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dark circles under eyes

Dark circles under eyes

Dark circles under eyes also known as “bags under the eyes”, periorbital hyperpigmentation, periocular hyperpigmentation, periorbital melanosis, dark circles, infraorbital darkening, infraorbital discoloration, or idiopathic cutaneous hyperchromia of the orbital region, are defined as bilateral, round, homogeneous pigment macules on the infraorbital regions 1, 2. Dark circles under eyes is a common condition encountered in dermatology practice 3. Dark circles under eyes happen when the skin beneath both of your eyes appears darkened. Dark circles under eyes is an ill-defined entity that presents as bilateral round or semicircular homogenous brown or dark brown pigmented macules in the periocular region 4. Dark circles under eyes can affect an individual’s emotional well-being and influence quality of life.

Dark circles under eyes are different from bruising around your eye from an injury or redness and swelling in one eye caused by an infection. Dark circles under your eyes usually are not a sign of a medical problem. Dark circles under eyes are caused by multiple etiologic factors that include being tired or by lack of sleep, genetic, excessive pigmentation, dermal melanin deposition, postinflammatory hyperpigmentation secondary to atopic or allergic contact dermatitis, periorbital edema, increases melanin and hemosiderin deposition, shadowing due to skin laxity and tear trough associated with aging, superficial location of vasculature, increased visibility of blood vessels and shadowing due to skin laxity 5, 6. Sometimes, what appear to be dark circles under your eyes may merely be shadows cast by puffy eyelids or hollows under your eyes that develop as a normal part of aging.

There is scarcity of data regarding the incidence and prevalence of dark circles under eyes due to its transitory nature and lack of reasonable etiological explanation 1. In an Indian study 7, it was found that dark circles under eyes was most prevalent in the age group of 16 to 25 years (i.e., 95 out of 200 patients [47.50%]). Among the 200 patients studied, it was more prevalent in women (162 [81%]) than men and the majority of the affected women were housewives (91 45.50%]) 7.

Some of the most common causes of true dark circles under eyes are:

  • Allergies
  • Bulging fat and muscle loss
  • Atopic dermatitis (eczema)
  • Contact dermatitis
  • Fatigue
  • Hay fever (allergic rhinitis)
  • Heredity
  • Increased pigmentation (melanin)
  • Loss of fatty tissue in the eyelid or around the eye
  • Puffy eyelids
  • Shadowing due to anatomic shape of the orbit
  • Skin pigment irregularities
  • Rubbing or scratching your eyes
  • Sun exposure, which prompts your body to produce more melanin, the pigment that gives skin its color
  • Skin changes that happen with aging
  • Thin, translucent skin

People who are prone to dark circles under the eyes include:

  • The elderly (but they are also a common complaint in adolescents)
  • People of non-white ethnic background
  • People with a genetic predisposition to dark circles under the eyes.

Dark circles under eyes usually aren’t a medical problem. If discoloration and swelling appear under just one eye and seem to get worse over time, talk to your doctor. Dark circles under eyes can be an extremely complex condition to treat. If you want a more lasting solution than concealers and over-the-counter creams can provide, see a dermatologist for advice. For dermatologists, dark circles around eyes fall among the most difficult complaints to address. In most cases, there is little information regarding th cause and no gold-standard treatment option 8.

A history and physical examination would certainly be required to make the best determination of what treatment would be best for you. Ethnicity, medications, medical conditions, etc. can have a role in the cause and treatment of dark circles around the eyes.

Depending on what’s causing the dark circles under your eyes, your doctor may recommend prescription creams or a combination of treatments to erase or reduce discoloration. Laser therapy or chemical peels can be helpful in some cases. Hollows that cause shadows can be smoothed with injectable fillers, and surgery can eliminate puffy lids.

Home remedies for dark circles under your eyes may be all you need to help manage dark circles under eyes.

Dark circles under eyes anatomy

Externally, the upper and lower eyelids span the superior and inferior orbital rims to the eyelid margin, respectively 9. Their most anterior layer is composed of thin skin with underlying orbicularis muscle. The orbicularis muscle is the primary protractor of the eyelid, aids in maintaining eyelid strength and tone (primarily in the lower lids), and is subdivided into a palpebral (pretarsal and preseptal) and orbital segment. The names of each division of the muscle are given based on the structures they overly. The orbicularis muscle and skin form the anterior lamella of the upper and lower lids. The posterior lamella of the eyelids changes in structure depending on location. In the upper lid it consists of the tarsus and palpebral conjunctiva inferiorly, and the conjunctiva and Müller’s muscle above the tarsus. In the lower lid the posterior lamella is composed of the tarsus and conjunctiva superiorly and continues as the lower lid retractors (capsulopalpebral fascia and
inferior tarsal muscle) and conjunctiva below. Figure 1 details relevant anatomical structures of the upper and lower lids.

