Dark circles under the eyes is a frequent request for treatment by patients coming in to see for many different issues. The plethora of available treatments on the internet from vanishing and bleaching creams to laser surgery is a testament to the commonality of the problem. It also suggests that most of these treatments are not effective because they simply don’t work or are used on the wrong type of dark circle problem.

By anatomic location, lower eyelid skin is darker than the skin on the rest of the face because it is very thin (and can show the color of the underlying muscle) and due to shadows from the overhanging brows. When exaggerated dark circles are present, there are several reasons why they may be there including thinness of the lower eyelid skin, hyperpigmentation, hemosiderin staining,  deep set eyes, and the arcus deformity.

Diagnosing which of these causes of dark circles is obviously critical to selecting what may work. In general, dark circles are hard to treat and there is no magical solution. The goal of dark circle treatment should be improvement but do not expect a complete cure. (no matter what the marketing hype says)

If the problem is thin skin, there is little that can be done to substantially thicken it. Vitamin A and C creams and pulsed light treatments may provide some improvement over time. But these are really unlikely to make significant improvements.However, camouflaging the dark with concealers or mineral makeup-based foundations is the most effective and cost efficient approach for thin skin.

Hyperpigmentation is a common cause  and is often seen when substantial lower eyelid bags are present as well. It is a very common cause in dark-skinned patients. When large eyelid bags are present, standard lower blepharoplasty (eyelid tuck) should first be done. This will not make all the hyperpigmentation go away but it will help. A secondary chemical peel, such as 25% or 35% TCA can also be done although there is the risk of causing hyperpigmentation by doing a chemical peel also in some patients. The key is to use melaniin-suppressing creams before and after a chemical peel.  Lower eyelid hyperpigmentation can also be treated by topical creams that contain retin A (exfoliating) and hydroquinone (bleaching) agents. My current favorite is TriLuma cream (available by prescription) because it contains Retin A, hydroquinone, and steroids all in one. This has to be used for several months before any improvement can be expected. In very resistant hyperpigmentation, the use of intense pulsed light (BBL, Broad Band Light) may also be tried but the power setting should be low and careful eye protection done. It will require several BBL treatments to get much improvement.

There are also some cases of dark circles that are due to leaching of blood products (hemosiderin) into the thin lower eyelid skin. Once has to look very carefully to separate this from hyperpigmentation. Topical Vitamin K or creams that contain arnica may be helpful. Pulsed light that is filtered for 560 or 590nm wavelengths may also be effective.

Deep set or hollow eyes as a cause of dark circles requires a surgical solution. The bone on the lower rim of the eye is deficient or flat causing the lower eyelid to indent in. This pulls the lower eyelid in, exaggerating the natural shadowing effect. The area under the eyelid must be built out using either fat grafts, orbital rim implants or fat transposition. Lower eyelid fat transposition is the simplest and most reliable method. By releasing fat from underneath the eye and bringing it out over the rim of the bone, the lower eyelid is better supported and the depth of the hollow is decreased. (as well as the shadowing) Implants also bulk up the bone but the thin skin of the lower eyelid may make it possible to feel or even see them. Free fat grafts are soft and pose no potential problems of infection or feeling them but they are unreliable as to how much will survive after surgery.

The arcus deformity is an often undiagnosed dark circle cause. It is caused by an abnormal attachment of the lower eyelid to the bone which makes the lower half of the eyelid dip in while the upper half is loose and filled with fat which bulges out from under the eye. As one ages, this lower eyelid look worsens creating darker and darker circles. This arcus deformity can be released through a transconjunctival (inside the lower eyelid) approach, allowing fat to balloon out into the dark circle area. In some cases, fat grafts can be added as well to further bulk up the area.

As the many causes of dark circles suggest…there is no one magical solution. That is why there are some many products and methods out there. The key is to knowing why the dark circle are there. Otherwise one is throwing darts at a target…blindly. Improvement in dark circles of the lower eyelid is possible but identifying the cause is critical…something internet products and home remedies do not do.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis