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p>Editorial: An approach to dark circles under the eyes</p
doi: 10.18282/jsd.v1.i2.67
Copyright © 2016 Aghaei S. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0
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medium, provided the original work is properly cited.
An approach to dark circles under the eyes
Shahin Aghaei
Iran University of Medical Sciences, Tehran, Islamic Republic of Iran
Keywords: Infraorbital darkening, periorbital darkening, dark circles, eyes, treatment, therapy
Citation: Aghaei S. An approach to dark circles under the eyes. J Surg Dermatol 2016; 1(2): 55–56;
Correspondence to: Shahin Aghaei, Roonik Skin Clinic, #78, Asad-abadi Ave., Tehran, Islamic Republic of Iran,
Received: 12th July 2016; Published Online: 29th July 2016
ho does not loath looking in the mirror after
a long and sleepless night? Periorbital
melanosis, popularly known as “dark circles”
(DC) under the eyes, is a common and frustrating
cosmetic grievance in both men and women, although in
most cases it is not a sign of a severe medical
condition[1,2]. DC is inevitably a sign of exhaustion, but
anxiety seems to deteriorate facial appearance through
the development of DC[3].
There has been little research dedicated to
investigating the cause of this common disorder. The fact
that various treatment modalities carried out in the past
resulted in inconsistent outcomes shows that pinpointing
the cause of DC is not exactly a walk in the park. There
are multiple factors that cause DC in a majority of
patients. Possible reasons include excessive pigmentation,
along with thin and luminous lower eyelid skin overlying
the orbicularis oculi muscle. As people grow older, the
skin gets thinner and collagen fibers are lost, at times
augmenting the advent of tiny blood vessels beneath the
eyes, thus making the area seems darker. While lack of
sleep and aging certainly play a role in under-eye
discoloration, so do genetics, allergies, hormonal
abnormalities, and accumulated skin damage[4,5].
Certain conditions such as fluid disproportion or
locally swollen eyelids can also cause shades that make
the area under the eyes seem darker. Some researchers
also speculated that DC has a tendency to run in families.
Brown circles could also form as a result of hyperpig-
mentation triggered by chronic eye-rubbing, sun
exposure, or genetics. When there is no apparent cause, it
could be due to termed idiopathic cutaneous
hyperchromia of the orbital region (ICHOR)[6].
Numerous treatments have been used for this complaint
with various results, including topical lightening creams,
chemical peelings, lasers, and even fat injections. None
of the treatments have proven to be uniformly effective
and thus there is a need for newer approaches[7-9].
In spite of its prevalence and cosmetic importance,
there are only a few reported works in literature
regarding DC. A virtuous description of this condition is
unavailable and there is neither an overall understanding
about the pathogenesis nor an agreement about the main
factors responsible for it. Treatment modalities are
chosen in empirical ways, frequently resulting in
suboptimal outcomes. It is important to identify the
probable cause and choose appropriate treatment
DC is less responsive to standard treatments due to
its multifactorial etiology and the presence of melanin in
skin layers. Nevertheless, even a mild-to-moderate
improvement in appearance can enhance the quality of
life of patients; hence topical therapies and simple
physical therapies can be used to treat patients seeking to
improve the cosmetic appearance of their eyes[10]. Instead
of fighting an uphill battle against the genes, one can also
turn to corrective coloring makeup.
Aghaei S
doi: 10.18282/jsd.v1.i2.67
Conflict of interest
The author declared no potential conflict of interest with
respect to the research, authorship, and/or publication of
this article.
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... It results in the appearance of tiredness in the patient. 1 This condition may be due to excessive pigmentation, thin and translucent lower eyelids, and shadowing owing to skin laxity and tear trough. [2][3][4] POH is challenging to treat and lacks a straightforward and reliable therapeutic strategy due to its complex pathogenesis and etiology. 1 The objective of this study was to provide clinicians with a guide to the evaluation and treatment of POH using three therapeutic modalities. ...