A significant difference between upper and lower eyelid anatomy is that a primary function of the upper lid is to elevate the eyelid to allow a clear and full field of vision. As the lower lid lies below the visual axis, it inherently does not need or have this function. As such, there are two retractor muscles of the upper lid: the powerful levator muscle–aponeurosis complex and the sympathetically driven Müller’s muscle that acts as an accessory eyelid elevator. The previously mentioned inferior tarsal muscle in the lower lid is the analogue of Mueller’s muscle of the upper lid.

The orbital septum is a connective tissue structure arising from the arcus marginalis periosteum at the orbital rim and fusingwith the levator aponeurosis approximately at the level of the superior tarsus in the upper lid and with the lower eyelid retractors 5 mm below the tarsus in the lower lids. In the lower lid, the combined orbital septum–lower eyelid retractors continues to insert onto the inferior tarsus. In both the upper and lower lids, the eyelid fat lies posterior to the septum.

In the upper lid there are two fat compartments: medial (nasal) and central. The nasal fat pocket is denser,whiter, and contiguous with the deeper extra and intraconal fat compartments. Thus it is orbital fat in structure and composition. The central eyelid fat pad is less dense, yellower in color, and separated from orbital fat by the levator aponeuorsis. This is true eyelid fat. These differences are important and will be discussed further in the section of eyelid aging. There is no third fat pad in the upper lid. The lacrimal gland, which normally sits in a fossa situated on the posterior surface of the superolateral rim, can prolapse and clinically appear as eyelid fullness. This should not be mistaken for a fat pad.

As opposed to the upper lid, there are three fat compartments in the lower lid: nasal, central, and temporal. All three pads are in continuity and orbital in nature. The nasal and central fat pads are separated by the inferior oblique muscle, and the central and lateral pads by the arcuate ligament. The lower lid is suspended to the medial and lateral orbital rims by canthal tendons, with the lateral attachment 2 mm higher than the medial one, giving rise to the normal lateral canthal slant.

Evaluation and treatment of “dark circles” requires a thorough understanding of periocular anatomy, especially with respect to the tear trough, also known as the nasojugal groove, a natural depression that extends inferolaterally from the medial canthus to the midpupillary line. In most individuals, it is no longer than 3 cm. The continuation of the tear trough is the lid–cheek junction, also known as the palpebromalar groove, which begins at the midpupillary line and runs parallel to the orbital rim. In a study of cadaveric lower lid and midface dissections, it was demonstrated that the tear trough and lid–cheek junction correspond to the junction between the palpebral and orbital portions of the orbicularis oculi muscle. The skin overlying the palpebral orbicularis (lower eyelid skin) was thin and had no subcutaneous fat, while the skin over the orbital orbicularis (cheek skin) was thicker and was separated from the underlying muscle by the malar fat pad.

Thinning of the skin, atrophy of malar fat with age, and enlargement of the orbital bony space result in an increasingly hyperpigmented concavity at the medial border of the eyelid and cheek known as the tear trough deformity. Clinically, the severity of the tear trough deformity can be categorized into 3 classes based on the length of the defect. In class I patients, the hollowing is limited to the medial one-third of the orbit. Class II patients have a defect that extends to the midpupillary line, while class III patients have a full depression that continues circumferentially along the orbital rim. Severity of the tear trough deformity parallels malar fat atrophy. Therefore, as the midface becomes flatter, dark circles appear more prominent.

Figure 1. Eye anatomy

Eye anatomy

Abbreviations: ROOF = retro-orbicularis oculi fat; SOOF = suborbicularis oculi fat.

[Source 10 ]

Figure 2. Periorbital ligaments

Periorbital ligaments

Footnote: (A) Coronal view of the orbitomalar and zygomaticocutaneous ligaments. (B) Sagittal view of the three retaining ligaments of the midface: the orbitomalar ligament (OL), zygomaticocutaneous ligament (ZL), and masseteric cutaneous ligament (MCL).

[Source 11 ]

Figure 3. Nasojugal groove

Nasojugal groove

Footnote: Frontal view of a man with typical lid–cheek interface depressions.

Abbreviations: NJG = nasojugal groove, V deformity; OMG = orbitomalar groove.

