Treatment of Infraorbital Dark Circles Using a Low-Fluence
Q-Switched 1,064-nm Laser
TIAN-HUA XU, MD,?ZHEN-HAI YANG, MD,?YUAN-HONG LI, MD,?JOHN ZS CHEN, MD,y
SHU GUO, MD, PHD,zYAN WU, MD,?WEI LIU, MD,yXING-HUA GAO, MD,?CHUN-DI HE, MD,?
LONG GENG, MD,?TING XIAO, MD,?AND HONG-DUO CHEN, MD?
doped yttrium aluminium garnet (QSNY) laser in treating infraorbital dark circles.
To evaluate the efficacy and safety of the low-fluence 1,064-nm Q-switched neodymium-
PARTICIPANTS AND METHODS
participated in this open-label study. Participants underwent eight sessions of low-fluence QSNY laser treat-
ment at 4.2J/cm2at 3- to 4-day intervals. A spot size of 3.5mm was used, with a pulse duration of 8ns. The
melanin deposition in the lesional skin was observed in vivo using reflectance confocal microscopy (RCM).
Morphologic changes were evaluated using a global evaluation, an overall self-assessment, a narrow-band
reflectance spectrophotometer, and a skin hydration measurement instrument.
Thirty women with infraorbital dark circles (predominant color dark brown)
Twenty-eight rated their overall satisfaction as excellent or good. The melanin index indicated a sub-
stantial decrease, from 225.84 at baseline to 182.65 (po.05). RCM results showed a dramatic decrease of
melanin deposition in the upper dermis. Adverse effects were minimal.
Twenty-six of 30 patients showed global improvement that they rated as excellent or good.
in the upper dermis. Treatment of infraorbital dark circles using low-fluence 1,064-nm QSNY laser is safe
The characteristic finding for dark-brown infraorbital dark circles is melanin deposition
The authors have indicated no significant interest with commercial supporters.
cosmetic concern, and many individuals seek treat-
ment for this common condition, but limited litera-
ture exists regarding the cause and treatment of this
condition. The etiology of infraorbital dark circles
may include dermal melanin deposition, postinflam-
matory hyperpigmentation (PIH) secondary to atopic
or allergic contact dermatitis, periorbital edema,
superficial location of vasculature, blood flow stagna-
tion, and shadowing due to skin laxity.1–3
nfraorbital dark circles refer to darkness of the
infraorbital eyelids. They can be a significant
Dark circles can be divided into two broad categories
according to their predominant colorFdark brown
or red–violet. For the dark brown circles, dermal
melanin deposition was hypothesized to be the
pathophysiological factor. Thus, we designed our
study to evaluate whether dark brown circles could
be treated effectively using the low-fluence 1,064-nm
Q-switched neodymium-doped yttrium aluminium
garnet (QSNY) laser.
Rather than taking a biopsy specimen from the lower
eyelid skin before and after the procedure, we used in
vivo laser confocal microscopy to study changes in
dermal melanin deposition.
Patients and Methods
Thirty Chinese women with a mean age of 35.5
(range 20–42), Fitzpatrick skin type III to IV, and a
& 2011 by the American Society for Dermatologic Surgery, Inc. ? Published by Wiley Periodicals, Inc. ?
ISSN: 1076-0512 ? Dermatol Surg 2011;37:797–803 ? DOI: 10.1111/j.1524-4725.2011.01956.x
Departments of?Dermatology andzPlastic Surgery, No. 1 Hospital of China Medical University, Shenyang, China;
ySheftel Associates Dermatology, Tucson, Arizona;yDepartment of Dermatology, General Hospital of the Air Force,
history of dark brown infraorbital dark circles for at
least 1 year participated in this study. Exclusion
criteria were any sign of infection or inflammation
around the eyes, pregnancy, use of oral retinoids in
the previous 12 months, current use of nonsteroidal
antiinflammatory drugs, and exposure to ultraviolet
irradiation within 4 weeks of treatment. The Med-
ical Ethics and Human Research Committee of
China Medical University approved the study. Before
enrolling in the study, all participants were informed
of the risks, benefits, and possible complications of
the treatment, and each participant provided
Treatment Protocols: Participants were treated using
the low-fluence 1,064-nm QSNY laser (Quantum
equipped with QSNY handpiece, Lumenis Co., Santa
Clara, CA) at 3- to 4-day intervals. A spot size of
3.5mm was used, with a fluence of 4.2J/cm2and a
repetition of rate of 5Hz. All areas were treated using
two passes. The end point was slight redness. After
the procedure, the treated areas were compressed with
an ice bag for 5 to 10 minutes to reduce any burning
sensation and erythema. Before the procedure, for
ocular protection, participants received a drop of
0.5% proparacaine hydrochloride in the eye, and the
eye was then protected using a sterile eye shield.