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Objective Evaluation and comparison of the efficacy and safety of 3 different modalities of treatment for dark circles that function via different modes of action. Methods In total, 45 female patients with periorbital hyperpigmentation were randomly selected to participate from those attending the outpatient dermatology clinic of Al‐Zahraa University Hospital within a 6‐month period. Patients were divided into 3 groups, and the groups were subjected to different types of therapy: group A, carboxy therapy; group B, chemical peel; and group C, vitamin C mesotherapy. Results No statistically significant differences were detected in improvements in pigmentation or the degree of patient satisfaction between any of the groups. However, the mesotherapy group reported more of a burning sensation following treatment than the other 2 groups but also showed a significant improvement in pigmentation and patient satisfaction compared with the carboxy group. Conclusion All 3 treatment modalities were effective in the reduction in periorbital pigmentation. However, mesotherapy showed a significant improvement in pigmentation and a higher level of patient satisfaction compared with the other types of treatment.
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Periorbital dark circles (PODC) are a common worldwide cosmetic problem. It is difficult to treat due to complications in its pathogenesis and aetiology. Available lines of treatment for PODC include whitening creams, topical retinoid acid, chemical peeling, laser therapy, carboxytherapy, autologous fat transplantation, injectable fillers and surgery (blepharoplasty).The aim of this study isto evaluate and compare the efficacy of chemical peels using trichloroacetic acid (3.75%) and lactic acid (15%) in a gel formula with that of carboxytherapy, in the treatment of periorbital hyperpigmentation.Two groups of patients with PODC were included in the study, named Group A and B in which each group consisted of 15 patients. Group A was assigned for patients who received treatment with chemical peeling with a combination of trichloroacetic acid (3.75%) and lactic acid (15%) in a gel formula, once a week for four weeks. Group B was assigned for patients who received carboxytherapy that was performed by subcutaneous and intradermal injection of CO2 once a week for four weeks. All patients were assessed by digital photographs, before and after treatment, by observing the improvement in the grade of PODC. Reports of patient satisfaction and global tolerance were evaluated by three medical observers. There was a significant improvement in the grade of PODC in both groups. The degree of improvement of PODC in group A was excellent, with good grade in 93.4% of the treated patients while fair grade in 6.6% of them. There was a statistically significant improvement in the pigmented type. The degree of improvement of PODC in group B was excellent, with good grade in 86.7% of the treated patients while fair grade in 13.3% of them. However, no statistically significant difference between the two groups was observed. Minimal and transient side effects were noticed; however, it did not require further treatment. In conclusion, the two methods of treatment were effective in the treatment of PODC, with the improvement of PODC observed from the first treatment session with both chemical peeling and carboxytherapy.
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Periorbital hyperpigmentation is a commonly encountered condition. There is very little scientific data available on the clinical profile and pathogenesis of periorbital hyperpigmentation. Periorbital hyperpigmentation is caused by various exogenous and endogenous factors. The causative factors include genetic or heredity, excessive pigmentation, postinflammatory hyperpigmentation secondary to atopic and allergic contact dermatitis, periorbital edema, excessive vascularity, shadowing due to skin laxity and tear trough associated with aging. There are a number of treatment options available for periorbital hyperpigmentation. Among the available alternatives to treat dark circles are topical depigmenting agents, such as hydroquinone, kojic acid, azelaic acid, and topical retinoic acid, and physical therapies, such as chemical peels, surgical corrections, and laser therapy, most of which are tried scientifically for melasma, another common condition of hyperpigmentation that occurs on the face. The aim of treatment should be to identify and treat the primary cause of hyperpigmentation as well as its contributing factors.
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Periorbital melanosis (under eye dark circles) is an often idiopathic cosmetically disturbing condition that is poorly responsive to currently available treatment modalities. We present the case of a 48-year-old man (skin phototype V) with significant idiopathic periorbital melanosis and who had good to excellent reduction in periorbital melanosis with the new DermaFrac™, which combines microneedling with simultaneous infusion of a serum containing active ingredients. The possible mechanisms of benefit are discussed. DermaFrac™ may be an innovative and effective new treatment option for patients with periorbital melanosis.