[Source 9 ]

How to get rid of dark circles under eyes

There are a number of treatment options available for periorbital hyperpigmentation. Among the available alternatives to treat dark circles are topical depigmenting agents, such as hydroquinone, kojic acid, azelaic acid, and topical retinoic acid, and physical therapies, such as chemical peels, surgical corrections, and laser therapy, most of which are tried scientifically for melasma, another common condition of hyperpigmentation that occurs on the face. The aim of treatment should be to identify and treat the primary cause of hyperpigmentation as well as its contributing factors.

Mild to moderate dark circles under eyes often respond well to simple and inexpensive treatments, such as:

  • Get enough sleep or extra sleep. Although short nights don’t usually cause dark circles under eyes, a lack of sleep may make you paler, so shadows and circles you already have become more obvious.
  • Stop smoking
  • Sleep with extra pillows to elevate the head and reduce eyelid swelling. Elevate your head with two or more pillows to prevent puffiness that develops when fluid pools in your lower eyelids.
  • Massage temporary swelling while applying a cold compress
  • Cold compresses. Dilated under-eye blood vessels may contribute to dark circles under your eyes. Cold compresses also minimize the appearance of prominent blood vessels. Try holding a cold compress, a chilled teaspoon or a bag of frozen peas wrapped in a soft cloth against the area to make these vessels constrict.
  • Cosmetic camouflage. Make-up can be used to change the coloration of any exposed skin.
  • Light-reflecting concealers (these are often yellow or gold in color) covered by translucent face powder. These should be applied in the shadows, not on the puffy skin.

There are many home-made ingredients that can help make the dark circles less visible. For example it is said that putting teabags under the eyes, drinking plenty of fluids and a lot of rest can suffice.

Topical application of the gel containing 2% phytonadione, 0.1% retinol, 0.1% vitamin C and 0.1% vitamin E was fairly or moderately effective in reducing dark under‐eye circles, especially in cases of hemostasis, over a short treatment period in healthy Japanese adults  12. This treatment also slightly decreased wrinkles 12.

Preparation H (is a popular brand of medications used in the treatment of hemorrhoids) the version with phenylephrine HCl 0.25% will constrict the capillaries resulting in the temporary reduction of the appearance of dark circles 13. The cream has less petrolatum than the ointment which is important to avoid the greasy appearance.

Other vasoconstrictors such as tetrahydrozoline hydrochloride as found in Visine may offer similar temporary results. Use should be limited in order to avoid a rebound effect.

Dark circles under eyes classification

Recently, Huang et al 14 performed a clinical analysis and proposed classification on the basis of clinical pattern of pigmentation and vasculature. Dark circles under eyes was classified into pigmented (brown color), vascular (blue/pink/purple color), structural (skin color), and mixed type based on the clinical appearance assessed by the physician. The mixed type of dark eye circle included the following four subtypes: as pigmented-vascular (PV), pigmented-structural (PS), vascular-structural (VS), and a combination of the three.

Pigmented type (P) appears as infraorbital brown hue. Vascular (V) type appears as infraorbital blue, pink, or purple hue with or without periorbital puffiness. Structural type (S) appears as structural shadows formed by facial anatomic surface contours. It can be associated with infraorbital palpebral bags, blepharoptosis, and loss of fat with bony prominence. Mixed type (M) combines two or three of the above appearances. This classification can help in introducing the therapeutic modalities on the basis of dark circles under eyes type, as different types of dark circles under eyes respond to different types of treatment.

Dark circles under eyes causes

There are very little scientific data available on the clinical profile and pathogenesis of dark circles under eyes 1. Various exogenous and endogenous factors are possibly implicated in its pathogenesis. The causative factors include genetic or heredity, excessive pigmentation, postinflammatory hyperpigmentation secondary to atopic and allergic contact dermatitis, periorbital edema, excessive vascularity, and shadowing due to skin laxity and tear trough associated with aging 1.

Pigmentation under the eyes is associated with dermal deposition of melanin. Dermal melanin deposition is often due to post-inflammatory pigmentation, which may follow:

  • Sun exposure
  • Atopic dermatitis
  • Contact dermatitis
  • Rubbing or scratching the eyes.

Loss of fatty tissue in the eyelid or around the eye (tear trough) is associated with:

  • Ageing. The hollowness around the eyes can be inherited but it is almost always worsened by continued fat loss around the eyes/face that occurs in the aging process. take this analogy: the face is like a balloon, except it is filled with fat instead of air; when air is taken out of a balloon, the balloon deflates with resultant saggy hollow tissue; the same can be said of the face except it is fat that is melting away with age. adding volume in these hollow areas around the eyes (and face) can help create more youthful, rested appearance with natural results.
  • Genetic factors
  • Smoking.

