Dark Eye Circles

Dark Eye Circles: Laying “I’m Tired” to Rest

22 April 2018

Eva Mendes, Victoria Beckham, Katie Holmes and Kristen Stewart- what do they have in common in this picture? The look of fatigue and dark eye circles.

If the eyes are the window to your soul, then dark eye circles are the purveyors of our worst kept secrets. Late nights, signs of aging and one too many drinks the previous night are all dead giveaways with our raccoon eyes. While they may seem innocuous, dark eye circles make us look tired, haggard and older than our years. Getting a good night’s rest and cutting back on our alcohol intake may seem like reasonable fixes for dark eye circles, but for some of us, these persistent dark eye circles can fail to budge despite our best efforts and concealers.

Kim Kardashian making another appearance on the blog for her dark circles. Dark eye circles are a lot more common than you think!

If you too, suffer from dark eye circles and struggle to mask your raccoon eyes, take heart that you are not the only one. Studies have shown that dark eye circles occur in an overwhelming 47.5% of males and females and as early as 16 years of age-even celebrities like Katy Perry and Kim Kardashian are not spared. A study published in the Journal of American Medical Association Dermatology that analysed the top 10 movie villains also showed that Darth Vader was found to be afflicted by dark eye circles1. The prevalence of dark eye circles in Singapore has not been studied yet, but it is one of the most common problems that my patients face.

Movie trivia aside, dark eye circles can be caused by a combination of genetics and aging, making them notoriously difficult to treat. To know what treatment(s) work for you, let us first understand what exactly are dark eye circles, which are sometimes confused with eyebags.

MORE TO IT THAN MEETS THE EYE: WHAT EXACTLY ARE DARK EYE CIRCLES?
WHAT IS THE PROBLEM WITH DARK EYE CIRCLES?

 

What happened to Ron Weasly?

Dark eye circles are a relative darkening of the lower eyelid skin and impart a tired, old and dull look to our faces. Given the prevalence of dark eye circles and how distracting they can look, countless beauty companies have flocked to create eye creams and concealers that promise to mask these panda eyes. But beyond hiding these dark circles, is there a more definitive treatment for the rest of us who want to look refresh and rejuvenated with the freedom to go without makeup?

WHAT ARE THE CAUSES OF DARK EYE CIRCLES?

 

To a certain extent, it is true that fatigue and one too many margaritas culminate in these dark undereye patches. However, the underlying culprits are a combination of genetics and aging- and that helps to explain why dark eye circles are more pronounced in certain ethnic groups2.

There are 4 main causes of dark eye circles3-7: –

 

1. Prominence of blood vessels under the skin (most common cause in Asians)

2. Hollowing of the under-eye area creating a shadow effect (“tear trough deformity”)

3. Excess pigmentation

4. Lifestyle and other causes

Let us discuss each cause of dark eye circles in greater detail. Understanding the causes will then reveal why dark eye circles cannot be tamed with cosmetic creams alone.

1) Prominence of blood vessels

Skin thinning due to a loss of collagen and elastin as we age leads to the skin of the lower eyelid looking translucent, which unravels the underlying blood vessels. Prominent veins also impart a dark grey-blue colour to the under eye skin, contributing to dark eye circles. Periods of stress (including pregnancy and menstrual periods) and nasal congestion from allergic rhinitis also contribute to congestion of these blood vessels and worsen dark eye circles.

A study of dark eye circles in Asians found that the most common cause of dark eye circles was blood vessels causing this dark grey-blue colour in dark eye circles. My experience in treating dark eye circles in Singapore is also very similar; with blood vessels being a major cause followed by hollowing and pigmentation.

2) Hollowing of under eye area creating a shadow effect

The next most common cause of dark eye circles is the loss of skin elasticity and collagen leads to lax skin and volume loss of the under eye area, which leads to shadows under the eye. This also known as a tear trough deformity and is best treated with fillers to plump up the volume and stretch the skin to remove the shadows causing dark eye circles (more details below).

