What are the treatment options for an adult patient with dark circles under the eyes, considering potential underlying conditions such as anemia or allergies?

Dark Circles Treatment

Understanding the Underlying Causes

Dark circles under the eyes are primarily caused by four distinct mechanisms: excessive melanin pigmentation, vascular congestion and translucent skin showing underlying vasculature, structural shadowing from tear troughs and fat herniation, and skin laxity with wrinkles. 1, 2 The key to effective treatment is identifying which mechanism predominates in your patient, as this determines the therapeutic approach.

Diagnostic Assessment

Examine for these specific features to guide treatment selection:

• Pigmentation-predominant: Brown discoloration that persists with gentle skin stretching, more common in darker skin types (Fitzpatrick III-VI) 1, 2
• Vascular-predominant: Blue-purple hue that blanches with pressure, visible superficial vessels, associated puffiness 3, 2
• Structural-predominant: Shadowing that changes with lighting angles, visible tear trough deformity, infraorbital fat herniation 4, 1, 2
• Skin quality issues: Thin, translucent skin overlying orbicularis oculi muscle, fine lines and wrinkles 1, 2

Treatment Algorithm by Primary Etiology

For Pigmentation-Predominant Dark Circles

Start with topical depigmenting agents containing vitamin C (THD ascorbate), which has demonstrated significant improvement in melanin-related pigmentation. 3 A multicorrective topical eye cream with THD ascorbate, peptides, and botanical extracts showed efficacy across diverse skin types (Fitzpatrick I-VI) in reducing infraorbital darkness over 12 weeks. 3

• Apply twice daily to the infraorbital area
• Expect visible improvement by 4-6 weeks, with continued enhancement through 12 weeks 3
• This approach is safe across all Fitzpatrick skin types 3

For more severe pigmentation unresponsive to topicals after 12 weeks, consider referral to dermatology for deep-depth chemical peels (phenol-based), which have shown success in Fitzpatrick skin types I-V when combined with addressing structural components. 5

For Vascular-Predominant Dark Circles

Use topical formulations targeting microvasculature congestion and permeability, specifically products containing caffeine and chrysin. 3 These ingredients reduce vascular congestion and hemoglobin degradation-related pigmentation. 3

• Apply twice daily, focusing on areas with visible blue-purple discoloration
• Laser Doppler measurements demonstrate objective reduction in vascular congestion within 12 weeks 3
• Adjunctive measures include cold compresses and adequate sleep to minimize vascular congestion 3

For Structural-Predominant Dark Circles (Tear Trough/Fat Herniation)

Refer to oculoplastic surgery or dermatology for procedural interventions, as topical treatments cannot address anatomical shadowing. 1, 5, 2 Transconjunctival blepharoplasty addresses pseudoherniation of orbital fat, which creates shadowing. 5

• Surgical correction is the definitive treatment for tear trough deformity and fat herniation 5, 2
• Hyaluronic acid fillers may be considered as a non-surgical alternative, though this requires specialist expertise 2
• Age-related fat atrophy in the infraorbital region contributes to hollowing and shadowing 4

For Thin, Translucent Skin

Recommend topical treatments that improve skin quality and thickness, including peptides and prebiotic botanical extracts. 3 These ingredients enhance skin barrier function and overall skin health. 3

• Bioavailable peptides stimulate collagen synthesis and improve skin thickness 3
• Prebiotic Inula Helenium supports skin microbiome and barrier function 3
• Improvement in skin translucency reduces visibility of underlying vasculature 3

Addressing Underlying Medical Conditions

Anemia Screening

Check complete blood count if patient reports fatigue, pallor, or has risk factors for iron deficiency. 1 Anemia can exacerbate the appearance of dark circles by increasing visibility of underlying vasculature through pale, thin skin. 1

• Correct iron deficiency anemia with oral iron supplementation if confirmed
• Recheck hemoglobin after 8-12 weeks of treatment

Allergic Conjunctivitis

If patient reports ocular itching, watery discharge, or seasonal variation, treat underlying allergic conjunctivitis with preservative-free ocular lubricants and topical antihistamine eyedrops. 4, 6

• First-line: Preservative-free artificial tears 4 times daily 4
• Second-line: Add topical antihistamine (olopatadine or ketotifen) twice daily 4
• Chronic eye rubbing from allergies worsens periorbital pigmentation 1

Atopic Dermatitis with Eyelid Involvement

For patients with eyelid eczema contributing to periorbital darkening, consider tacrolimus 0.1% ointment applied once daily to lid margins (avoiding direct eye contact), but refer to ophthalmology within 4 weeks for monitoring. 4

Critical Pitfalls to Avoid

• Do not use topical corticosteroids around the eyes without ophthalmology supervision, as prolonged use causes skin atrophy, telangiectasia, and increased intraocular pressure. 4, 7
• Do not promise rapid results—topical treatments require 12 weeks for maximal effect, and structural causes require procedural intervention. 3
• Do not overlook red flags requiring urgent ophthalmology referral: visual loss, moderate-to-severe eye pain, corneal opacity, or severe purulent discharge indicate serious ocular pathology, not simple dark circles. 4, 6
• Avoid preserved eyedrops if treating concurrent dry eye, as preservatives cause corneal epithelial breakdown and worsen ocular surface disease. 4

Combination Approach for Multifactorial Cases

Most patients have multiple contributing factors. 1, 2 Start with a multicorrective topical eye cream containing THD ascorbate, caffeine, chrysin, peptides, and botanical extracts applied twice daily, which addresses pigmentation, vascular congestion, and skin quality simultaneously. 3 This approach demonstrated significant improvement across all objective measures (chromameter, VISIA imaging, laser Doppler) and subjective assessments in a 12-week study. 3

• Reassess at 12 weeks to determine if structural intervention is needed 3
• If inadequate response, refer to dermatology or oculoplastic surgery for procedural options 1, 5, 2