Bulging or puffy eyelids may be due to systemic conditions, particularly:

  • Thyroid disease
  • Anemia
  • Dermatitis
  • Hay fever (allergy).

Thin translucent skin is commonly observed with:

  • Age
  • Genetic factors.

Shadowing is more noticeable at times, due to:

  • Fatigue or lack of sleep
  • Periorbital edema (puffy eyelids)
  • Dehydration (sunken eyes).

Superficially located blood vessels and blood stasis may contribute to the darkened appearance.

Environmental causes

Ultraviolet radiation aggravates dark circles under eyes 15 and some lifestyle factors may contribute to developing dark circles under eyes, including lack of sleep, stress, alcohol overuse, and smoking, although not clinically substantiated 16.

Genetics

Periorbital hyperpigmentation is considered to have a genetic basis. Goodman and Belcher 17 reported many families with pigmentation around the periorbital area in several members of the family. Some were mildly affected and some severely affected. Many of them recognized the pigmentation early in childhood and stated that pigmentation increased with age. They were also aware that stress made pigmentary changes more intense, while rest and good health seems to produce lessening of color 17. Gellin et al reported a familial case in which 22 members were affected in six generations that had a genetically determined form of hyperpigmentation involving the periorbital area 17.

Periorbital pigmentation due to dermal melanocytosis. Dermal melanocytosis is characterized by the presence of melanocytes in the dermis. Clinically, these lesions are recognizable by their distinctive grey or blue-grey appearance. Dermal melanocytosis causing periocular hyperperpigmentation can be due to congenital or acquired causes 18. Dermal melanocytosis can be placed into the pigmentary class of Huang et al’s classification 14.

Nevus of Ota, also known as oculodermal melanocytosis or nevus fuscocaeruleus ophthalmomaxillaris, is a type of congenital dermal melanocytosis that involves the areas innervated by the first and second divisions of the trigeminal nerve. It appears as speckled or mottled brown-grey to blue-black patches that may involve the skin, conjunctiva, sclera, tympanic membrane, or oral and nasal mucosa of the affected dermatomes. If it is located infraorbitally, it can be a cause of periorbital hyperpigmentation.

Nevus of Hori was first described in 1984 by Hori et al 19 and is defined as acquired, bilateral nevus of Ota-like macules. Clinically, it presents with blue-brown to slate-grey mottled hyperpigmentation with a predilection for the malar region, which may extend to involve the periocular area causing dark circles. A distinct lack of ocular or mucosal involvement differentiates the nevus of Hori from other forms of dermal melanocytosis. Reports have linked sun exposure, hormonal changes in pregnancy, and chronic atopic dermatitis to occurrence of nevi of Hori 18.

Postinflammatory hyperpigmentation

Excessive pigmentation can also be due to postinflammatory hyperpigmentation secondary to atopic and allergic contact dermatitis and other dermatological conditions (e.g., lichen planus pigmentosus) and can be drug induced, such as in the case of fixed drug eruptions and erythema dyschromium perstans (Figure 5) 20. Periorbital hyperpigmentation can be caused by rubbing and scratching of skin around the eyes and by accumulation of fluid due to allergy as in atopic dermatitis and allergic contact dermatitis.

Figure 5. Periorbital hyperpigmentation due to postinflammatory hyperpigmentation

Periorbital hyperpigmentation
[Source 1 ]

Superficial location of vasculature

Superficial location of vasculature and thin skin overlying the orbicularis oculi muscle is another common cause of periorbital hyperpigmentation 16. Superficial location of vasculature usually involves the entire lower eyelids with a violaceous appearance due to prominent blood vessels covered by a thin layer of skin, more in the inner aspect of the eyelid, and is usually accentuated during menstruation. When the lower eyelid is manually stretched, the area of darkness spreads out without blanching or significant lightening and results in deepening of violaceous color, which could be used as a diagnostic test to confirm the vascularity 4.

Tear trough depression

Tear troughs represent an anatomical location that becomes depressed with age, centered over the inferio-medial orbital rim. It is an age-related change. It occurs mainly because of loss of subcutaneous fat and thinning of overlying skin of the orbital rim ligaments, combined with cheek descent, conferring hollowness to the orbital rim area. A combination of the hollowness and the overlying pseudoherniation of the infraorbital fat accentuate the shadowing in the tear trough causing dark circles, depending on the lighting condition (Figure 6) 16.

