period of 1 year from April 2018 to March 2019. Patients with dermatoses involving periorbital area alone or with other sites of the body of either sex or age group attending the department of dermatology were included in the study. They were informed about the project and written informed consent was obtained in vernacular language. A detailed history was taken, and a thorough local and systemic examination was carried out according to prestructured pro forma. Dermoscopic examination of each lesion was done using contact polarized dermoscope (DermaIndia) which has the magnification up to ×100. Investigations including hemoglobin levels, Vitamin B12, serum cholesterol, and Wood's lamp examination were done as and when required. Statistical analysis was performed using Epi Info Version 7 software. Mean and standard deviation was calculated for quantitative data. Qualitative data were presented as frequency and percentage and compared using Chi-square test. P ≤ 0.05 was considered as significant.
| Results|| |
Out of total of 275 patients with dermatoses affecting the periorbital region, 106 (38.5%) patients belonged to the age group of 41–60 years, followed by 78 (28.4%) patients in 19–40 years age group. Male-to-female ratio of 1.16:1 was seen with 148 (53.8%) females and 127 (46.2%) males.
About 95 (34.5%) cases had an occupation which involved indoor activities, followed by 59 (21.5%) cases who had an occupation which involved outdoor activities and 121 (43.0%) were retired or unemployed. Majority of 166 (60.36%) cases were asymptomatic, while 44 (16%) presented due to esthetic concern, 36 (13.09%) with pruritus, and 29 (10.54%) with redness.
Of 275 patients, 173 (62.9%) patients did not have any associated comorbidities, while 55 (20%) patients had hypertension, followed by 39 (14.2%) patients with diabetes mellitus. Forty-eight (17.4%) had an error of refraction, followed by lack of sleep in 24 (8.7%), history of smoking in 22 (6.5%), and cosmetic use in 19 (6.9%) patients as an aggravating factor.
A total of 195 (70.9%) patients did not have any ophthalmological complaint, while around 33 (12%) patients complained of watering of eyes, followed by 26 (9.5%) patients who complained of defective vision due to their skin lesion.
Amongst extra periorbital sites, the face was involved in 197 (71.6%) patients, followed by the neck in 21 (7.6%) and upper extremities in 17 (6.2%), while in 49 (17.8%) patients, exclusively periorbital region was involved.
The most common group of dermatoses encountered in our study was skin tumors in 68 (25.1%) cases, followed by disorders of pigmentation in 48 (17.4%) cases.
Of 275, 68 (25.1%) patients were found to have skin tumors, of which seborrheic keratosis was the most common, and common seborrheic keratosis (CSK) variant was seen in 28 (10.2%), followed by dermatosis papulosa nigra (DPN) in 21 (7.6%) patients. Syringoma was the most common appendageal tumor seen in 8 (2.9%) patients, followed by trichoepithelioma in 3 (0.4%) patients. Only a single case of pigmented basal cell carcinoma (BCC) was seen among malignant skin tumors.
Of infective conditions seen in 36 cases (13.6%) patients, 12 (4.5%) were of verruca vulgaris, followed by 10 (3.6%) pyoderma and 6 (2.2%) of molluscum contagiosum (MC).
Out of 275, 48 (17.4%) patients were diagnosed to have a disorder of pigmentation. Periorbital hyperpigmentation (POM) was seen in 29 (10.5%) patients, followed by vitiligo in 12 patients (4.4%).
Allergic dermatitis was the most common cause of periorbital dermatitis seen in 17 (6.2%) patients, followed by atopic dermatitis in 7 (2.5%) patients. Nevoid conditions were seen in 11 (4%) patients in which melanocytic nevi was seen in 8 (2.9%) patients, while 3 (1.1%) patients had nevus of Ota. Dermoscopic features of skin tumors, periorbital infections, disorder of pigmentation periorbital dermatitis, and nevoidal conditions are tabulated in [Table 1].
