A very common cosmetic concern that patients complain of is darkness of the skin under the eyes. They feel that the darkness makes them look sad, tired, stressed, unwell and old. It affects a wide range of ages, both sexes, all races, worsens with the aging process and genetic factors can be involved. Dark circles can be a difficult problem to treat as a variety of conditions can cause dark circles and often multiple factors can be present at the same time.
WHY ARE DARK CIRCLES SO COMMON?
The skin under the eye is extremely thin which makes it very translucent and underlying vessels much more visible. The skin thinness also contributes to increased vulnerability to environmental damage and sensitivity to irritation. Around the eye is one of the first areas of skin to show the signs of aging. As we age the skin under the eye becomes even thinner, the cheek fat shrinks and the bony orbit enlarges . The under eye area is also highly susceptible to fluid accumulation and swelling. This is partly because fluid can readily become trapped there and partly because fluid in this area drains through the nose. Hence anything that causes nasal congestion and blockage can contribute to swelling under the eye as well as back pressure causing dilation of blood vessels resulting in darkening of the skin.
WHAT ARE THE MAIN CAUSES OF DARK CIRCLES?
The 2 main types of things that can cause Dark Circles are
- CONTOUR CHANGE: The natural contour can be altered through either swelling under the eyes or from the development of a depression called a Tear Trough Deformity. The resultant change in normal contour results in a shadowing effect.
- SKIN CHANGE: The thin skin under the eyes can be easily damaged resulting in increased pigmentation and wrinkling. Underlying blood vessels can become congested and more prominent. Often there is a combination of skin changes.
HOW IS SWELLING UNDER THE EYE TREATED?
If the swelling is due to ‘bags under the eyes’ caused by herniation of the under eye fat pad, then the best solution is surgery, in a procedure called a Blepharoplasty. Whilst fat pad herniation occurs most commonly after middle age it can occur in younger people in which case there is often a family history of the same condition.
It is important to realise that swelling under the eyes can in some patients be a sign of an underlying medical issue such as thyroid, renal or cardiovascular disease and this should be suspected if swelling suddenly appears and/or there is swelling in other areas of the body. Appropriate medical assessment and investigation is necessary.
If the swelling under the eye is more intermittent and due to ‘puffiness’ caused by local fluid collection then treatment is focused on managing the cause if possible and reducing aggravating factors. Common causes of puffiness include seasonal allergies and sinus infections that can be improved with appropriate medical treatment. Allergies should be suspected if there are other symptoms such as sneezing, runny nose and dry eyes. Sinus infections should be suspected if there is pain and cheekbone tenderness. Treatments include over the counter products such as anti-histamines and decongestants, prescription medications and on occasion procedures such as sinus washout.
Anything that irritates the skin under the eyes can cause fluid to accumulate as well as increasing the risk of developing pigmentation. Common irritants include rubbing the eyes frequently, crying, harsh cosmetics (such as cleansers and makeup remover) and sleeping in eye makeup.
Sleep deprivation and stress from excess alcohol, caffeine and sugar can affect the adrenal gland and contribute to swelling under the eyes. Excess computer screen time and dehydration have been implicated as well.
Some people find changing sleeping position can help reduce eye swelling as sleeping on your stomach or side can contribute to swelling overnight through gravity. If someone constantly wakes up with puffy eyes then it can be worth trying sleeping on your back and or using an extra pillow.
Various home remedies can be effective in reducing puffiness presumably through the constriction of leaky blood vessels. Chilled tea bags, slices of cucumbers, frozen peas etc. can be useful short term measures. Some people find topical creams can also give temporary relief.
HOW IS A TEAR TROUGH DEFORMITY TREATED?
Dark circles are often not due to swelling or changes in skin colour but are created by a shadowing effect caused by a loss of volume under the eye. This change is caused by genetic factors combined with aging related loss of the fat pad under the eye (Infraorbital Fat Pad) and can be exacerbated by significant weight loss. The hollow that develops that extends from the inside of the lower eyelid to under the eye is called a Tear Trough Deformity.
The treatment of the Tear Trough is through the use of a Dermal filler. This is a specialised technique and results are very injector dependent. The correct choice of filler is critical and the correct technique is paramount to avoid visible lumps under the skin. There are important blood vessels and nerves under the eye that need to be avoided. Often quite small amounts of an appropriate Dermal filler can give quite dramatic long term correction in this area.
HOW ARE EYE WRINKLES TREATED?
Wrinkles on the outer border of the eye (Crows Feet) and inner nose area (Bunny Lines) respond very well to anti-wrinkle injections. Fine wrinkles directly under the eye in younger patients can sometimes be softened with anti-wrinkle injections but only very low doses can be used in this area. Under eye injections are not effective if there is excess skin and importantly as people get older care needs to be taken as if there is significant skin laxity anti-wrinkle injections can potentially result in drooping of the lower eyelid.
Many eye creams are promoted as being effective in smoothing under eye lines and in fact because the skin is so thin in this area quite good results can be achieved with topical creams. We find ELASTIDERM Eye Gel (Obagi) or DNA Eye Cream (Rationale) very good options.