Figure 6. Tear trough deformity presenting as dark circles

tear trough deformity presenting as dark circles under eyes
[Source 1 ]

Extension of pigmentary demarcation lines of face

Pigmentary demarcation lines (PDL) are borders of abrupt transition between hyperpigmented skin and lighter areas. According to the site, they have been labeled A to H lines. F and G types are present over the lateral side of orbit and present as V-shaped and W-shaped patches, respectively (Figure 7) 21. In a study by Malakar et al. 21, 100 Indian patients with a diagnosis of darker circles were evaluated. Their results showed that in 92 percent of study patients, periorbital melanosis was an extension of the pigmentary demarcation line over the face.

Figure 7. Periorbital hyperpigmentation with pigmentary demarcation line (G type)

Periorbital hyperpigmentation with pigmentary demarcation line

Allergies, asthma, and eczema

Any condition that causes the eyes to itch can contribute to darker circles due to rubbing or scratching the skin around them. Hay fever sufferers particularly will notice under-eye “smudges” during the height of the allergy season. Some food allergies can also cause the area under the eyes to appear darker 22.

Medications

Any medications that cause blood vessels to dilate can cause circles under the eyes to darken. Because the skin under the eyes is very delicate, any increased blood flow shows through the skin.

Ocular hypotensive drugs or prostaglandin analogues, such as latanoprost and bimatoprost, which are used as ocular hypotensive eye drops in patients with glaucoma, can also cause periorbital hyperpigmentation 23. Patients develop periocular hyperpigmentation most frequently between 3 to 6 months of initiating bimatoprost therapy. Complete reversal of pigmentation occurs after discontinuation of bimatoprost 24. It was reported that the increased melanogenesis in dermal melanocytes and increased transfer of melanin granules to basal epidermis is the likely mechanism of bimatoprost-induced hyperpigmentation.

Anemia

The lack of nutrients in the diet, or the lack of a balanced diet, can contribute to the discoloration of the area under the eyes. It is believed that lack of mineral iron can cause dark circles as well. Iron deficiency is the most common type of anemia and this condition is a sign that not enough oxygen is getting to the body tissues.

The skin can also become more pale during pregnancy and menstruation (due to lack of iron), which again allow the underlying veins under the eyes to become more visible.

Fatigue

A lack of sleep or excessive tiredness can cause paleness of the skin, which again allows the blood underneath the skin to become more visible and appear more blue or darker.

Some skin care experts say that fatigue has nothing to do with the dark circles, but it has to do with when one lies down. Gravity can cause fluid to collect in the lower eye lid.

Age

Dark circles are likely to become more noticeable and permanent with age. Excess folds of skin under the eyes will also make dark circles more pronounced.

Medical conditions

Another cause may be bad blood circulation. Cardio exercise increases blood circulation and may help the dark circles to disappear.

The area directly located under the eyes are closely related to kidneys and liver, so the appearance of dark circles may indicate problems or weakness in the kidney or liver activity.

Dark eye circles could be a sign of excessive loss of water from the body (dehydration).

Periorbital edema

The eyelid region has a spongy property, which can lead to fluid accumulation due to systemic and local causes. Diagnostic features that suggest edema includes worsening in morning or after eating salty meals. The history of variability in intensity and extension is important to determine the influence of edema on periorbital hyperpigmentation 25. When compared with normal orbital fat, edema is still present in downward gaze and does not change much in upward gaze 4.

Dark circles under eyes signs and symptoms

Clinically, dark circles under eyes is characterized by light- to dark-colored, brownish-black pigmentation surrounding the eyelids. Dark circles under eyes gives a tired look to the patient.

Dark circles under eyes diagnosis

Correct diagnosis of dark circles under the eyes can be difficult. It involves:

  • Personal, medical and family history
  • Physical examination
  • Wood lamp evaluation, which allows the clinician to assess the depth of pigmentation.

Diagnosis is mainly based on clinical examination. It is important to differentiate the dark eyelid skin with shadowing due to tear trough. Manual stretching of the lower eyelid skin can help to differentiate between true pigmentation and shadowing effect. Although the former retains its appearance with stretching, the latter improves or resolves entirely. An increase in violaceous discoloration on manual stretching of the lower eyelids is due to thin eyelid skin or hypervascularity of lower eyelid 26.

Wood’s lamp examination can be done to differentiate between the epidermal and dermal pigmentation 27. The variations in epidermal pigmentation become more apparent under Wood’s light. For dermal pigmentation, this contrast is less pronounced. Ultrasonographic evaluation can help to differentiate the vascular cause from the periorbital puffiness.

