What causes and treatments are available for periorbital discoloration (dark circles under the eyes)?

Dark Circles Under the Eyes: Causes and Treatment

Dark circles under the eyes result from multiple overlapping mechanisms—primarily infraorbital hollowing with fat atrophy, dermal melanin deposition, superficial vascularity showing through thin skin, and shadowing from age-related tissue descent—requiring identification of the dominant cause to guide treatment selection. 1, 2

Primary Causes

The periorbital region is particularly vulnerable to visible aging changes because it has minimal subcutaneous fat compared to other facial areas. 3 The key causative mechanisms include:

Structural/Anatomic Factors

• Infraorbital hollowing and tear trough deformity from age-related deep fat atrophy is the most common structural cause, creating shadowing that appears as darkness. 3, 4
• Vascular degeneration decreases blood flow to facial tissues, accelerating fat shrinkage and collagen loss in the periorbital area. 3
• Skin laxity with downward tissue sagging creates shadows that manifest as dark circles. 1, 5
• Periorbital puffiness and infraorbital palpebral bags (protruding retroseptal fat pads) contribute to shadowing. 4

Pigmentary Factors

• Dermal melanin deposition causes brown-hued hyperpigmentation, more common in skin of color patients. 1, 6, 2
• Post-inflammatory hyperpigmentation from atopic or allergic contact dermatitis. 1, 2

Vascular Factors

• Superficial vasculature visibility through thin, translucent lower eyelid skin creates blue-to-purple discoloration. 1, 2, 4
• Periorbital edema increases vascular prominence. 1, 2

Clinical Classification

Use Wood's lamp examination and ultrasonography to classify dark circles into pigmented (brown), vascular (blue/purple), structural (shadowing), or mixed type—with mixed type representing 78% of cases. 4 This classification directly determines treatment approach.

• Pigmented type: 5% of cases 4
• Vascular type: 14% of cases 4
• Structural type: 3% of cases 4
• Mixed type: 78% of cases 4

Ultrasonography can measure pre-septal thickness in patients with periorbital puffiness and identify protruding retroseptal fat pads in infraorbital bags. 4

Treatment Algorithm

For Pigmented Type (Brown Hue)

• Topical depigmenting agents: hydroquinone, kojic acid, azelaic acid, or topical retinoic acid as first-line therapy. 2
• Chemical peels for refractory cases, with extreme caution in skin of color patients to avoid worsening pigmentation. 6, 2
• Sun protection is mandatory as a cornerstone of therapy. 6

For Vascular Type (Blue/Purple Hue)

• Address underlying causes: allergic/atopic dermatitis, sleep disturbances, nutritional deficiencies. 6, 2
• Topical treatments have limited efficacy for pure vascular causes. 2
• Laser therapy may be considered but carries risk of worsening pigmentation. 6, 2

For Structural Type (Shadowing/Hollowing)

• Platelet-rich fibrin (PRF) therapy is deemed extremely effective for minimizing facial aging related to vascular degeneration and fat atrophy. 3
• Dermal fillers for tear trough deformity and infraorbital hollowing. 6, 2
• Surgical correction for significant skin laxity, palpebral bags, or blepharoptosis. 2, 4

For Mixed Type (Most Common)

Since 78% of patients have multiple contributing factors, treatment must address all identified components sequentially or simultaneously. 4 Start with the most prominent causative factor based on Wood's lamp and ultrasound findings. 4

Critical Management Principles

Complete medical history with review of systems and physical examination is essential before aesthetic treatment, as dark circles may indicate underlying dermatitis, allergy, systemic disorders, sleep disturbances, or nutritional deficiencies. 6

Safety Considerations

• Chemical peeling, filler injection, and laser therapy carry significant risk of worsening pigmentation if not performed carefully. 6
• Non-ablative fractional photothermolysis has shown response in skin of color patients when appropriately selected. 6

Timing of Intervention

Without intervention, periorbital hyperpigmentation usually progresses over time, making early intervention and management preferable. 6 The condition affects quality of life by making individuals appear sad, tired, stressed, and old. 6

Common Pitfalls

• Treating aesthetically without identifying underlying medical causes (dermatitis, allergies, systemic disease). 6, 2
• Using aggressive treatments in skin of color patients without considering increased risk of post-inflammatory hyperpigmentation. 6
• Failing to classify the type of dark circles before selecting treatment, leading to ineffective therapy. 4, 5
• Neglecting sun protection, which undermines all other therapeutic interventions. 6