For longer term results it is worth considering Skin needling which can be combined for optimal results with PRP (Platelet Rich Plasma)
For more severe wrinkles that are present at rest then laser resurfacing procedures can be considered. Fractionated lasers are preferred to fully ablative lasers but there can be a significant downtime with this procedure and post treatment wound care is critical.
HOW ARE PROMINENT UNDER EYE BLOOD VESSELS TREATED?
Blood vessels under the eye sit close to the surface of the skin and because the skin is so thin in this area any increase in the number of blood vessels or congestion of the existing blood vessels can be quite noticeable. Due to the skin being so thin is this area light can be reflected off the blood vessels just under the skin to give a dark appearance.
Vascular congestion is best treated by addressing the cause of the congestion just as it is when treating swelling under the eye. Often vascular congestion and under eye swelling occur at the same time.
Eye creams that contain caffeine can constrict underlying blood vessels and give short term relief. Larger blue veins that can be both unsightly in their own right as well as contributing to congestion can be treated by long pulse YAG laser treatment (EXCEL V). These blue veins should only be treated if they are over the bone and not the eye and appropriate eye protection is important.
HOW IS UNDER EYE PIGMENT TREATED?
Increased pigmentation in the skin is particularly common in darker skinned individuals because of the greater melanin content in their skin to start with. Proper assessment to evaluate if under eye pigmentation is primarily the result of sun damage, hormonal stimulation (Melasma) or from skin irritation is critical as this determines the management plan.
Genetics can play a role in some patients with often a history of other family members having similar pigmentation. On examination there can be pigmentation on the upper eyelid as well as the lower and this group of patients can be particularly difficult to treat and often conservative management with appropriate concealer and advice about avoiding aggravating factors such as sun exposure may be the best option.
If an inflammatory skin disease such as Excema is involved then addressing the inflammation and avoiding aggravating the condition by local rubbing etc. is critical.
If the under eye pigmentation is part of a more generalised pigmentation issue such as Melasma then it can be treated as part of the overall management of this condition with topicals, lasers and medications.
If the under eye pigmentation is primarily from sun damage then topical creams, peels and laser treatments all have a place.
Topicals containing green tea are thought to be helpful in reducing pigmentation but strong scientific evidence is lacking. Some patients rather than buying green tea extracts put wet green tea bags in their fridge and then use for 10-15 minutes each day as a mask.
Prescription creams such as Retinoic acid can help lessen pigmentation but need to be used sparingly and slowly introduced to minimise irritation. Hydroquinone can also help to lighten under eye pigment but again needs to be introduced slowly. Arbutin is a plant extract that can be used typically at 3% to treat pigmentation especially melasma.
Superficial chemical peels such as Glycolic acid peels (20%) can help with lightening. Priming the skin with Retinoic acid or Hydroquinone for 2-4 weeks before chemical peels in this area is recommended to minimise post inflammatory hyperpigmentation especially in darker skinned patients.
Lasers such as the Q Switch REVLITE, the Q Switch Ruby and the 1927 FRAXEL laser can be useful in selected cases of under eye pigmentation but eye protection is critical.
Whatever the cause of Dark Circles under the eye there are some general things to remember that can help in managing and reducing the condition.
MOISTURISER: Daily moisturiser at night to prevent dryness, dehydration and irritation.
CLEANSER: Gentle cleanser only.
CONCEALER: Choose a colour that matches or is slightly lighter than your skin tone. If mild use a liquid formula but if significant use a cream. Consider if certain colours will work better to conceal skin discolouration eg blue toned under eye circles think peach colour, brown pigment think orange and red discolouration think yellow or green concealer. Use a breathable product if possible eg LYCOGEL.
MAKE UP: Remove with gentle pads and don’t leave make up on overnight.
SMOKING: Avoid smoking as it damages collagen, dehydrates the skin and causes premature aging. Smoking speeds the loss of collagen from your skin and will worsen bags under your eyes.
SUNSCREEN: Use sunscreen daily around the eyes as UV light induces and can worsen pigmentation. Physical sunscreens, which are the ones that contain active mineral ingredients such as Titanium Dioxide or Zinc Oxide, are usually less irritating to the skin than chemical sunscreens.
SUNGLASSES: Wear quality sunglasses outside to protect your eyes and the skin around your eyes. Choose larger lenses that protect the sides as well. In Australia sunglasses with a EPF (Eye Protection Factor) rating of 9 or 10 are best. UV 400 is a term referring to 100% UV protection.
SLEEP: Aim for 8 hours a night. If swelling in morning consider sleeping on back or with extra pillow. Avoid using more than 1 pillow as it can alter neck and back alignment. Late nights followed by too little sleep can result in dark circles under the eyes.
TOPICALS: Most over the counter creams that claim to get rid of dark circles provide mild improvement at best and not lasting improvement. Consider the cost effectiveness of using these products.
HOME REMEDIES: There are many home remedies that have been tried as soothing treatments to reduce under eye puffiness. Green tea bags (caffeinated) left in fridge overnight then applied for 10-15 minutes next day. Cucumber slices have been long used to reduce puffiness. Place thick slice from fridge over closed eye lying down for 10-15 minutes daily.
DIET: Some associate dark circles and puffiness with a lack of Vitamin K, Vitamin B12 and antioxidants. Eat plenty of green leafy vegetables and take a daily multivitamin supplement. Excess salt can cause fluid retention so reduce salt intake.