Ophthalmologist Miss Jennifer Doyle explores how to tailor topical skincare to achieve the best results in the delicate eye area.
Audrey Hepburn had it right when she highlighted the cosmetic importance of the periorbital area. One of her famous quotes said, “The beauty of a woman must be seen from in her eyes, because that is the doorway to her heart, the place where love resides.” This is reflected in the fact that blepharoplasty (eyelid surgery to remove excess skin/fat) is one of the most common surgical cosmetic procedures performed worldwide.1 Being one of the thinnest areas of skin found on the body, the periorbita is one of the first to show signs of ageing.2 This article explores how we should tailor our patient’s topical skincare to address the specific concerns of this delicate area.
Why periorbital skin needs care
The periorbital area is often one of the top areas patients will want to rejuvenate. Whilst there is a variety of modalities at an aesthetic practitioner’s disposal, from anti-wrinkle injections and dermal fillers to laser resurfacing or platelet-rich plasma (PRP), it is important for any practitioner to know what topical agents are available to stave off further ageing changes, or that can be used to augment the result of more invasive treatments.
When we think about aesthetic concerns in the periorbital area, the most common things that our patients complain about include dark circles, puffiness and fine lines and wrinkles. The appearance of this area can influence how others perceive your wellness or mood, so it’s no wonder this is a top area for concern.5
Whichever cosmeceutical skincare ranges you use in your clinic, you will notice that many formulate a line of products that specifically target the periorbital area. Why is this the case? Is it just a marketing gimmick? The periorbital skin is delicate, with eyelid skin being the thinnest found in the body, measuring on average 0.2mm in thickness.3 For comparison, the skin on the tip of the nose is typically 3.3 times thicker than the upper eyelid skin, and the skin of the brow/forehead is 2.8 times thicker.4 Its delicate nature, along with its proximity to the eye itself, means that caution must be used when applying topical agents.
When we think about the periorbital area, there is a variety of active products found in medical-grade skincare that can help to rejuvenate the area.
I firstly always recommend starting by ensuring that your patient is aware of the impact of ultraviolet (UV) exposure on skin ageing and is taking appropriate steps to protect their skin. Protecting the periocular skin from UV radiation follows the same principles as protecting the rest of the skin, however it is often neglected. This is evident in the burden of skin malignancies seen in this region.7 Many sunscreens may advise against use around the periocular region, especially avoiding contact with the eyes and eyelids for risk of irritation, should the product enter the eye. So, what are our other options and do they work? Over the years, we have become more conscious of protecting our eyes against UV exposure with sunglasses, but do they protect the periocular skin as well? Whilst conclusive evidence standardise what UV protection is advised for eyes,8 in general UV protection sunglasses do provide some protection to the periocular area.9,10 However, the amount of protection will depend on the size of the lens, distance from the face, as well as any reflection or scattered UV. Interestingly, antireflective coatings increase reflection of UV radiation to the eye and periocular skin.8Advising patients if they are outside in sunny conditions to supplement this protection with other methods such as sunhats can add further protection. I will now explore how products including retinoids, antioxidants, caffeine, growth factors and peptides can be used to actively rejuvenate the area.