Participants were instructed to avoid sun exposure and
to wear a broad-spectrum sunscreen (sun protection
factor ?30) during and after the treatment.
Evaluation Criteria: Participants were required to
rinse their face thoroughly using a neutral lotion
and rest in a temperature- (201C) and humidity-
controlled (40%) room for at least 30 minutes before
the examination. They were photographed using a
digital camera (Nikon 40S, Tokyo, Japan) under the
same lighting conditions before the session (T0),
during the treatment (Tx: 3 days after x sessions of
treatment), 3 months after the last session (M3), and
6 months after the last session (M6).
Global Improvement Seen in Blind Evaluation
A blind evaluation was undertaken in which three
investigators rated improvements based on before-
and-after photographs using four grades (0=no
improvement ( o25% clearance), 1=fair improve-
ment (25–49% clearance), 2=good improvement
(50–74% clearance), and 3=excellent improvement
( 475% clearance)).
Satisfaction Assessment of Participants
Participants were required to assess their satisfaction
on a 4-point scale (0=no improvement (not satisfied
at all), 1=fair improvement (slightly satisfied),
2=good improvement (moderately satisfied), and
3=excellent improvement (very satisfied)).
Noninvasive Measurement of Skin Color
The skin colors at the darkest point of the lower
eyelid and the highest point of the cheekbone (self-
control) were measured as the melanin index (MI)
and erythema index (EI) using a narrow-band
reflectance spectrophotometer (MX18, Courage and
Khazaka, Electronic GmbH, Cologne, Germany)
according to the European Group on Efficacy Mea-
surement of Cosmetics and Other Topical Products
Recommendations.4Each site was measured three
times, and the mean value was calculated.
In Vivo Laser Reflectance Confocal Microscopy
Reflectance confocal microscopy (RCM) relies on an
830-nm diode laser as the light source and yields
images covering an area of 400?400mm with lat-
eral digital resolution of 1 to 2mm per pixel and an
axial resolution of 3 to 5mm per pixel. Dermal
melanin deposition was examined using RCM before
and after laser therapy. One trained dermatopathol-
ogist read the series of horizontal scanning fields of
vision and rated the decrease of melanin granules in
the dermis using four grades (0=o25% clearance,
1=25–49% clearance, 2=50–74% clearance, and
3= ?75% clearance).
Adverse Effects Recorded
Adverse effects were determined by questioning
patients and observing skin responses, including
erythema, edema, and dyspigmentation. Participants
DERMATOLOGIC SURGERY 798
DARK CIRCLES TREATED USING A 1,064-nm LASER
were also asked to report an average pain score on a
scale of 1 to 10, with 1 as mild pain and 10 as severe
Statistics: For database management and statistical
analysis, we used SAS software, version 6.12 (SAS
Institute, Inc., Cary, NC). Continuous variables and
categorical variables were presented as means and
frequencies, respectively. Means were compared
using analysis of variance procedure t-tests (least
significant difference). All statistical tests were
two-tailed and po.05 was considered statistically
Global Improvement Found in Blind Evaluation
Twenty-six of 30 patients (86.67%) achieved excel-
lent or good improvement after eight treatment
sessions. The mean score was 2.47 (range 0–3) after the
final treatment and remained at 1.97 at the 6-month
follow-up visit. See Figures 1 through 3 for details.
