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Surgery and Cosmetics

Dark Circles Under the Eyes

Doris M. Hexsel, MD, Taciana Dal'Forno

Wednesday, December 10, 2008

Dark circles are unaesthetic blemishes around the eyes, especially at the lower eyelid, that are frequently seen in both men and women.1 Patients complaining of dark circles under their eyes were found to have three different conditions contributing to this discoloration:

  1. SHADOWS: the shadowing is secondary to the bulging contour of the lower lid (nasojugal groove) (Figure 1);
  2. VESSELS: bluish color secondary to the venous network subcutaneously (Figure 2) and/or reddish color secondary to the visible dermal capillary network (Figure 3);
  3. PIGMENT: brown color secondary to superficial melanin (Figure 4) or brown/blue secondary to dermal melanin.2

These three factors are not always present and any one of them can prevail. In addition, other authors reported multiple etiologic factors, including dermal melanin deposition, postinflammatory hyperpigmentation secondary to atopic or allergic contact dermatitis and periorbital edema. As the lower eyelid skin is very thin, any increase or decrease of blood flow or changes of the branches that irrigate it can worsen dark circles. These factors also worsen with ageing due to pigment changes, loss of skin elasticity, and aggravation of the nasojugal groove.

Its treatment should be directed to the causal factors as changes of blood vessels, pigments, and skin irregularities. Few studies published in indexed literature approach the treatment of dark circles. However, from the clinical point of view, treatments can be divided into five categories: dietary supplement, topical therapy, peelings, lasers and fillers. They can be used alone or in combination

Figure 1 Figure 2


Figure 3 Figure 4

Dietary supplement

Dietary supplement can be used as adjunctive treatment of dark circles. One study evaluated the effects on skin in post-menopausal women of a dietary supplement that contained soy extract, fish protein polysaccharides, extracts from white tea, grape seed and tomato, vitamins C and E as well as zinc and chamomile extract. Clinical grading after 6 months of treatment showed that the active group had a significantly greater improvement of skin conditions, including dark circles.4

Topical therapy

There is a variety of commercial topical products for the treatment of dark circles. Many of the active ingredients of these products have not yet been studied to prove their real efficacy in treating dark circles. In general, among others, these products contain antioxidants, bleaching agents, moisturizing and stimulants of new collagen formation, such as as vitamins C and E, Q10 coenzyme, retinoid acid, glycolic acid, hydroquinone, furfuriladenine, and kojic acid.

A multicenter study investigated an eye cream containing a proprietary mixture of human growth factors and cytokines in combination with caffeine, bisabolol, glycyrrhetinic acid, and sodium hyaluronate for periorbital rejuvenation. The study revealed that clinical signs, including dark circles, showed significant improvement after 6 weeks of twice-daily application.5

Vitamin K or phytonadione can lighten the skin and avoid periorbital vasodilation. A study by Elson evaluated the use of vitamin K combined with retinol 0.15% for the treatment periorbital hyperpigmentation. It was demonstrated that this preparation was effective in improving dark circles in 93% of the patients.6 In another study, a gel containing 2% phytonadione, 0.1% retinol and 0.1% vitamins C and E, was fairly or moderately effective in reducing dark circles over a short treatment period in healthy Japanese adults.7

Chemical peelings

Although there is no support in the literature, chemical peelings can be used for the treatment of dark circles. They act through exfoliation, abrasion, and shedding of the superficial skin cells. In this indication, chemical peels reduce pigmentation of the skin (Figures 5 and 6), significantly improving some cases of dark circles. The choice of the agent, concentration, number of applications, etc will depend on each patient's needs. The most frequently used peels for dark circles are TCA and phenol peels.


Figure 5 Figure 6


The most commonly used lasers to treat dark circles are the Ruby or Nd:Yag, the Q-Switched Alexandrite laser, the carbon dioxide laser and the Intense pulsed light (IPL).2, 8 They improve dark circles by acting on specific chromophobes for each laser and/or light source, like water, hemoglobin, and melanin. By targeting these chromophobes, they improve vascular and pigment alterations. Furthermore, they stimulate collagen production, thus improving the flaccidity that worsens dark circles. The number of sessions and the results may vary from patient to patient, according to the type of laser or light source. The use of sunscreen during treatment is highly recommended.

