Dark circle refers to conditions that present with relative darkness of the periorbital skin or eyelids. It can affect individuals with a wide range of age, both sexes and all races. It worsens with the aging process of skin sagging and altered subcutaneous fat distribution. It has significant cosmetic concern for female patients and males as well now days.

Excessive Pigmentation

Excessive pigmentation is due to dermal melanocytosis or post inflammatory hyper-pigmentation secondary to some disease like atopic dermatitis. It is seen as slightly brownish curved band along inferior orbital rim. Dermal melanocytosis is due to congenital causes like Nevus of Ota or environmental causes like excessive sun exposure and drug ingestion. Histologicaly characterized by the presence of melanocytes in the dermis.

Post inflammatory hyper pigmentation is due to rubbing or scratching the periorbital area. The causes are air born contact dermatitis, fragrance allergy, atopic dermatitis etc.

Other causes of periorbital hyper pigmentation include Erythema dyschromicum perstans, fixed drug eruption Familial conditions - genetically determined form of hyper-pigmentation involving the periorbital area.

Thin, Translucent Lower Eyelid Skin Overlying The Orbicularis Oculi Muscle Because of thin, translucent lower eyelid the subcutaneous vascular plexus or vasculature contained within the muscle become prominent. The violaceous appearance is more prominent in the inner aspect of the lower eyelids and is usually accentuated during menstruation in females.

Shadowing Due To Skin Laxity And Tear Trough

Another cause of infraorbital dark circles is shadowing due to skin laxity and tear trough associated with aging. Collagen and elastin present in the eyelids and periorbital skin undergo ultraviolet induced and age related degeneration. In addition the damaged epidermis releases collagenases, which further contributes to collagen degeneration resulting in dermatochalasia and periocular rhytides which are common manifestations of aging. Skin laxity due to photo ageing imparts a shadowing appearance on the lower eyelids that results in infraorbital dark circles.

The tear trough is a depression centered over the medial side of the inferior orbital rim. It is also an age-related change due to the loss of subcutaneous fat with thinning of the skin over the orbital rimligament that confers hollowness to the orbital rim area. Combination of the hollowness and the overlying pseudoherniation of the infraorbital fat accentuate the shadow in the tear trough depending on the lighting conditions.

Treatment Options for Dark Circles

  • • Topical Agents
  • • Chemical Peeling
  • • Lasers
  • • Autologous Fat Transplantation and fillers
  • • Surgery – Laser Blepharoplasty The therapeutic modalities must differ depending on the cause because Periorbital dark circles are due to multiple factors.
  • Topical Agents:

    • • Hydroquinone
    • • Topical retinoic acid (RA), 0.01% to 1
    • • The Kligman formulation
    • • Other compounds used as depigmenting agents include azelaic acid, steroids, kojic acid, and pidobezone etc.
    • • Vit-C: in serum form is less irritating and has better penetration into the skin. Daily application or massaging Vit-C (VC-15) after microdermabrasion, chemical peel or Laser treatment gives better lightning of periorbital area.

    Chemical Peeling

    • • Chemical peeling is defined as the application of one or more chemical agents that lead to controlled destruction of the skin, resulting in the removal of lesions localized in the epidermis or in the upper dermis.
    • • Peels can be superficial, medium, or deep.
    • • Different peels use around eye for periorbital pigmentation are:
    • •Refinity Peel (Glycolic acid 70%) and Cosmederm Peel (Glycolic acid 50%)
    • •Biphasic Peel

    Biphasic Peel: it is composed of two phase in one peeling session. The first phase active ingredients contain a mixture of alpha-hydroxy & beta- hydroxyl acids that help in removing facial blemishes, leaving fresh skin, improving surface and skin tone. The second phase helps in absorption of specific active ingredients effective against pigmentation or controls the progression of premature ageing.

    Lasers

    Safety should be emphasized when treating dark circles with lasers, because the eye is particularly vulnerable to laser injury. Therefore, use of proper eyewear (goggles, wrap-around glasses, or preferably internal metallic eye shields) is crucial. The retina and the choroid contain the highest concentration of melanin in the body, and eye damage is possible even through closed eyelids. When treatment is necessary near the eyes, a large metal eye shield should be inserted over the Autologous Fat Transplantation And Fillers This modality of treatment is useful when the cause for periorbital darkness is thin and translucent lower eyelid skin overlying the orbicularis oculi muscle. It hides the vascular areas and reduced the transparency of the skin. Use of hyaluronic acid gel to fill the periorbital hollows and restores volume has emerged as a less invasive procedure with good results.

    Surgery – Laser Blepharoplasty Trans-conjunctival blepharoplasty is done to remove pseudoherniation of the orbital fat as well as lax skin which reduces the shadowing effects. Removal of excess skin of upper eye lid improves dark circle considerably. Blepharoplasty assisted with Ultra Pulse CO2 Laser is the latest trend in this surgery.

    Summary:

    • 1. Multi-factorial in etiology hence find out the cause before you treat.
    • 2. The brown and blue-grey color caused by dermal melanin deposition.
    • 3. Bluish color secondary to the visible dermal capillary network, and shadowing secondary to skin laxity and bulging.
    • 4. When excessive pigmentation is cause, treat with topical bleaching agent, chemical peels and lasers.
    • 5. Dark circles mainly due to the eyelid bulging caused by orbital fat pseudoherniation should be corrected primarily using transconjunctival blepharoplasty.
    • 6. If dark circles are combined with prominent skin laxity, skin tightening or excision is recommended.
    • 7. Autologous fat transplantation may be a treatment option for patients with infraorbital darkening due to prominent vascularity and thin skin.
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