Dark Circles Under the Eyes: Different Treatments for Different Causes
Dark circles under the eyes are a frequent request for treatment. The plethora of treatments available on the internet, from fading and whitening creams to laser surgery, is a testament to the similarity of the problem. It also suggests that most of these treatments are ineffective because they simply don’t work or are used on the wrong type of dark circles problem.
By anatomical location, the skin of the lower eyelid is darker than the skin of the rest of the face because it is very thin (and may show the color of the underlying muscle) and because of shadows due to drooping eyebrows. When there are exaggerated dark circles, there are several reasons why they may be there. The main causes are thinning of the lower eyelid skin, hyperpigmentation, hemosiderin (blood product) staining, sunken eyes, and arch deformity.
Diagnosing which of these causes of dark circles is obviously essential to select what can work. In general, dark circles are difficult to treat and there is no magic solution. (no matter what the marketing hype says) If thin skin is the problem, there is little that can be done to substantially thicken it. Vitamin A and C creams and pulsed light treatments may improve over time. However, camouflaging the darkness with concealer or mineral makeup is the most effective and cost-effective.
Hyperpigmentation is a common cause and is particularly prone in dark-skinned people. It can be treated initially with topical creams containing 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 dark circles, the use of intense pulsed light (BBL, Broad Band Light) can also be tried, but the power setting must be low and the eye protection careful. Medium depth chemical peels (25% TCA) can also be tried, but they are also prone to inducing hyperpigmentation. The eyelid should be treated before and after the chemical peel with melanin suppressants to avoid this potential problem.
Staining with hemosiderin, byproducts of many blood vessels in this area, can also stain the thin skin of the eyelid. This cause can be difficult to determine. When present, it can be treated with topical creams containing vitamin K or arnica or pulsed light treatments using 560nm or 590nm filters.
Sunken or sunken eyes as a cause of dark circles require a surgical solution. The bone at the lower edge of the eye is deficient or flat, causing the lower eyelid to droop. This draws the lower lid in, exaggerating the natural shading effect. The area under the eyelid should be constructed using fat grafting, orbital rim implants, or fat transposition. Lower eyelid fat transposition is the simplest and most reliable method. By releasing the fat from under the eye and bringing it over the edge of the bone, the lower eyelid is better supported and the depth of the socket is reduced. (as well as shading) Implants also increase the bone, but the thin skin of the lower eyelid can make it possible to feel or even see it. Free fat grafts are gentle but unreliable as to how long you will survive after surgery.
Arch deformity is an often undiagnosed cause of dark circles. It is caused by an abnormal attachment of the lower eyelid to the bone that causes the lower half of the eyelid to sag while the upper half is loose and full of fat that protrudes below the eye. As one ages, this aspect of the lower eyelid worsens creating darker and darker circles under the eyes. This arch deformity can be released through a transconjunctival (inside the lower eyelid) approach, allowing fat to swell in the dark circle area. In some cases, fat grafting may also be added.
As you can see, there are numerous causes of dark circles and this explains why there are so many topical treatment solutions being advocated…but none of them really work. It is possible to improve dark circles on the lower eyelid, but it is essential to identify the cause … something that Internet products do not do.