What causes dark circles under the eyes?

Parting Thoughts
What causes dark circles under the eyes?
Blackwell Publishing Inc
Fernanda Magagnin Freitag, MD, & Tania Ferreira Cestari, PhD
Department of Dermatology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Abstract
Dark circles under the eyes (DC) are defined as bilateral, round, homogeneous pigment
macules on the infraorbital regions. Despite its significant prevalence, there are a few
published studies about its pathogenesis. DC are caused by multiple etiologic factors that
include dermal melanin deposition, postinflammatory hyperpigmentation secondary to
atopic or allergic contact dermatitis, periorbital edema, superficial location of vasculature,
and shadowing due to skin laxity. The purpose of this review is to discuss some of the
available evidences about the anatomic features that could explain dark circles and the
proposed treatments for this unpleasant condition.
Keywords: dark circles, eye bags, periorbital hyperpigmentation
Introduction
Aesthetic facial concerns have been the main reason for
dermatological consults in the last few years. Pigmentary
disorders, like melasma, solar melanosis, rhytides, and
loss of elasticity are among the most common complaints.
As patients grow older, although physically and intellectually active, the importance of a younger or at least wellcared look increases.1 Besides the common alterations
related to the intrinsic and extrinsic aging processes, there
is one that affects individuals of any age, both genders and
all races: the so-called “dark circles under the eyes” (DC).
Unfortunately, this manifestation worsens with skin sagging
and abnormal lipid deposits that appear later in life.2
Dark circle is not a formal medical term, but both patients
and dermatologists use it to indicate periorbital hypercromic
macules and patches. Although considered a phenomenon
within the limit of physiology, patients, especially women,
are really bothered and concerned about it, even relating
the presence of dark circles with significant impairment
on their quality of life. Skin conditions that are neither
health threatening nor associated with significant
Correspondence: Fernanda Magagnin Freitag, MD, Tr. Aurélio Porto,
57/601, CEP 90520-250, Porto Alegre, RS, Brazil.
E-mail: fefreitag@yahoo.com.br
Accepted for publication March 25, 2007
© 2007 Blackwell Publishing • Journal of Cosmetic Dermatology, 6, 211–215
morbidity, but that can affect the individual’s emotional
well-being, are gaining increased attention. Among the
pigmentary disorders, the most striking examples are
melasma and vitiligo, conditions that clearly influence
the quality of life, without an important relation to its
objective clinical severity, from the medical point of
view.3 Dark circles interfere with the face appearance,
giving the patient a tired, sad, or hangover look. Disguising
the lesions is almost mandatory for some individuals who
depend on a well-cared and positive appearance for their
work or social activities. Despite its prevalence, there are
few published studies about dark circles and its pathogenesis. As the individual anatomical basis for DC is not
clearly defined, treatments may render suboptimal results.
The purpose of this review article is to discuss some of
the available evidences about the anatomic features that
could explain dark circles and the proposed treatments
for this unpleasant condition.
There are no data about the prevalence of DC mainly
because of its transitory and floating nature, the lack
of reasonable etiologic explanations, and the fact that the
condition is considered just a cosmetic nuisance. A study
carried out by Gupta et al.4 evaluated the prevalence of
dissatisfaction with the appearance of skin of 32 women
with the eating disorders anorexia nervosa and bulimia
nervosa, compared with 34 healthy controls. They found
that 9% of American women below 30 years were dissatisfied
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Dark circles • F M Freitag & T F Cestari
with darkness under the eyes against 38% of women with
eating disorders (P < 0.007). These figures give us an
idea about how commonly this complaint is reported by
patients in daily dermatological practice.
Dark rings under the eyes are defined as bilateral, round,
homogeneous pigment macules on the infraorbital regions.
There is no doubt that they are worsened by general
fatigue, especially lack of sleep. This idea is corroborated
by the daily fluctuation of the lesions intensity, according
to the patient status. For this reason, they have been
regarded as a mere physiologic phenomenon.5 Dark
circles are more pronounced in certain ethnic groups and
are also frequently seen in multiple members of the same
family. These hereditary observations raise a question:
are there any anatomic or histological characteristics
in these populations that could give us a reasonable
etiologic explanation?
Histological characteristics of infraorbital darkening
suggest that they are caused by multiple etiologic factors
that include dermal melanin deposition, postinflammatory
hyperpigmentation secondary to atopic or allergic contact
dermatitis, periorbital edema, superficial location of
vasculature, and shadowing due to skin laxity.6
Dermal melanin deposition
Watanabe et al.5 studied periorbital biopsies of 12 Japanese
patients with DC, showing that all of them had dermal
melanosis in the histology. According to the authors, the
melanosis could be interpreted as dermal melanocytosis
based on the findings of the anti-S100 protein and MassonFontana silver stainings. However, if melanocytosis is
a fixed finding, what could explain the daily fluctuation
on these patients’ condition? The authors speculate that
thickening of the dermis, caused by edema, leads to an
enhanced incidence of diffused light reflection from the
pigments, which then results in increased darkness of the
skin. They concluded this, based on the studies of West
et al.7 that successfully treated infraorbital pigmentation
using carbon dioxide (CO2) laser, without any corresponding improvement in melanin spectrometry readings.
These authors speculated that the efficacy of the CO2
laser depended on the tightening of dermal tissues and
improvement on the skin surface texture, which caused
the Tyndall effect (Fig. 1a,b).