Histopathology

Histological characteristics of dark circles under eyes suggest that it can be both epidermal and dermal in nature. Biopsy specimen must be stained with routine hematoxylin and eosin. Special stains can also be used. Fontana-Masson silver stain can be used to stain melanin. Hemosiderin deposits seen in few cases (resulting from extravasation and superficial location of vasculature) can be stained with Perl’s potassium ferrcyanide 21.

Dark circles under eyes treatment

The aim of treatment should be to identify and treat the primary cause of hyperpigmentation as well as its contributing factors. Possible causative factors of dark circles under eyes include excessive pigmentation, thin and translucent lower eyelid skin overlying the orbicularis oculi muscle, and shadowing due to skin laxity and tear trough, but because multiple factors cause dark circles under eyes in the majority of patients, it is essential to identify the cause and choose the appropriate treatment according to the cause 28.

Given their multifactorial nature and the fact that individual patients may have more than a single underlying cause treatment of dark circles under the eyes depends on its nature. General measures include:

  • Get enough sleep or extra sleep. Although short nights don’t usually cause dark circles under eyes, a lack of sleep may make you paler, so shadows and circles you already have become more obvious.
  • Stop smoking
  • Sleep with extra pillows to elevate the head and reduce eyelid swelling. Elevate your head with two or more pillows to prevent puffiness that develops when fluid pools in your lower eyelids.
  • Massage temporary swelling while applying a cold compress
  • Cold compresses. Dilated under-eye blood vessels may contribute to dark circles under your eyes. Cold compresses also minimize the appearance of prominent blood vessels. Try holding a cold compress, a chilled teaspoon or a bag of frozen peas wrapped in a soft cloth against the area to make these vessels constrict.
  • Cosmetic camouflage
  • Light-reflecting concealers (these are often yellow or gold in color) covered by translucent face powder. These should be applied in the shadows, not on the puffy skin.

Unfortunately, many of the home remedies on the market lack evidence of efficacy.

There are a number of treatment options available for dark circles under eyes. Among the available treatment options for dark circles under eyes include topical depigmenting agents, such as hydroquinone, kojic acid, azelaic acid, topical retinoic acid, and physical therapies, including chemical peels, surgical corrections, and laser therapy, most of which are tried scientifically for melasma, another common condition of hyperpigmentation, which also occurs on the face 16. Also different modalities are used according to cause of dark circles under eyes.

Medical treatments to reduce pigmentation can include:

  • Protection from sun exposure using sunglasses
  • Topical agents; however dermal pigmentation responds poorly, and eyelids are sensitive so the stronger products may irritate (see melasma)
  • Chemical peels to reduce fine lines and surface pigmentation
  • Laser or intense pulsed light (IPL) treatments.

Loss of tissue (hollowing) and tear trough can be managed by aesthetic medical and surgical procedures:

  • Fillers (dermal implants) e.g., hyaluronic acid injections or fat grafts. The main indication for eyelid filler injection is for cosmetic reasons to add volume around the eyes, although it is also used for functional reasons (such as mechanically altering the eyelid to help close the eye better) 29. Eyelid filler is injected in hollow under eyes (tear trough area) to improve or eliminate dark circle, tired appearance. it can also be injected into hollow upper eyelid/brow area. It should be stated that filler injection is considered off-label when injected around the eyes, however they have been used for many years with great safety record. There are various filler materials available on the market. It is important to use safe, temporary, reversible filler types around the eyes. That includes the hyaluronic acid gel products and more specifically Belotero or Restylane as these two are the softest and retain least amount of fluid. Hyaluronic acid gel products are reversible using hyaluronidaze. These fillers, on average, last longer than one year around the eyes.
  • Surgery to remove excess fat, muscle and skin (surgical blepharoplasty or laser eye-lifting procedure).

Considerable training and experience are required to optimize results. Improvement may be partial. An incorrect technique may make the dark circles look more prominent than before the procedure.

Topical agents

Topical phenolic or nonphenolic bleaching agents are used in the treatment of hyperpigmentation, particularly hydroquinone and tretinoin. The mechanism of action of most bleaching agents is inhibition of tyrosinase enzyme, which inhibits the conversion of dopa to melanin, hence leading to a reduction of the melanin content of the epidermis.

Hydroquinone

Also known as 1,4 dihydrobenzene, hydroquinone is the most prescribed bleaching agent worldwide. It is used in strengths of 2 to 6%. The effect of treatment generally becomes evident after 5 to 7 months of therapy, hence the treatment should be given for at least three months 30.