It has long been known that retinoids can help improve fine lines, wrinkles and photoaged skin.11 A recent prospective study by Park et al. in 2016 looked at the efficacy at treating periorbital wrinkles specifically.12 Participants (n=19) applied 0.1% tretinoin cream each night to the right periorbital area for three months. Outcomes were assessed using digital photography, and blinded evaluation of these were carried out by five independent dermatologists, which found that wrinkles decreased by 21% after 12 weeks. The study compared the improvement in wrinkles from tretinoin use to fractional Er:YAG laser and intense pulsed light (IPL) therapy (treated to the left periorbital area for comparison), and found they all resulted in a similar degree of wrinkle improvement. Participants, when surveyed, indicated that they preferred the tretinoin as it was the most minimally invasive and convenient to use. Interestingly, this is in spite of the fact that seven out of 19 of the participants experienced adverse effects from the tretinoin; including erythema, burning sensation, peeling and pruritis. These symptoms were classed as mild in severity in all and did decrease towards the end of the treatment period.12
With more than 30% experiencing adverse effects from the tretinoin application, this highlights how delicate the skin is in the periorbital area. Studies such as this have contributed to many cosmeceutical companies developing retinoids of a lower strength, such as 0.1%, specifically marketed for use in the periocular area. One can also counsel your patients that as your skin becomes more accustomed to using the retinoid, the adverse effects are less likely;12 gradually increasing the usage of the retinoid can therefore help to minimise adverse effects. It is also important to advise patients to not get any of the product in the eye itself, as retinoids can cause damage to the surface of the eye.13,14
Vitamin C is an antioxidant that has been shown to not only reduce the appearance of fine lines and wrinkles by promoting collagen formation and scavenging free radicals, but also has a brightening effect on the skin by inhibiting melanogenesis.15 Skin tightness can also be improved, which could be useful with the under-eye area where increased laxity of the skin can lead to a baggy appearance.6 Other antioxidants include vitamin E, vitamin B3 (niacinamide) and green tea, all of which have an antiageing effect by scavenging free radicals. Whilst they are safe to use in the periocular area, dermatitis is a potential side effect, of which the patient should be warned.3
A range of cosmetic, as well as cosmeceutical eye products, contain caffeine but it is rarely found as the main sole ingredient. Have you ever wondered why? It is often claimed that caffeine can reduce puffiness of the under-eye bags. Boaventura et al. reviewed the supporting evidence and found that the clinical studies that evaluated the efficacy of caffeine in the periorbital area were often tested in conjunction with other ingredients (e.g. antioxidants).16 It is therefore difficult to evaluate what effect caffeine alone has on the area and calls for further research to be done to fully evaluate the benefit of topical application to the skin.
There is a wealth of evidence suggesting that growth factors and cytokines have a rejuvenating effect in improving wrinkles and repairing photodamaged skin.17-19 Hussain et al. evaluated their use in the periorbital area in 2008 and found that periorbital wrinkles improved by 33% on average over a six-month treatment period. They also carried out histological evaluation, which revealed an increased thickness of the epidermis, increased fibrocytes and fibroblasts, and a reduction in elastosis.20 Many other studies support that the use of growth factors in the periorbital area can improve the appearance of wrinkles in the periorbital area.21,22,23 Growth factors have also been used following blepharoplasty and shown to improve the incision scar appearance; this is thought to be due to the role they play in wound healing.24 Mild adverse events, including itching and redness of the skin, have been noted and patients should be warned about this on commencing treatment; these symptoms were found to resolve after discontinuation of the product.14 Ocular irritation has occurred if the cream inadvertently entered the eye, but no long term serious adverse effects have been found.21
Topical application of peptides has been shown to rejuvenate the skin by stimulating collagen and elastin production.3 They have even been advocated as a stand-alone treatment for the rejuvenation of the periocular skin.25 Reivitis et al. carried out a prospective study that specifically looked at the periocolar area in 2013, which evaluated the use of a topical treatment containing tripeptide and hexapeptide on 10 patients, twice daily over a 12-week period. They carried out evaluations using photography as well as patient questionnaires. After 12 weeks, they found a 41% improvement in periocular wrinkles, a 29% improvement in the under-eye hollows, 48% improvement on the under-eye bags and 39% improvement in dark circles. All patient questionnaires also noted an improvement in skin quality.25 You will note the small number of patients involved in this study, and this is not unusual. Peptide technology is relatively new and as interest grows, more research with larger study numbers are anticipated.
In summary, the periocular skin is delicate and is often one of the first areas to show the signs of ageing. Always ensure that your patients are aware of the impact of UV exposure and are taking appropriate measures to protect their periocular area, as it is often neglected. There is some evidence for the beneficial effect of active products including retinoids, antioxidants, caffeine, growth factors and peptides, but interest and research into the use of these products is always growing. Skincare ranges often have dedicated lines for topical treatments to the eye area, reflecting the different nature of the skin in this area. In general, advising patients to apply products sparingly to the periocular area given its small size and the thinness of the skin is advisable. Being aware that adverse effects may be accentuated in this area due to the delicacy of the skin and advising your patients of such is key. When thinking about active products like retinoids for example, you may find them in a lower strength, and can also advise your patients to gradually increase the frequency of their use to minimise adverse effects. Whichever of these products you choose to recommend to your patients, be aware that they can cause local irritation to the skin, or to the eye itself should it inadvertently enter the eye, and warn your patients of the above. Most adverse effects in the literature are limited to mild irritation, and reversed upon ceasing use of the product, which is also reassuring.