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Idiopathic cutaneous hyperchromia at the orbital region (ICHOR) is a cutaneous hyperchromia characterised by bilateral darkening of the eyelid and orbital skin that contrasts with the adjoining facial skin. ICHOR is frequent in dark skin. It interferes with the face appearance which often causes difficulties in societal acceptance and may impact quality of life. The aim of this investigation was to study the epidemiology, clinical features and risk factors associated with ICHOR in Indian patients and also to study the distribution of melanin and haemoglobin in ICHOR patients. This study also assessed the relevance of SIAscopy technique (spectrophotometric intracutaneous analysis (SIA)), a new objective non-invasive method to measure melanin and haemoglobin concentration in vivo. Thirty-three patients diagnosed with ICHOR at the All India Institute of Medical Sciences, New Dehli, India, were included in the study. Epidemiological data were collected through a self-administrated questionnaire. Standard photographs were taken from each patient and SIAscopy measurements were done on dark circles and normal skin. Surprisingly our study showed no significant correlation between ICHOR prevalence and family history, atopic and contact dermatitis, contemporaneous melasma and hormonal factors. The study confirms that sun exposure is a risk factor of dark circles aggravation. Indeed patients tend to reduce sun exposure after the onset of dark circles. SIAscopy analysis reveals significant differences in the concentration of total melanin, of dermal melanin and of haemoglobin between ICHOR skin and normal skin of the same patient. This study confirms that melanin deposits and blood stasis in dark circles may play a role in ICHOR pathogenesis and cause the darkening of skin under eyes. SIAscopy provides objective diagnostic information about ICHOR.
Background: Dark circles (DC), seen in the periorbital area, are defined as bilateral, round, homogeneous pigmented macules whose aetiology is thought to be multifactorial. Available treatments include bleaching creams, topical retinoic acid, chemical peels, lasers, autologous fat transplantation, injectable fillers and surgery (blepharoplasty). Objective: To evaluate the efficacy and safety of a combination of microneedling and 10% trichloroacetic acid (TCA) peels in the treatment of DC. Materials and methods: Thirteen female patients with mild to severe infraorbital DC were included in the study. The patients were aged between 21 and 61 years. They were treated with Automatic Microneedle Therapy System-Handhold and topical application of 10% TCA solution to each infraorbital area for five minutes. The effect was photo-documented and a Patient and Physician Global Assessment was evaluated. Safety was assessed by evaluating early and delayed adverse events. Results: Almost all patients showed significant aesthetic improvement. Both Physician and Patient Global Assessment rated a fair, good or excellent response in 92.3%. The procedure was well tolerated. Mild discomfort, transient erythema and oedema were quite common during or immediately after the procedure. The patients were followed up regularly every month for four months, and no recurrence was recorded. Conclusion: Microneedling and 10% TCA constitute an innovative combination treatment for DC with encouraging results and minor side effects.
Periorbital hyperpigmentation (POH) is a common worldwide problem. It is challenging to treat, complex in pathogenesis, and lacking straightforward and repeatable therapeutic options. It may occur in the young and old, however the development of dark circles under the eyes in any age is of great aesthetic concern because it may depict the individual as sad, tired, stressed, and old. While "dark circles" are seen in all skin types, POH is often more commonly seen in skin of color patients worldwide.1 With a shifting US demographic characterized by growing number of aging patients as well as skin of color patients, we will encounter POH with greater frequency. As forecasted by the US Census, by 2030 1 in 5 Americans will be 65 plus years old and greater than 50% of the population will possess ethnic skin of color.2 The disparity in the medical community's understanding of POH versus popular demand for treatment is best illustrated when you have only 65 cited articles to date indexed on PubMed line3 compared to the 150,000,000 results on Google search engine.4 Most importantly POH may be a final common pathway of dermatitis, allergy, systemic disorders, sleep disturbances, or nutritional deficiences that lends itself to medical, surgical, and cosmeceutical treatments. A complete medical history with ROS and physical examination is encouraged prior to treating the aesthetic component. Sun protection is a cornerstone of therapy. Safety issues are of utmost concern when embarking upon treatments such as chemical peeling, filler injection, and laser therapy as not to worsen the pigmentation. Without intervention, POH usually progresses over time so early intervention and management is encouraged. The objective of this study was to review the current body of knowledge on POH, provide the clinician with a guide to the evaluation and treatment of POH, and to present diverse clinical cases of POH that have responded to different therapies including non-ablative fractional photothermolysis in two skin of color patients. J Drugs Dermatol. 2014;13(4):472-482.