|Figure 1: Dermoscopic image of common seborrheic keratosis showing (a) fissures and ridges (b) fingerprint-like structures (green arrow)|
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|Figure 2: (a) Trichoepithelioma affecting the forehead, glabella, and inner canthus of eyes, (b) Dermatoscopy showing few arborizing vessels (red arrow), multiple milia-like cysts and rosettes with whitish background (black arrow)|
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|Figure 3: (a) Pigmented basal cell carcinoma below the right lower eyelid, (b) Dermoscopy of Pigmented basal cell carcinoma showing arborizing vessels (green arrow), blue–gray globules (blue arrow), blue–gray ovoid nests (red arrow)|
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|Figure 4: (a) Filliform warts affecting the left lower eyelid, (b) Dermatoscopy showing finger-like papilla (red arrow), Red brown dots in center of papilla (green arrow)|
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|Figure 5: Herpes zoster ophthalmicus affecting upper eyelid, inner canthus, and right side ofthe forehead|
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|Figure 6: (a) Periorbital melanosis in a young female, (b) Dermatoscopyof periorbital melanosis showing globules (green arrow) and exaggerated pigment network (black arrow)|
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|Figure 7: Dermoscopy of vitiligo showing perifollicular hyperpigmentation (black arrow) in a star burst pattern|
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|Figure 8: (a) Melanocytic nevus below the right lower eyelid, (b) Dermoscopy showing globules (blue arrow), bluish gray reticular, homogenous and globular pigmentation (red arrow)|
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Among 85 patients (45.5%) with miscellaneous conditions, senile comedones were seen in 30 patients (10.9%), followed by xanthelesma palpebrarum (XP) in 18 (6.5%) patients. Dermoscopic features of various miscellaneous conditions are tabulated in [Table 2].
|Table 2: Miscellaneous dermatoses affecting periorbital areas and their dermoscopic findings|
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|Figure 9: (a) Senile comedones over both eyelids, (b) Dermatoscopy of senile comedones showing comedone-like opening (red arrow)|
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|Figure 10: (a) Xanthelesma palpebrum over both upper eyelids, (b) Dermatoscopy of XP showing orange yellow homogenous structure (red arrow)|
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| Discussion|| |
The periorbital region is predisposed to multiple dermatoses which are very common disorders in all age groups irrespective of sex. The periorbital area owing to its easy visibility makes the condition psychologically distressing to the patient. The periorbital area may be affected by a vast number of dermatoses such as infectious or noninfectious diseases, inflammatory dermatoses, systemic diseases, drug reactions, benign and malignant lesions, traumatic lesions, and esthetic complications such as pigment dyschromia. Other dermatoses such as XP and vesiculobullous disorders are also frequently encountered in this area.
The dermatoses reported in our study were skin tumors (25.1%), followed by disorders of pigmentation (17.4%), infection (13.1%), and periorbital dermatitis (11.6%) which are comparable with other reported studies [Table 3].
|Table 3: Comparison of incidence of different periorbital dermatoses with other studies|
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The most common periorbital tumor encountered in the present study was CSK (10.2%), followed by DPN (7.6%). This was in consonance with the study of Indradevi et al., Besra et al., Nalini et al., Arjun et al., and Shetty et al.
Comedo-like (CL) openings, fissures and ridges (FR), and sharp demarcation (SD) were consistent findings on dermoscopy in CSK. DPN had characteristic CL and FR. Fingerprint (FP) and network-like (NL) structures were commonly seen in flat SK. These findings are consistent with the study reported by Rajesh et al.
Syringoma is a benign adnexal tumor of intraepidermal eccrine ducts, occurring frequently in women of 3rd and 4th decades. The most commonly affected area is the face, particularly the eyelid and periorbital regions. Studies reported syringoma as the second most common periorbital tumor with a higher proportion ranging from 5.3% to 10.9% which is higher than our study with 2% of cases.,,, Palpebral syringomas are a common cutaneous pathology in Down syndrome, but we did not observe any such association in the present study. Ankad et al. reported lesion of syringoma with light brown pigmentation with multifocal whitish areas and a delicate pigment network at the periphery, brownish pseudo network occupying whole lesion and tiny white dots which was also seen in our study.