Postinflammatory hyperpigmentation
secondary to atopic or allergic contact
dermatitis
Dark circles are prevalent in allergic individuals. In this
set of population, they are believed to be caused by
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Figure 1 Dark circles due to periorbital melanin deposition (a,b).
rubbing and scratching the skin around the eyes and by
accumulation of fluid due to facial allergy8,9 (Fig. 2).
Periorbital edema
The eyelid region seems to have a “sponge” property that
helps the accumulation of fluid in systemic or local edema
situations. Diagnostic features that suggest eyelid fluid
deposit include its worsening in the morning or after a
salty meal, the purplish color, and the undefined contours
of the regional fat complements. The history of variability
in intensity and extension is important to determine the
influence of edema on DC. Besides, when compared with
the normal orbital fat, edema is still present in down-gaze
and does not change much in up-gaze.10
Superficial location of vasculature
As patients grow older, loss of the subcutaneous periorbital fat and skin atrophy may lead to unveiling of the
© 2007 Blackwell Publishing • Journal of Cosmetic Dermatology, 6, 211–215
Dark circles • F M Freitag & T F Cestari
Figure 2 Atopic face in a 10-year-old boy.
orbital vasculature. The bluish color is secondary to the
visible dermal capillary network11 (Fig. 3a,b).
Tear trough depression
The tear trough is a depression centered over the medial
inferior orbital rim. It deepens as patients age because the
infraorbital fat is displaced anteriorly, creating shadowing
below it on the dependence of lighting conditions.12 The
condition aggravates with the eyelid and midface aging
because of the loss of subcutaneous fat with thinning
of the skin over the orbital rim ligaments that, combined
with cheek descent, confer a hollowness aspect to orbital
rim area10 (Fig. 4a,b).
Treatment
Among the available alternatives to treat dark circles are
bleaching creams, topical retinoic acid, chemical peels,
and, recently, laser therapy.7 Despite the great number of
available topical medications and creams to attenuate
dark circles, there are no evidence-based studies to support
their use. In the last decade, laser and intense pulsed light
are increasingly being used in cosmetic dermatology.11
West and Alster7 treated 12 female patients with
skin types I–III using CO2 laser resurfacing. The average
of three melanin measurements was obtained from the
infraorbital regions using a reflectance spectrometer,
before the procedure and 3, 6, and 9 weeks after treatment. Clinical improvement was scored independently
by two blinded evaluators using a 1 to 4 scale with
< 25% lightening (1); 25–50% (2); 51–75% (3); and
> 75% clearance (4). The obtained average score was 2.5
© 2007 Blackwell Publishing • Journal of Cosmetic Dermatology, 6, 211–215
Figure 3 Fair-skinned mother (a) and daughter (b) with the same
pattern of dark circles. The bluish color is secondary to the visible
dermal capillary network.
corresponding to an improvement of 50% 9 weeks after
laser resurfacing. The after treatment melanin readings
were not significantly different from those obtained preoperatively. Recently, Watanabe et al.5 treated eight patients
with dark circles, one to five times, using Q-switched
ruby laser (694 nm). Five cases received more than one
session. The clinical improvement of four patients was
scored as good (two cases) and excellent (two cases).
Epstein,13 in 1999, used transconjunctival blepharoplasty and deep-depth phenol chemical peel simultaneously
to treat hyperpigmentation of the skin and pseudoherniation of the orbital fat, both contributing causes for
infraorbital darkening. The authors referred successful
outcomes and a low incidence of complications. Manuskiatti et al.11 recommended a multiple stage treatment,
considering the different etiologic factors related to DC:
the shadowing secondary to the bulging contour of the
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Dark circles • F M Freitag & T F Cestari
Conclusions
Despite its prevalence and cosmetic importance, there are
few published studies in the scientific literature about
dark circles. Even a good definition of this condition is
lacking. We think the term infraorbital ring-shaped melanosis
proposed by Watanabe et al. does not encompass its
etiology in a global manner.
As there is neither a general understanding about
dark circles pathogenesis nor a consensus about the
major responsible features, treatments are chosen in a
simplified way, rendering suboptimal results most of
the time. It is important to identify the specific anatomic
problem of each patient in order to individualize treatment. Actually, published studies about dark circles constitute short case series without any separation among
different groups according major causative aspects.
Finally, dermatologists frequently face this complaint
and are the most prepared specialists to deal with almost
all causative aspects of dark circles. This editorial aims
to enhance curiosity about dark circles, stimulating
dermatologists to conduct more detailed basic research
and efficacy studies on this subject.
References
Figure 4 Loss of subcutaneous fat with thinning of the skin
combined with cheek descent confers the hollowness aspect (a,b).
lower eyelid, bluish color secondary to the visible dermal
capillary network, and brown color caused by dermal
melanin. They used CO2 laser first to ablate the epidermis,
eliminate competing epidermal melanocytes, and remove
the epidermis itself. Then, they applied Q-switched
alexandrite laser that emits light at 755 nm wavelength
and removes dermal melanin more efficiently. The hyperpigmentation starts fading in 6 to 8 weeks, and the
healing process was completed with a very acceptable
cosmetic result.
Treatment of dark circles related to tear trough depression is more complex, including invasive surgical procedures to elevate the soft tissues from the underlying
maxilla, fat repositioning or fat extrusion, and septal
reset.14 The use of hyaluronic acid gel to fill the periorbital
hollows and restore volume emerges as a less invasive
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214
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