What are the treatment options for dark circles under the eyes?

Treatment of Dark Circles Under the Eyes

The treatment of infraorbital dark circles should be tailored to the underlying etiology: hyaluronic acid fillers for volume loss and tear trough deformities, laser therapy (Q-switched Nd:YAG for pigmentation, long-pulsed Nd:YAG for vascular components, CO2 for skin laxity), topical agents for hyperpigmentation, or combination approaches when multiple factors coexist. 1

Diagnostic Approach

Before initiating treatment, identify the primary contributing factor(s):

• Volume loss/tear trough deformity: Hollowing in the infraorbital region, visible shadowing, sunken appearance 1, 2
• Hyperpigmentation: Brown discoloration, more common in darker skin types (Fitzpatrick III-VI) 3
• Vascular component: Blue-purple hue from visible periorbital vessels 1
• Skin laxity: Loose, wrinkled periorbital skin contributing to shadowing 1
• Thin skin: Translucent appearance allowing visualization of underlying structures 2

Rule out systemic causes including dermatitis, allergies, sleep disturbances, and nutritional deficiencies through targeted history and examination before proceeding with aesthetic treatments. 3

Treatment Algorithm by Etiology

Volume Loss and Tear Trough Deformities

Hyaluronic acid fillers are the primary treatment for volume-related dark circles, with technique varying by skin thickness and fat prolapse:

• Thick eyelid skin with minimal fat prolapse: Place filler in the pre-periosteal plane in the tear trough, palpebro-malar, and naso-jugal grooves 2
• Thin eyelid skin with moderate fat prolapse: Use microdroplet subdermal placement in the preseptal tear trough area to avoid Tyndall effect (blue-gray discoloration) and visible lumps 2
• This approach showed good aesthetic outcomes in 330 treated eyelids with good longevity and low complication rates 2

Hyperpigmentation-Predominant Dark Circles

Q-switched Nd:YAG laser is the treatment of choice for pigmentation, combined with topical depigmenting agents:

• Q-switched Nd:YAG laser targets melanin deposits effectively 1
• Topical agents should be used adjunctively to enhance and maintain results 1
• Sun protection is mandatory as a cornerstone of therapy to prevent worsening 3
• Exercise caution in darker skin types (Fitzpatrick IV-VI) to avoid post-inflammatory hyperpigmentation 3

Vascular Component

Long-pulsed Nd:YAG laser targets visible periorbital vessels causing blue-purple discoloration 1

Skin Laxity and Wrinkles

Fractional CO2 laser addresses loose and wrinkled periorbital skin that contributes to shadowing and dark circle appearance 1, 3

Combination Therapy

When multiple etiologies coexist, combination treatment yields superior results:

• Tear troughs + hyperpigmentation: Fillers + Q-switched Nd:YAG laser + topical agents 1
• Tear troughs + vascular component: Fillers + long-pulsed Nd:YAG laser 1
• Volume loss + skin laxity: Fillers + fractional CO2 laser 1

A study of 34 patients demonstrated that all three treatment modalities (fillers alone, lasers alone, or combination) were effective with minimal side effects, with 82% of patients rating improvement as excellent 1

Alternative and Adjunctive Therapies

Ozone therapy has emerged as an alternative biostimulator that reduces spots and wrinkles, showing reasonable clinical improvement in case reports with just two sessions, though evidence remains limited 4

Critical Safety Considerations

• Avoid Tyndall effect: Use appropriate filler placement technique based on skin thickness and fat prolapse to prevent blue-gray discoloration 2
• Minimize post-inflammatory hyperpigmentation: Exercise extreme caution with chemical peels, fillers, and laser therapy in darker skin types to avoid worsening pigmentation 3
• Ensure proper patient selection: Patients with thick eyelid skin and negligible fat prolapse respond best to traditional pre-periosteal filler placement 2
• Address underlying medical conditions: Treat any systemic disorders, allergies, or nutritional deficiencies before or concurrent with aesthetic interventions 3

Expected Outcomes

Non-surgical treatments are capable of correcting and improving dark circles with minimum complications and downtime when matched appropriately to the underlying cause 1. Early intervention is encouraged as periorbital hyperpigmentation usually progresses over time without treatment 3.