Tear trough deformities are mainly due to age and chronic sun damage. Other contributing factors to dark eye circles are prominent eye muscles, pseudoherniation of fat tissue under the eye and volume loss (hollowing) of the cheek which accentuate the shadow effect (i.e. eye bags).

3) Excess pigmentation

Acquired, bilateral Nevus of Ota is a type of pigmentation that can contribute to dark eye circles Excess pigmentation or dark spots are the true bona fide dark eye circles. The real McCoy of discolouration of the under-eye area, pigmentation can be caused by a multitude of causes- melasma, post inflammatory hyperpigmentation from eczema, sun spots…etc. To distinguish whether your dark eye circles are caused by pigmentation or a shadow effect; manually stretch the skin beneath your eyes. The former remains and the latter improves with stretching.

4) Lifestyle and other causes

Habits like lack of sleep, alcohol, salt, vitamin deficiencies and caffeine can also worsen underlying dark eye circles.

HOW DO I KNOW WHAT IS THE CAUSE OF MY DARK EYE CIRCLES?

 

Simple tests that you can do at home is to manually stretch the skin beneath your eye. Pigmentation retains its appearance but hollowing/shadowing is improved. Pressing on the under eye area may cause blood vessels to blanch; but do note that this does not necessarily happen all the time.

Vascular prominence and a true tear trough deformity are the 2 most common causes of dark eye circles. Patients can also more than one cause overlapping with another. To take the guesswork out of your dark eye circles, I would advise you to speak to your doctor.

DARK EYE CIRCLE TREATMENTS: WHAT ACTUALLY WORK

 

What works for you depends on what is the cause of your dark eye circles. Do you now understand why beauty creams do not work for dark eye circles most of the time?

The main modalities of treating dark eye circles in Singapore are- tear trough fillers, lasers and topical lightening medications. Let’s go through the details of each treatment.

Tear trough fillers

Perhaps one of the most commonly requested treatment for dark eye circles in Singapore is fillers. Fillers plump up sunken areas with volume loss to overcome the shadow effect8. Fillers also have an added effect of stretching the skin to correct fine lines, giving a more youthful and refreshed appearance. Even Katy Perry has openly admitted to using tear trough fillers to correct her dark eye circles!

Fillers are made up of hyaluronic acid, which are hyrophillic in nature; meaning that these fillers attract water molecules to hydrate and fill the volume loss. What this also means is that the undereye area (tear trough) should not be overcorrected at the point of injection to prevent swelling around the eye. Examples of fillers brands and types commonly used for the tear trough are Restylane Vital or Vital Light and Juvederm’s Volbella.

Newer and improved dermal fillers like Teosyal Redensity II also contain lightening active ingredients like antioxidants (glutathione, alpha-lipoic acid, N-acetyl-L-cysteine) and amino acids to have additional lightening and rejuvenation of the skin of the lower eyelid in order to reduce the discoloration of dark eye circles.

How is the filler administered?

 

Fillers are injected in very small amounts either by using a needle, cannula or pen.

Is it painful?

 

Numbing cream is applied to the tear trough area before injecting the filler into the tear trough. The fillers I choose also contain Lidocaine, an analgesic, to provide additional numbing. You might feel that it is akin to ant bites and is generally very tolerable.

How fast can I see results for dark eye circles?

 

Immediately. Do note that there may be some swelling from the entry of the filler and once that swelling subsides in a few days, you should see a more natural appearance.

How many times do I need to undergo filler injections
for dark eye circles? And how often?

 

Usually once is enough for dark eye circles. Although I routinely review my patients one to two weeks later after any swelling has subsided to ‘top up’ or correct any residual hollowing for dark eye circles. It is better to under correct than over correct because the a swollen looking under eye is very unforgiving!

Fillers should last you approximately 9-12 months. However, it has been shown that smoking increases the rate of filler breakdown.

What are the pros and cons of undergoing
a tear trough filler for dark eye circles?

 

Pros:

· Non-invasive

· Immediate results

· Additional benefits of rejuvenating and brightening of the tear trough area for enhanced anti-aging effects

· Reversible. Hyaluronidase, the antidote, can dissolve the filler.

Cons:

· Common reactions are bruising and swelling due to presence of small blood vessels under the skin

· Risk of blue coloured swelling under the eye if the filler is injected too superficially (Tyndall’s effect).

· Overcorrection causes swelling

· Entry into arteries causing blockage of surrounding vessels have been reported to cause rare complications like blindness and discolouration of the tissue (necrosis)/

Q-switched lasers

 

In my older post, 10 Things You Need to Know Before Having Lasers for Your Pigmentation, I discussed Q-switched laser extensively for treating pigmentation. Pigmentation causing dark eye circles can be treated effectively with Q-switched lasers to reduce the dark discolouration contributing to dark eye circles9-11.

To understand more about treating pigmentation with lasers, you can read my post here.

Fractional CO2 laser

 

Where lasers are concerned, Fractional CO2 lasers are the big guns for rejuvenating the skin of the tear trough area. Fractional lasers stimulate collagen formation to replace collagen loss with age and sun exposure12,13. Fractional CO2 best targets laxity, discolouration and wrinkles around the eyes and works best when combined with tear trough fillers in cases with hollowing or shadowing for a synergistic effect for treating dark eye circles.

How does Fractional CO2 laser work?

 

Fractional CO2 laser is one of the advances in non-surgical skin rejuvenation and is well known as the gold standard in treating depressed acne scars. Unlike traditional ablative skin resurfacing treatments, ‘fractional’ as the name suggests; creates columns of treatment zones while leaving up to 95% of the skin intact. Doing so leaves behind ‘normal’ skin for faster healing. Collagen production is stimulated, making skin firmer, denser and treats fine lines and lax skin around the eyes and this improves the appearance of dark eye circles.

How is Fractional CO2 different from Q-switched laser?

 

Fractional CO2 laser is very different from Q-switched laser. Think of it as a stronger form of laser than Q-switched laser; although IT is a lot more technical and complex than this.

Fractional CO2 laser has a different wavelength and properties compared to the Q-switch Nd-Yag laser. This allows deeper penetration of the Fractional CO2 laser with greater collagen stimulating and skin renewal properties.

Is there any downtime?

 

Unfortunately, yes. Downtime is a period when you do not look your best and sun avoidance is a must. This is not to say that you cannot go to work; you can in fact perform your daily activities. However, you may have temporary redness on your face and you may choose to avoid certain activities like important meetings and hot yoga sessions.

Fractional CO2 has a temporary downtime of 3 to 7 days for most people; for the first 2 days you may experience redness and the next 2-3 days you can get darkening or ‘stamp’ marks on your face. I find that recovery is hastened with the right topicals; stay tuned for my post on Growth Factor serums and my personal experience with Fractional CO2 laser!

 

Is it safe?


Yes, Fractional CO2 laser is very safe. Of course, like any medical treatments there can be complications and risks like post-inflammatory hyperpigmentation, scars, skin infection…etc. In the hands of safe and experienced doctors and with the appropriate aftercare, the risks of complications should be low.

What are the pros and cons of Fractional CO2 laser
for dark eye circles?

 

Pros: 

· Non- invasive

· Treats fine lines, improves texture and complexion around the eyes for a younger and more refreshed look

· Improves skin laxity

· Can treat some types of pigmentation

Cons: 

· Downtime of 3-7 days.

CAN EYE CREAMS WORK FOR DARK EYE CIRCLES?

 

Another common question and the short answer is:
that depends on the active ingredients inside these eye creams.

The problem with over the counter creams or beauty products is that (1) they are not bound to their nebulous claims and; (2) if they contain active ingredients at a high enough concentration, they will require a doctor’s prescription.