Periorbital hyperpigmentation (POH) is one of the most commonly encountered conditions in routine dermatology practice. There are only few published studies about its prevalence, classification, and pathogenesis but none showing its association with habits, and other medical conditions in Indian patients. To determine prevalence and type of POH, common causative factors, and its association with personal habits and other disorders within various age and sex groups. Two hundred patients attending the dermatology OPD were included in study and were subjected to detailed history, careful clinical and Wood's lamp examination, eyelid stretch test and laboratory investigations. Clinical photographs of all patients were taken. POH was most prevalent in 16-25 years age group (47.50%) and in females (81%) of which majority were housewives (45.50%). Commonest form of POH was constitutional (51.50%) followed by post inflammatory (22.50%). Lower eyelids were involved in 72.50%. Grade 2 POH was seen in 58%. Wood's lamp examination showed POH to be dermal in 60.50%. Faulty habits were observed viz. lack of adequate sleep (40%), frequent cosmetic use (36.50%), frequent eye rubbing (32.50%), and lack of correction for errors of refraction like myopia in 12% patients. Strong association of POH with stress (71%), atopy (33%) and family history (63%) was noted. Periorbital hyperpigmentation is a multi-factorial entity. It is absolutely essential to classify the type of POH and determine underlying causative factors in order to direct appropriate measures for better and successful outcome in future.
Dark eye circle (DEC) is a common problem that usually lacks detailed classification in the etiology and structural variations. A newly-developed DEC Assessment Score using Wood's lamp and ultrasonogram will provide a more precise evaluation of DEC for improving treatment results. Sixty-five cases, including eight males and 57 females with a mean age of 38.9 years, were enrolled. DEC were classified into pigmented (brown), vascular (blue to purple), structural, and mixed type by Wood's lamp and ultrasonogram. A scoring system with nine parameters, including brown hue, pigmented lesions, blue/pink/purple hue, periorbital puffiness, shadow hue, infraorbital palpebral bags, infraorbital grooves, blepharoptosis, and skin type, was used for clinical evaluation. Pigmented, vascular, structural, and mixed types of DEC represented 5%, 14%, 3%, and 78%, respectively. Thirty-three cases with periorbital puffiness were found to have higher "pre-septal thickness" than those of 20 controlled cases (P = 0.032). Fourteen patients with infraorbital palpebral bags were proved to have protruded retroseptal fat pads by ultrasonography. Pigmentation and vascular and structural components may play important roles in DEC. Detailed classification of DEC types will access physicians in the decision of appropriate therapeutic modalities.
Many patients who request cutaneous carbon dioxide (CO2) laser resurfacing for correction of periorbital rhytides also complain of "dark circles" under their eyes. This study was conducted in order to determine the effectiveness of high-energy pulsed CO2 laser treatment in reducing infraorbital hyperpigmentation. Significant lightening of infraorbital hyperpigmentation was observed 9 weeks following CO2 laser resurfacing. Melanin reflectance spectrometry readings did not correlate with clinical findings. This study represents the first report of the successful use of a non-pigment-specific laser system for the treatment of infraorbital dark circles. The lack of correlation of melanin spectrometry readings with clinical assessment likely represents an insufficient follow-up time period.
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.