Assessment of Overall Satisfaction of Participants:
After eight treatment sessions, 93.3% of patients
rated their results as excellent or good, which indi-
cated that they were satisfied or extremely satisfied
with the treatment. The mean satisfaction score was
2.33 (range 0–3) after the series of treatments and
remained at 2.00 at the 6-month follow-up visit. See
Figures 1 through 3 for details.
Effects of QSNY Treatment on MI and EI: There
was a decrease in MI measured at the darkest point
of the infraorbital dark circles from 225.84 (T0) to
211.66 (T2, p4.05), 203.45 (T4, p4.05), 193.56
(T6, p4.05), 182.65 (T8, po.05), 178.28 (M3,
po.005), to 180.67 (M6, po.005). See Figure 4A
Meanwhile, the EI at the darkest point of the infra-
orbital dark circles decreased from 406.89 (T0) to
378.41 (T2, p4.05), increased a little to 386.12 (T4,
p4.05), and then dropped to 369.56 (T6, p4.05),
373.01 (T8, p4.05), 361.08 (M3, po.005), and
367.27 (M6, p4.05; Figure 4B).
The MI and EI at the highest point of the cheekbone
(self-control) remained unchanged with treatment.
Effects of QSNY Treatment on Melanin Deposition
in the Dermis According to RCM: Before treatment,
RCM images showed greater melanin deposition in
the upper dermis of the dark circles area than in
cheekbone skin, although there was no significant
difference in epidermal melanin density in the dark
circles than in the cheekbone area (Figures 5 and 6).
After eight treatment sessions, four of 30 subjects
(13.3%) obtained more than 75% clearance of
melanin deposition in the upper dermis, 16 (53.3%)
obtained 50% to 74% clearance, eight (26.7%)
obtained 25% to 49% clearance, and two obtained
less than 25% clearance (Figure 7). Meanwhile,
the melanin granules in the control site (the highest
Figure 1. Mean global improvements noted by investigators in the blind assessment and the overall evaluation of the
patients showed an increased mean score with treatment. After eight treatment sessions, patients rated their improvement
as greater than 50%, and they were satisfied or extremely satisfied with the treatment.
37:6:JUNE 2011 799
XU ET AL
point of the cheekbone) remained at a low level
during and after each treatment.
Assessment of Adverse Effects: The low-fluence
QSNY laser caused mild pain (mean score of
2.43 on a scale of 1–10). No participant needed
any topical anesthetic or systemic sedative.
Transient erythema and slight edema were observed
and usually resolved within 0.5 to 1 hours after the
procedure. No scarring, hyperpigmentation,
hypopigmentation, or other side effects were
observed. All patients could return to work and re-
sume normal daily activity without downtime im-
mediately after each treatment.
Although infraorbital dark circles are a common
cosmetic concern, there is limited research on their
etiology, histology, and therapy. Watanabe and
colleagues conducted a study of 12 patients with
Figure 2. A 23-year-old woman (A) before, (B) 4 weeks after
eight sessions, and (C) 6 months after treatment using the
yttrium aluminum garnet laser. This patient obtained excel-
lent results (scored 3 by the patient and investigators in the
Figure 3. A 44-year-old woman (A) before, (B) 4 weeks after
eight sessions, and (C) 6 months after treatment using low-
fluence 1,064-nm Q-switched neodymium-doped yttrium
aluminum garnet laser. She was extremely satisfied with the
results (scored 3 by both the patient and investigators in the
DERMATOLOGIC SURGERY 800
DARK CIRCLES TREATED USING A 1,064-nm LASER
bilateral suborbital homogenous pigment macules.
They found that all 12 patients demonstrated dermal
melanocytosis with the Masson-Fontana silver stain
and S-100 stain.1Thus, a variety of melanin-targeted
lasers, including the Q-switched ruby (694nm)
laser1,3,5and the Q-switched alexandrite (755nm)
laser,6have been tried in treating dark brown
infraorbital dark circles. Some results have been
encouraging, although the treatment induced PIH
and erythema in some patients. A large-scale study is
still necessary to obtain a better understanding of
The low-fluence QSNY laser was safe in treating
PIH, cafe ´-au-lait spots, and melasma without
tissue splatting, bleeding, or crust formation.7–10
Thus, the fluence of 4.2J/cm2was chosen for
our study based on previous clinical experience
with this laser.