There is a plethora of eye creams, with a good number of them making the list of ‘Best Eye Creams’ of various magazines and editors (also notice that the products on the list change every year?). My advice is to look out for eye creams that contain retinol and vitamins C, E and K. These are the active ingredients that have been found to demonstrate improvement of dark eye circles with consistent use over 8 weeks. Skincare plays a crucial role in protecting your skin so it pays to be intelligent about what is going into your skincare!

WHAT DOESN’T WORK FOR DARK EYE CIRCLES?

 

Cucumber slices, tomatoes, rose water, mint leaves and tea bags. Sorry to burst these myths but let’s be objective and intelligent about beauty!

And that’s it! Thank you for taking the time to read my educational post on dark eye circles. In Singapore, dark eye circles is a common concern for my patients and the top three causes are (1) Vascular (blood vessels); (2) Hollowing or tear trough deformity; and (3) Pigmentation. The most common ways of treating dark eye circles in Singapore are with fillers and lasers. Eye creams show limited results but if you would like to try them, look out for retinol and vitamins C, E and K in eye creams.

I thought it would be useful to discuss some of the common issues surrounding dark eye circles because it is a very common problem in Singapore. I’ve deliberately avoided highlighting or dissing any specific products because this meant to be purely educational. I’d love to hear your comments and if you have any questions, please leave a comment!


REFERENCES

1. Dermatologic Features of Classic Movie Villains: The Face of Evil. Croley et al. JAMA Dermatol. 2017 Jun 1;153(6):559-564.

2. Physiological and lifestyle factors contributing to risk and severity of peri-orbital dark circles in the Brazilian population. Matsui et al. An Bras Dermatol. 2015 Jul-Aug;90(4):494-503.

3. Dark circles: etiology and management options. Friedmann and Goldman. Clin Plast Surg. 2015 Jan;42(1):33-50

4. Periorbital hyperpigmentation in Asians: an epidemiologic study and a proposed classification. Ranu et al. Dermatol Surg. 2011 Sep;37(9):1297-303.

5. Definition of the tear trough and the tear trough rating scale. Sadick et al. J Cosmet Dermatol. 2007 Dec;6(4):218-22.

6. Determination of Melanin and Haemoglobin in the Skin of Idiopathic Cutaneous Hyperchromia of the Orbital region (ICHOR): A Study of Indian Patients. Verschoore et al. J Cutan Aesthet Surg. 2012 Jul;5(3):176-82.

7. Infraorbital dark circles: definition, causes, and treatment options. Roh and Chung. Dermatol Surg. 2009 Aug;35(8):1163-71.

8. The American Society for Dermatologic Surgery. 2012 ASDS on Dermatologic Procedures.

9. A split-face comparison of low-fluence Q-switched Nd: YAG laser plus 1550 nm fractional photothermolysis vs. Q-switched Nd: YAG monotherapy for facial melasma in Asian skin. Kim et al. J Cosmet Laser Ther. 2013 Jun;15(3):143-9.

10. Treatment of infraorbital dark circles using a low-fluence Q-switched 1,064-nm laser. Xu et al. Dermatol Surg. 2011 Jun;37(6):797-803.

11. Treatment of acquired bilateral nevus of ota-like macules (Hori’s nevus) with a combination of the 532 nm Q-Switched Nd:YAG laser followed by the 1,064 nm Q-switched Nd:YAG is more effective: prospective study. Ee et al. Dermatol Surg. 2006 Jan;32(1):34-40.

12. Treatment of lower eyelid rhytids and laxity with ablative fractionated carbon-dioxide laser resurfacing: Case series and review of the literature. Tierney et al. J Am Acad Dermatol. 2011 Apr;64(4):730-40.

13. Dual-depth fractional carbon dioxide laser resurfacing for periocular rhytidosis. Kotlus. Dermatol Surg. 2010 May;36(5):623-8.


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