Frequently observed acute side effects include mild skin irritation, itching, postinflammatory hyperpigmentation, and transient hypochromia. Long-term use can lead to exogenous ochronosis, leukomelanoderma en confetti, nail discoloration, and colloid millium 31.

Hydroquinone was reported to cause cancer in rodents, yet human carcinogenicity has not been established. A number of studies have shown that hydroquinone is safe and no cases of skin cancer or internal malignancy have been reported with topical application of hydroquinone, which has been used for more than 50 years 32. Hydroquinone has also been used safely in the periocular area 33.

Triple combinations

The United States Food and Drug Administration (FDA) has approved a modified combination of the Kligman’s formula, containing 4% hydroquinone, 0.05% tretinoin, and 0.01% fluocinolone acetonide for use in melasma and various other pigmentary disorders 34, but its long-term use in the periorbital area is a concern since it contains a topical steroid.

Kojic acid

Kojic acid is a naturally occurring fungal derivative produced by Aspergillus species and Penicillium species. It acts by inhibiting tyrosinase, and is used in a concentration ranging from 1 to 4% 35.

In a study conducted by Lim et al. 35, it was found that the addition of kojic acid to a gel containing 10% glycolic acid and 2% hydroquinone further improves pigmentation in melasma. Although there are no studies, kojic acid has been tried anecdotally in the treatment of periorbital hyperpigmentation and has been found to be effective. Side effects of kojic acid include erythema and contact dermatitis 35.

Azelaic acid

Azelaic acid (1,7- heptanedicarboxylic acid) was initially developed as a topical antiacne agent, but because of its effect on tyrosinase, it has also been used in the treatment of hyperpigmentary disorders such as melasma. Its mechanism of action includes the inhibition of DNA synthesis and mitochondrial enzymes, thereby inducing direct cytotoxic effects on the melanocyte 36.

In vitro studies show that azelaic acid interferes with DNA synthesis and mitochondrial enzymes in abnormal melanocytes and fibroblasts 37, thus neither leukoderma nor exogenous ochronosis are associated with its use. It can be used safely for prolonged periods of time. Since it was found to be effective for facial postinflammatory hyperpigmentation, it is a potentially promising agent for periocular hyperpigmentation due to postinflammatory hyperpigmentation.

Arbutin

Arbutin is an extract of leaves of the bearberry shrub and the cranberry, pear, or blueberry plants. It inhibits tyrosinase activity, but also inhibits melanosome maturation. Its effects are dose-dependent, but high concentrations of arbutin can cause hyperpigmentation. It is available in a concentration of 3% 38.

A randomized open study by Ertam et al 38 found that gel containing topical arbutin was effective in reducing pigmentation in melasma patients. Arbutin can also be used in other facial hyperpigmentation including dark circles under eyes.

Topical vitamin C

Vitamin C, an antioxidant, has also been used for the treatment of hyperpigmentation. Because ascorbic acid is unstable in many topical preparations, esterified derivatives, such as L-ascorbic acid 6-palmitate and magnesium ascorbyl phosphate are used in compounds.

L-ascorbic acid is the predominant cutaneous antioxidant. It scavenges the free oxygen radicals in the aqueous compartment which trigger melanogenesis. Vitamin C promotes collagen production and conceals color of blood stasis, which could improve appearance of dark circles under the lower eye lid 39.

Ohshima et al 39 showed that vitamin C and its derivatives, such as magnesium ascorbyl phosphate and ascorbic acid glucoside, inhibit melanogenesis in human melanocytes. They used two types of 10% vitamin C lotion, sodium ascorbate and ascorbic acid glucoside for six months in a split-faced manner for dark circles. Melanin index, erythema index, thickness, and echogenecity of the dermis of the bilateral eyelid was measured and it was found that there was lightening of pigmentation owing to an increase in dermal thickness due to concealment of dark discoloration from congested blood. However, they did not find any significant difference in melanin index.

Sunscreens

Hyperpigmentation can be improved with sunscreen alone as reported by Guevara and Pandya in a study conducted in patients with melasma 40. Patients should be cautious while using chemical sunscreen in the delicate eye area. Similarly, broad spectrum sunscreen and ultraviolet (UV) coated sunglasses are considered to be beneficial in dark circles under eyes.