For ethical reasons, we did not biopsy the dark
circles before or after the procedure. Instead,
we used noninvasive RCM to study the dermal
melanin deposition during the treatments.
Optical ‘‘sectioning’’ of the skin allows for the
assessment of tissue pathology at a cellular-level
resolution. Before treatment, RCM images showed
greater melanin deposition in the upper dermis
of the dark circles area than in the cheekbone
area. Meanwhile, there was no significant difference
in epidermal melanin density between the dark
circles and the cheekbone, indicating that the
dark-brown infraorbital circles might be
attributed to melanin deposition in the upper
Based on these results, we chose the QSNY
laser to treat dark brown infraorbital dark
Our study showed that, after eight treatment
sessions, mean MI values decreased significantly
(po.05). No recurrence was observed during the
The RCM images showed a clear and significant
decrease in melanin granules in the upper dermis
with ongoing treatment sessions.
The nanometer-scale pulse width of QSNY is
not sufficient for the vascular vessels to become
thermocoagulated, although with the increased
metabolic rhythm induced by QSNY, the
stagnation of blood vessels got some alleviation
simultaneously, as the finding that mean
EI at the darkest point of the infraorbital dark
circles also decreased gradually with each
QSNY treatment suggested. At the 6-month
follow-up visit, EI still remained at a lower
Figure 4. Effects of low-fluence 1,064-nm Q-switched neo-
dymium-doped yttrium aluminum garnet laser on (A) mel-
anin index and (B) erythema index in women with
infraorbital dark circles.
37:6:JUNE 2011 801
XU ET AL
Assessment of adverse effects revealed that partici-
pants had minimal downtime. The erythema and
edema induced by the treatment lasted for approx-
imately 0.5 to 1 hour. None of the patients developed
pigmentary disorders, crust formation, or pinpoint
bleeding. The average pain score was rated as low,
and the pain was considered tolerable.
This is the first report on treating dark-brown
infraorbital dark circles in Chinese women using
the low-fluence 1,064-nm QSNY laser. Because
this is a preliminary noncontrolled study,
further studies with posttreatment histological
examinations and longer follow-ups are still
Figure 5. Epidermal melanin (indicated by the red arrow) shown using reflectance confocal microscopy: (A) epidermal
melanin of infraorbital dark circles and (B) epidermal melanin of cheekbone. There was no significant difference between
the epidermal melanin density of the dark circles and that of the cheekbone.
Figure 6. The melanin deposition in the upper dermis (indicated by the red arrow) shown using reflectance confocal
microscopy (RCM): (A) melanin deposition of infraorbital dark circles and (B) melanin deposition of cheekbone. The RCM
images showed greater melanin deposition in the upper dermis than in the cheekbone area.
DARK CIRCLES TREATED USING A 1,064-nm LASER
Conclusion Download full-text
The treatment of dark-brown infraorbital dark cir-
cles with low-fluence 1,064-nm QSNY laser is safe
and effective in Chinese women.
ported by the Program for Changjiang Scholars and
Innovative University Research Team (Code No.
IRT0760), the National Science Fund (Code:
30972658), and Shenyang Science & Technology
This study was partly sup-
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Address correspondence and reprint requests to: Yuan-
Hong Li, MD, PhD, Department of Dermatology, No. 1
Hospital of China Medical University, 155 N. Nanjing
Street, Shenyang 110001 P. R., China, or e-mail:
Co-correspondence: Prof. Hong-Duo Chen, MD, Depart-
ment of Dermatology, No.1 Hospital of China Medical
University, 155N. Nanjing Street, Shenyang 110001, P.R.
China. Tel: 186-24-83282642; Fax: 186-24-83282633,
or email firstname.lastname@example.org.
Figure 7. Melanin deposition (indicated by the red arrow) in the upper dermis shown using reflectance confocal micros-
copy: (A) before treatment (T0) and (B) after eight treatment sessions (T8). The clearance score for this participant was 3
XU ET AL