LOWER EYELID PROBLEMS

How many times a week do I get asked by my patients how to get rid of the "dark circles" under their eyes? The term is a catch-all used by physicians and patients to refer to problems that have a vast range of genetic, environmental, and skin-related causes. It is a common and frustrating problem, with little structure in its definition and few full-proof treatments. Below is my proposed classification system for the definition of dark circles and clinical pearls for their treatment. Most patients, however, have a combination of each type and multifactorial causes that need to be addressed.

Infraorbital fat pad protrusion. Also known as "eye bags."
Blepharoplasty is the best, and for now the only, solution for severe fat pad prominence. Referral to a board certified plastic surgeon or dermatologic surgeon is recommended.
If the protrusion is mild and tear troughs are prominent, fillers may be injected into the tear trough area to help mask the protrusion. My favorites for this area are hyalauronic acid fillers like Juvéderm Ultra or Restlyane, sometimes double diluted with normal saline or injected with a 32-gauge needle.

For loose skin with "bags," radiofrequency lasers can provide some benefit. The Thermage eyelid tip produces results over 3-6 months, with repeat treatment possible at 6 months. I always advise patients that this treatment is not a replacement for surgery but can provide some benefit in those who are not surgical candidates or who do not want surgery.

Infraorbital edema. Also known as "puffiness."
The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying or water retention from high blood pressure or eating high sodium foods are some of the reasons the loose, thin epidermis becomes edematous.
Treat seasonal allergies with over-the-counter allergy medications or prescription medications for resistant allergies or possible sinus infections.
I advise patients to switch their sleep position. Sleep position can be contributing to undereye bags through gravity. Sleeping on the side or stomach can encourage fluids to collect under the eyes. If patients report being a side sleeper, you may notice a heavier bag on the side they report sleeping on. Patients who wake up with puffy eyes can sleep on their back and add an extra pillow under their head.
I also advise patients to avoid rubbing their eyes, going to bed with makeup on, and using harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

Eye bags could be a sign of an underlying medical condition, especially if bags appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause undereye fluid retention and patients will need to see their primary care doctors for further evaluation.
Patients can place an ice pack, slices of cucumbers, chilled tea bags, refrigerated eye gels, or even a package of frozen peas on their eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

Periorbital hyperpigmentation. Also known as "dark circles."
Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin undereye skin. Patients should avoid rubbing the area. Chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened undereye skin.
Retinoic acid creams can help slough the dark pigmented skin. It should, however, be used in very small amounts that increase over a few weeks to avoid severe irritation.
Skin lightening creams with azaleic acid, kojic acid, and glycolic acid can be found in varying strengths. Hydroquinone creams have been successful in lightening undereye hyperpigmentation. Strengths in over-the-counter preparations start at 1-2% and in prescription strength can be compounded to higher than 4%, but caution should be used to avoid further irritation and potential post-inflammatory pigment from these products.Light chemical peels can assist in lightening dark undereye pigmentation. Peels with hydroquinone or retinoic acid can be used for an added lightening benefit.Intense pulse light can help minimize undereye pigmentation, particularly UV-induced pigmentation. Q-switched lasers have also been reported to be effective.

Infraorbital tear trough depression.
Most often, dark circles aren't about changes in the color of the skin. Instead, they're created by a loss of volume in the area around the eye, exposing the orbital bone and creating a hollow trough that shows up as a dark circle. These changes are often genetic, but significant weigh loss can also expose undereye tear trough depressions.The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Use caution, however; this is a highly technical and injector-dependent procedure.
There are crucial vascular structures around the eye that need to be avoided, and over-filled troughs will give patients a puffy appearance and may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not FDA approved to treat undereye depressions, so patients should be knowledgeable to the risks and benefits prior to undergoing these procedures.

Periorbital vascular prominence.
With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin, which can cast dark shadows and make the area appear dark.Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.For large blue veins, vascular lasers such as a long pulse Nd:YAG laser can be recommended. However, in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques.

Periorbital static and dynamic rhytids.
Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3-4 months apart will ensure long lasting benefits and because botulinum toxin wears off, repeat treatments are needed. Laser resurfacing with CO2 or fractionated CO2 lasers provide excellent benefit for periocular rhytides. A traditional CO2 laser may require repeat treatment in 6-12 months. Fractionated CO2 lasers typically require 4-6 treatments spaced about 4 weeks apart to provide benefit.

Overall tips:
For most of the types of infraorbital issues, makeup can help conceal or mask some imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If they have mild discoloration, I advise that they pick a liquid formula for more prominent imperfections. A cream, full coverage concealer works best. Patients should quit smoking, which dehydrates the skin and causes premature aging and collagen degradation. I always remind patients to apply sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. I advise patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated