Dark Circles Under Eyes

Dark Circles under the eyes are a common cosmetic complaint. In fact, the term is a misnomer since the ‘darkness’ almost never takes the shape of a full circle; it usually appears as a semi-circular area just below the eye. There are several distinct causes of ‘Dark Circles’ and as a result they may appear at almost any age, even during one’s twenties, and frequently become worse over time. When Dark Circles first appear, one cause may predominate; over time, it is not uncommon for several causes to contribute. A discussion of the most common causes follows.

1. The appearance of Dark Circles under the eyes is often due to the development of a semi-circular indentation known as the ‘tear-trough.’ The tear-trough extends from the inner eye corner down to the upper cheek. This indentation is usually the result of gravity’s downward pull on the cheek. Like taffy when it is stretched, the skin here thins and indents, forming the tear-trough. In addition, a bulge of fat in the lower eyelid [discussed below] pushes out the skin along the upper edge of the tear-trough, making the tear-trough appear deeper.

Treatment: Injectable fillers. Surgical options may be available in certain severe cases.

2. The appearance of Dark Circles under the eyes may be caused by bulging lower eyelids [bags]. These bulges appear in the space between the eyelashes of the lower eyelid and the top of the cheekbone, (the bony orbital rim). You can feel the orbital rim with the tip of your finger. These bulges are usually caused by small amounts of fat [adipose tissue] that push on the eyelid skin from behind. The bulging fat is a small part of the normal shock absorbing fatty cushion surrounding and protecting the egg shaped eyeball. As we age, a small amount of this fat pokes through its retaining wall and into both the upper and lower eyelids causing bulges and a tired or aged appearance. The lower eyelid bulges can cast a shadow on the semi-circular area located between the lower eyelid and the upper cheek thereby contributing to the appearance of Dark Circles.

Treatment: During the early stages, fillers; when advanced, lower lid blepharoplasty (surgery) to remove excess fat and skin. In some cases, pouches and excess skin may respond to treatment with fractionated resurfacing lasers and skin tightening with such instruments as Thermage®

3. Dark Circles under the eyes may be caused by large blue veins running under the lower eyelid skin and under the skin at the side of the nose, near the inner corner of the eye. To visualize these vessels more clearly, gently stretch the skin with your fingertips. These veins are less visible when we are young because they are finer and overlying skin is thick, thereby effectively concealing the veins. As we age, the veins enlarge and the skin thins. These veins can create, or contribute to, the appearance of dark-circles under the eye. Darkness in the under eye area makes one look fatigued whether or not they truly are. When it first appears, this type of dark circle can often be concealed with makeup. When the veins enlarge and concealing them with make-up is no longer successful, they can be treated with a specialized gentle laser that shrinks or eliminates them entirely, usually with a just few treatments. Since these veins are not involved in vision or normal eye function, it is safe to treat them.

Treatment: A 1064 nm Nd:Yag laser is used to perform this treatment. A treatment session usually takes a few minutes and does not break the skin, so cover-up can be applied immediately after. An over-the-counter antihistamine, taken by mouth a couple of hours before treatment helps to minimize swelling. If a second treatment is necessary, a minimum of one month between treatments is advised. Bruising is very uncommon; moderate swelling is common and can last one to three or more days. 

4. Temporary lower eyelid swelling or puffiness is a common problem caused by the accumulation of edema fluid in the skin of the lower eyelid. Frequent causes of temporary eyelid swelling include allergy; water retention (salty foods, menses); thyroid disorders; and sleeping without elevating one’s head. Swelling of the lower eyelid creates fullness above the tear-trough area, thereby making the tear-trough look deeper. In addition, a puffy lower eyelid may cause a shadow to fall on the tear-trough area further exaggerating the appearance of Dark Circles under the eyes. Thyroid disorders are a less common cause of eyelid puffiness and, when suspected, can be diagnosed with a simple blood test. Protruding fat pads usually cause persistent or “permanent” lower eyelid pouches, [Refer to #2 above].

Treatment: Control fluid retention by sleeping with your head slightly elevated, best accomplished by elevating the head end of the box-spring under your mattress 2 - 4 inches [a ‘2-by-4’ piece of wood is ideal]. A low salt diet accompanied by abundant water intake minimizes fluid retention by encouraging kidneys to get rid of salt: excess salt forces the body to retain water. Antihistamines and other medications can be effective in controlling swelling caused by allergies and cold compresses can temporarily shrink swollen tissue. 

5. The appearance of brown patches of pigmentation on the skin around the eye, and especially over the tear-trough area, produces a true darkening of skin color. The most common causes of increased pigmentation are sun spots (solar lentigines) and melasma (also known as chloasma). Melasma is sometimes called ‘the mask of pregnancy’ and can similarly be brought on by female hormones in the form of birth control pills and Estrogen replacement therapy.

Treatment: Topical bleaching/lightening products; exfoliation; chemical peels; and fractionated laser (Fraxel, etc.) Sun protection is especially important for prevention, as well as during and after treatment.

OTHER POTENTIAL CAUSES OR CONTRIBUTING FACTORS:
6. OIL GLANDS are numerous on the lower eyelid; they may be visible as tiny pale yellow dots. When oil from these glands accumulates on the skin surface, it is possible that it will darken upon exposure to air by a process known as oxidation (analogous to what happens when an apple is sliced open).

Treatment: Twice daily gentle cleaning, exfoliating, and moisturizing

7. EYEGLASSES may focus sunlight onto the skin of the tear-trough area, thereby magnifying damage from the sun’s ultraviolet [UV] rays (think of using a magnifying lens to start a campfire.)

Treatment: Sunscreen, sunglasses, corrective eyeglasses with a UV filtering coating.

8. XANTHELASMA are yellowish-orange oblong plaques that appear in the tear-trough area near the inner eye corner. They usually first appear in early middle age and are the result of cholesterol accumulating in the skin. Most people with xanthelasma have normal cholesterol blood levels although it can also appear in people with high levels.

Treatment: There are no topical medicines that can remove xanthelasma, though there are many effective treatments. Fractional laser resurfacing is very effective. Other treatments include spot chemical peeling, electro-cautery, and surgical excision.