BCC is the most common malignancy affecting the periorbital area worldwide, accounting for 80%–90% of all eyelid cancers in western literature. In the present study, only one patient had pigmented BCC on the left lower eyelid. Nalini et al. also observed pigmented and nodular BCC in 1.8% of patients. Dermoscopy findings of BCC in our study were consistent with those described in the literature.
Trichoepitheliomas are uncommon benign adnexal neoplasms that originate from the hair follicles. In the present study, arborizing vessels were present in all cases with other features like ivory white background, white globules, and homogenous brown structure. This features were consistent with the findings described by Navarrete et al.
In the present study, warts were the most common infection (4.0%), followed by pyoderma (3.6%). The most common periorbital infection in the study by Besra et al. was pyoderma (5.2%), followed by warts (3.6%), Indradevi et al. also reported a similar occurrence of periorbital infection in descending order of pyoderma (3.6%), followed by herpes zoster ophthalmicus (HZO) (2.3%) and warts (2.0%). Dermoscopy findings for verruca vulgaris were red dots (72.7%) and tadpole appearance (63.3%). A previous study also reported that the hallmark of plane warts was regularly distributed, tiny, red dots on a light brown to yellow background.
MC presenting as a single lesion or as several small, inflamed lesions is seen in 2.2% of cases of total 13.6% of infective conditions. In the present study, dermatoscopy showed crown vessels and polyglobular white–yellow structure in all cases. According to Lacarrubba et al. and Halias et al., dermoscopy of MC shows multiple, yellowish-white, lobulated, amorphous central structures surrounded by a crown of linear, fine, and sometimes blurred vessels, some of them branching. These vessels usually do not cross the center of the lobules., Ku et al. reported that large lesions showed typical polylobular structure and small ones showed four-leaved clover-like structures.
Borderline tuberculoid leprosy is the most common type of leprosy observed to affect the face presenting with large, well- to ill-defined hypopigmented patches. It is known for atypical presentations. In the present study, lesions of leprosy were characterized by yellow globules (100.0%) and decreased hair (66.7%). Balachandra A documented that dermoscopy of leprosy was characterized by white areas, yellow globules, linear branching telangiectasia, and decreased white dots as well as hairs.
HZO is characterized by reactivation of dormant varicella-zoster virus residing within the ophthalmic nerve. Dermoscopy revealed cloudy polyglobular structure and central brown dots in all cases. Dermatophytosis is a common infectious entity characterized dermoscopically by diffuse erythema (100%) and scaling (50.0%). Our findings were consistent with the ones described by Bhat et al.
Disorders of pigmentation
In the present study, disorder of pigmentation was seen in 17.9% of patients which included POM (10.5%), followed by vitiligo (4.4%), pityriasis alba (1.5%), and melasma (1.1%). Besra et al., Nalini et al., and Indradevi et al. reported similar results. Fatigue, lack of adequate sleep, excessive sun exposure, stress, aging, and emotional liability all may play a significant role in the development of POM.,
The most common pattern of pigmentation was mixed (48.2%), followed by epidermal (41.3%) and dermal (10.3%), which is comparable to the study by Ahuja et al. who reported mixed type of pigmentation in 52.0% of patients, epidermal type in 39.0% of patients, and dermal type in 9.0% of patients.
In the present study, Periorbital melanosis (POM) exhibited blotches (75.8%), globules (65.5%), exaggerated pigment network (41.3%), and reticular vessels (20.7%) in dermoscopy. These findings were in consonance with the study of Jage et al. where majority of the patients had multicomponent pattern and different patterns of pigmentation were blotches (30.0%), exaggerated pigment network (28.0%), coarse speckled (24.0%), fine speckled (20.0%), and globules (16%) with telangiectases (18.0%) and superficial dilated veins (20.0%).
In the present study, the most common dermoscopy findings in Pityriasis alba was the hypopigmented structure (100.0%) followed by scale (50.0%). Al-Refu et al. also observed similar dermoscopy findings.
The common allergens implicated in eyelid dermatitis from various studies include topical pharmaceutic products (antibiotics and corticosteroids), cosmetics (fragrance components, preservatives, emulsifiers, hair care, and nail products), metals (nickel), rubber derivatives, resins (e.g., epoxy resin), and plants. In the present study, the allergens implicated based on history were ophthalmic preparations (timolol eye drops, gentamicin, and ciprofloxacin ointment), eye makeup, and nail polish, but we could not confirm it by patch testing.
The prevalence of various types of dermatitis was different in previously reported studies. Airborne contact dermatitis (ABCD) (6.3%) was the most common dermatitis found in the study of R Indradevi et al., followed by atopic dermatitis (3.6%), allergic dermatitis (3.0%), and seborrhoeic dermatitis (1.3%).
Besra et al. observed that exogenous eczema (12.4%) was a more common cause compared to endogenous eczema (5.2%). The most common dermatitis was ABCD (8.0%), followed by atopic dermatitis (4.0%), allergic contact dermatitis (2.0%), and seborrheic dermatitis (SD) (0.8%) Allergic dermatitis (6.2%) was the most common cause of periorbital dermatitis, followed by atopic dermatitis (2.5%), ABCD (1.5%), and SD (1.5%), in our study
In the present study, red dots were seen in all cases of allergic dermatitis and ABCD. Exaggerated pigment network was also observed in one-fourth cases of ABCD. A pinkish hue was present in all cases of atopic dermatitis. SD was characterized by arborizing vessels and yellow scales in all lesions. Lallas et al. also reported that dotted vessels in patchy distribution (86.4%) and yellow scales (77.3%) were commonly seen in SD.
The periorbital region is a common site for the occurrence of certain nevoid conditions like nevus of Ota and port-wine stain. A total of 10.4% nevoid conditions were encountered in the study of Besra et al., of them, 8.4% had melanocytic nevi. The other nevoid condition was nevus of Ota (1.2%), port-wine stain as part of Sturge–Weber syndrome (0.6%), and verrucous epidermal nevus (0.6%). In the present study, melanocytic nevi were seen in 2.9% of cases, while nevus of Ota was seen in 1.2% of cases. Exaggerated homogenous pigment network and globules were observed in all cases of melanocytic nevi, whereas bluish-gray reticular and globular pigmentation was seen in nevus of Ota.
In the present study, miscellaneous conditions included senile comedones (10.9%), followed by XP (6.5%). In the study of Nalini et al., miscellaneous conditions were XP (4.6%) and periorbital edema (2.7%).
Milia are common benign keratinous cysts that occur most commonly on the face, particularly the eyelids and the cheeks. In the present study, milia were observed in the periorbital region in 2.2% of patients, while Nalini et al. observed it in 1.8% of cases.
Orange–yellow homogenous structure and the homogenous yellow–white structure was specific dermoscopy finding for XP and milia respectively.
In the present study, psoriasis was characterized by whitish scales and regular red dots in all cases. A previous study reported that the uniform distribution of the red dots within the lesion represents the dermoscopic hallmark of psoriasis. Light red background color and white superficial scales are also common dermoscopic findings of psoriasis. Trichotillomania was characterized by flame hair and perifollicular hemorrhage in 100.0% of cases. Histopathological correlation was not performed in all cases because of the esthetic concerns except in syringoma, trichoepithelioma, and BCC where diagnosis needs to be confirmed
| Conclusions|| |
Although not a cause of severe morbidity or mortality, POD is of cosmetic concern. This study analyses its behavior in a clinical setting by describing its basic demographic data and clinical presentation. Majority patients approached dermatologists for esthetic concerns. Dermoscopy aids in diagnosing common POD, which helps to reduce unnecessary invasive procedures such as biopsy as it may lead to scarring.
This is a hospital-based study with small sample size. Further community-based study with an adequate sample size should be conducted to evaluate the dermoscopy pattern of POD. Histopathological correlation was not performed in all cases. Collaborative study involving an ophthalmologist and dermatologist can have a broader view of dermatoses involving the periorbital area.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]