Chemical peels

Chemical peels may be used alone or in combination with treatments such as topical bleaching agents. Glycolic acid is the most widely used alpha hydroxy acid for chemical peeling. Glycolic acid 20% can also be used for periocular hyperpigmentation. Lactic acid 15% has been used in periorbital hyperpigmentation in combination with trichloroacetic acid 3.75% by Vavouli et al 41 and it was found that almost all the patients showed significant esthetic improvement. For treatment of dark circles under eyes in medium to darker skin, it is best to extend the peel to the entire face to avoid post-peel demarcation. For optimal outcome, pretreatment with a tretinoin and hydroquinone bleaching agent for 2 to 4 weeks is recommended before undergoing a chemical peel. The most disturbing side effect of chemical peels can be postinflammatory hyperpigmentation. This may be minimized with the help of priming agents, such as hydroquinone and tretinoin.

Lasers

In recent time, lasers have been used increasingly in cosmetic dermatology. Periorbital hyperpigmentation has been successfully treated with various noninvasive lasers that target pigment and vascularity. Various lasers that have been used for treating dark circles are: Q switched ruby laser (694 nm), Q switched alexanderite laser, and Nd:Yag laser (1064nm) 4.

In a study conducted by Watanabe et al. 18, patients with homogenous bilateral pigmented macules in the periorbital region were selected for study of dark circles. Five patients with infraorbital dark circles received 1 to 5 treatments with the Q switched ruby laser (694nm); four patients showed good response and two patients showed excellent results 27.

In another study on dark circles under eyes, Momosawa et al 33 combined Q switched ruby laser with a bleaching agent containing 0.1% tretinoin and 5% hydoquinone. The bleaching agent was applied for six weeks before the laser treatment. The purpose of this treatment was to improve epidermal pigmentation by accelerated discharge of epidermal melanin by tretinion and suppressing new epidermal melanogenesis by hydroquinone ointment. Fifteen out of 18 patients showed excellent or good results after 3 to 4 laser treatments with no complications. Thus, it was concluded that in treating dark circles under eyes, the Q switched ruby laser should be considered as first-line treatment and it was found effective in both dermal and epidermal pigmentation 33. The Nd:Yag laser (1064nm) is also effective in reducing the pigmentation and vascular component of infraorbital dark circles.

Skin laxity and tear trough deformity are age-related changes that they can be treated with lasers. Alster and Bellew 42 treated 67 patients with dermatochalasia and periorbital rhytides using CO2 laser resurfacing and found significant improvement.

Although ablative laser resurfacing is a well-accepted treatment modality for improving the appearance of photo-induced rhytides coexisting with periocular hyperpigmentation, but due to untoward side effects such as prolonged erythema, pigmentation, and infection, and in some cases scarring, great interest has been shown toward less invasive methods to treat photo-induced rhytides effectively. These include the pulsed dye laser, diode laser, 1064nm Nd:YAG laser, 1320nm Nd:YAG laser, 1540nm erbium glass laser, and intensed pulsed light laser sources.

Autologous fat transplantation

Autologous fat transplantation is used to treat periorbital hyperpigmentation due to thin and translucent lower eyelid skin overlying the orbicularis oculi muscle.

Fillers

Hyaluronic acid gel is used as a filler for three-dimensional reshaping of periorbital complex. Patient satisfaction is high, but some patients with dark circles noted darker pigmentation after hyaluronic acid gel. Bosniak et al 43 treated 12 patients with dark circles under eyes, tear trough deformity, or prominent nasojugal groove with the hyaluronic acid push technique. All patients experienced immediate improvement after the procedure. Excellent tear trough contour improvement was achieved in all patients and under eye dark circle improved. Minor post-injection erythema and edema were observed, which resolved within 72 hours.

Platelet-rich plasma

Recently, platelet-rich plasma has been used in treating dark circles due to tear trough deformity and wrinkles. A single session with intradermal injections of 1.5mL platelet-rich plasma was given into the tear trough area and wrinkles of crow’s feet. Effect was compared three months after treatment with baseline. The improvement in infraorbital color homogeneity was statistically significant 44.

Surgery

Blepharoplasty

Blepharoplasty helps in eliminating dark circles caused by shadows that are cast by fat deposits or excess skin 45. Transconjunctival blepharoplasty is a better approach than transcutaneous blepharoplasty so that no external visible scar is created. Epstein used transconjunctival blepharoplasty and deep depth phenol peel simultaneously to treat hyperpigmentaion of skin and pseudoherniation of orbital fat, which is a contributing cause for infraorbital dark circles 45.

Carboxytherapy

Paolo et al 46 used subcutaneous injections of C02 once a week for seven weeks in the periorbital area and found significant improvement in fine lines and dark circles under eyes.

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