One study was conducted in order to determine the effectiveness of high-energy pulsed CO2 laser treatment in reducing infraorbital hyperpigmentation. Significant lightening of infraorbital hyperpigmentation was observed 9 weeks following CO2 laser resurfacing. This study represents the first report of the successful use of a non-pigment-specific laser system for the treatment of infraorbital dark circles. Another study showed that all patients demonstrated improvement in periorbital hyperpigmentation with CO2 laser treatment.2

On the other hand, Lowe et al evaluated the clinical and histological appearance of infraorbital skin pigment in 17 patients with dermal melanin deposition treated with a Q-switched ruby laser. Of those patients treated with one Q-switched ruby session, 23.5% achieved a greater than 50% response. Of those treated twice, 88.9% achieved a greater than 50% response.10

In a recent clinical study, a total of 18 Japanese patients underwent combined therapy using Q-switched ruby laser to eliminate dermal pigmentation and topical bleaching treatment with tretinoin aqueous gel and hydroquinone ointment performed 6 weeks prior to reduce epidermal melanin. Seven of 18 patients (38.9 %) showed excellent clearing after treatment and eight patients (44.4 %) were rated as good. Only one patient (5.6 %) was rated as fair and none were rated as poor. Postinflammatory hyperpigmentation was observed in only two patients (11.1 %). This new treatment is considered effective for improvement of periorbital skin hyperpigmentation, with a low incidence of postinflammatory hyperpigmentation.11


Injectable hyaluronic acid can be used to augment the nasojugal groove to eliminate the shadowing that can give the appearance of dark circles (Figures 7 and 8).12-15 Steinsapir and Steinsapir reported a 2-year experience of treating these grooves with injectable hyaluronic acid gel. This case series demonstrates the usefulness of these fillers for the treatment of nasojugal grooves, with a low incidence of complications.12 The most common complications are hematomas and surface irregularities. Intravascular injections may occur, causing side effects of different degrees of severity, which can be prevented by the use of small and delicate canulas.

Figure 7 Figure 8


  1. Baumann L. Disorders of Pigmentation. In: Baumann L, ed. Cosmetic Dermatology. New York:McGraw-Hill 2004; p. 63-71.
  2. Manuskiatti W, Fitzpatrick RE, Goldman MP. Treatment of facial skin using combinations of CO2, Q-switched alexandrite, flashlamp-pumped pulsed dye, and Er:YAG lasers in the same treatment session. Dermatol Surg 2000;26(2):114-20.
  3. Freitag FM, Cestari TF. What causes dark circles under the eyes? J Cosmet Dermatol2007;6(3):211-5.
  4. Skovgaard GR, Jensen AS, Sigler ML. Effect of a novel dietary supplement on skin aging in post-menopausal women. Eur J Clin Nutr 2006;60(10):1201-6.
  5. Lupo ML, Cohen JL, Rendon MI. Novel eye cream containing a mixture of human growth factors and cytokines for periorbital skin rejuvenation. J Drugs Dermatol 2007;6(7):725-9.
  6. Elson M, Nacht S. Treatment of periorbital hyperpigmentation with topical vitamin K/vitamin A. Cosmetic Dermatol  1999;12(12):32.
  7. Mitsuishi T, Shimoda T, Mitsui Y, Kuriyama Y, Ka.wana S. The effects of topical application of phytonadione, retinol and vitamins C and E on infraorbital dark circles and wrinkles of the lower eyelids. J Cosmet Dermatol 2004;3(2):73-5.
  8. Fodor L, Ramon Y, Fodor A, Carmi N, et al. A side-by-side prospective study of intense pulsed light and Nd:YAG laser treatment for vascular lesions. Ann Plast Surg2006;56(2):164-70.
  9. West TB, Alster TS. Improvement of infraorbital hyperpigmentation following carbon dioxide laser resurfacing. Dermatol Surg 1998;24(6):615-6
  10. Lowe NJ, Wieder JM, Shorr N, et al. Infraorbital pigmented skin. Preliminary observations of laser therapy. Dermatol Surg  1995;21(9):767-70.
  11. Momosawa A, Kurita M, Ozaki M, et al. Combined therapy using Q-switched ruby laser and bleaching treatment with tretinoin and hydroquinone for periorbital skin hyperpigmentation in Asians. Plast Reconstr Surg 2008;121(1):282-8.
  12. Steinsapir KD, Steinsapir SM. Deep-fill hyaluronic acid for the temporary treatment of the naso-jugal groove: a report of 303 consecutive treatments. Ophthal Plast Reconstr Surg2006;22(5):344-8.
  13. Kane MAC. Treatment of tear trough deformity and lower lid bowing with injetable hyaluronic acid. Aesth Plast Surg  2005;29(5):368-72.
  14. Golberg R, Fiaschetti D. Filling the periorbital hollows with acid hialuronic gel: inicial experience com 244 injections. Ophthal Plast Recontr Surg  2006;22(5):335-41.
  15. Stephen B, Neil S, Marian C, Ioannis PG, Deborshi R. The hyaluronic acid push technique for the nasojugal groove. Dermatologic surgery  2008;34(1):127-131