What are the treatments for dark circles under the eyes?

Treatment of Dark Circles Under the Eyes

The most effective approach to treating dark circles under the eyes is to first identify and treat underlying allergic or inflammatory conditions—particularly allergic rhinitis and atopic dermatitis—with topical antihistamine eyedrops and environmental modifications, as these medical causes are frequently overlooked despite being highly treatable. 1

Initial Medical Evaluation

Before considering cosmetic interventions, a thorough assessment for treatable medical conditions is essential:

• Allergic rhinitis is the most common overlooked cause in both children and adults, presenting with associated symptoms including sniffing, throat clearing, eye rubbing, nasal congestion, and sneezing 1
• Inquire specifically about seasonal patterns, environmental triggers (dust, pollen, pet dander), family history of atopy, and ocular pruritus 1
• Atopic dermatitis frequently causes periorbital hyperpigmentation through chronic inflammation and repetitive rubbing 1
• Assess for systemic conditions including thyroid disease, nutritional deficiencies, and sleep disturbances that may contribute 2, 3

Treatment Algorithm Based on Etiology

First-Line Medical Management (When Allergic/Inflammatory Etiology Present)

For patients with allergic rhinitis or allergic conjunctivitis:

• Topical antihistamine eyedrops (olopatadine, ketotifen, or azelastine) twice daily provide rapid symptom relief 1
• Mast cell stabilizers (sodium cromoglycate or lodoxamide) four times daily for chronic or recurrent cases 1
• Preservative-free ocular lubricants help dilute allergens and inflammatory mediators on the ocular surface 1
• Environmental modifications: wearing sunglasses as allergen barrier, cold compresses, refrigerated artificial tears, hypoallergenic bedding, frequent clothes washing, and showering before bedtime 4

Critical Behavioral Intervention

• Strictly avoid eye rubbing, which worsens pigmentation, can cause keratoconus, and perpetuates the inflammatory cycle 4, 1

Second-Line Medical Management

If symptoms inadequately controlled with first-line therapy:

• A brief course (1-2 weeks) of low-potency topical corticosteroids may be added, but only after establishing diagnosis 1
• Consider topical cyclosporine or tacrolimus for severe or chronic cases 4
• Allergen-specific immunotherapy consultation for disease inadequately controlled with topical medications 1

Cosmetic/Procedural Options (After Medical Causes Addressed)

Multiple etiologic factors contribute to dark circles including dermal melanin deposition, postinflammatory hyperpigmentation, periorbital edema, superficial vasculature, and shadowing from skin laxity 5:

• Topical depigmenting agents: hydroquinone, kojic acid, azelaic acid, and topical retinoic acid for pigmentary component 3
• Chemical peels for hyperpigmentation (use with extreme caution to avoid worsening pigmentation, especially in skin of color) 2
• Hyaluronic acid fillers for tear trough deformity and shadowing 6
• Laser therapy including non-ablative fractional photothermolysis (safety concerns paramount to avoid post-inflammatory hyperpigmentation) 2, 6
• Sun protection is cornerstone of therapy regardless of treatment modality chosen 2

Critical Pitfalls to Avoid

• Never dismiss dark circles as purely cosmetic without evaluating for allergic rhinitis, atopic dermatitis, or systemic disease requiring medical treatment first 1
• Do not use topical corticosteroids empirically without establishing diagnosis, as they can worsen HSV infections and prolong adenoviral infections 1
• Avoid punctal plugs in allergic patients, as they prevent flushing of allergens and inflammatory mediators 1
• Oral antihistamines may paradoxically worsen the condition by inducing dry eye syndrome and impairing the tear film's protective barrier 4, 1
• Exercise extreme caution with chemical peels, fillers, and laser therapy in skin of color patients to avoid worsening pigmentation 2

When to Refer

• Ophthalmology referral for children or young people with moderate-to-severe symptoms unresponsive to topical treatment 1
• Allergy/immunology consultation for disease inadequately controlled with topical medications, to consider allergen-specific immunotherapy 1
• Dermatology referral for cosmetic interventions after medical causes have been addressed and optimized 2, 3

Key Clinical Pearls

• Periorbital hyperpigmentation is more commonly seen and more challenging to treat in skin of color patients 2
• Without intervention, dark circles usually progress over time, so early medical intervention is encouraged 2
• The multifactorial nature means individual patients may have more than one underlying cause requiring combination therapy 5, 6
• Always treat the medical component before pursuing cosmetic interventions to optimize outcomes and avoid complications 3