NEW ORLEANS – Addressing the problem of dark lower eyelid circles may require the use of multiple modalities, but defining the cause is the first step toward effective treatment, Dr. Joel E. Kopelman said at the annual meeting of the American Academy of Cosmetic Surgery.
Lower eyelid dark circles affect patients of all ages and races and often create a fatigued and sad appearance. Loss of volume in the eyelid, midfacial, and orbital areas; superficial and deep pigmentation; thin, translucent skin with a paucity of fat between the skin and orbicularis muscle; and shadowing from herniated or pseudo-herniated protruding fat all might contribute to the appearance of dark lower eyelid circles, he said.
Dr. Joel E. Kopelman
By first identifying the source of the dark circles, practitioners can make informed decisions about the correct course of treatment. “Some are easier to treat than others, but each one presents its own challenge,” said Dr. Kopelman, an ophthalmic plastic surgeon in Ridgewood, N.J.
Correcting the appearance of lower eyelid circles entails the use of one or more modalities, depending upon the etiology of the problem. “Volume restoration alone doesn’t address the entire problem, nor does it maximize the opportunity for improvement,” Dr. Kopelman said. “The issue of pigmentation is one that we often overlook.”
He recommends a primary skin evaluation with the use of a Wood’s lamp, which will assess the depth of pigmentation and intensify superficial pigment. If skin hyperpigmentation is the cause of the dark circles, lightening the skin with topical phenolic or nonphenolic depigmenting agents, and/or laser therapy, might help to significantly reduce lower eyelid skin pigmentation.
Hydroquinone (HQ) and Kojic acid are considered the strongest phenolic bleaching agents, he noted. Topical application of these compounds should start at twice a day for 4-6 weeks, but long-term use of these treatments can lead to irritation, so treatment should be spread out and/or lessened as needed.
Nonphenolic bleaching compounds also can be used to treat pigmentation. “Over time, these compounds can yield nice blanching without the toxicity of HQ, but you have to use them for several months to get the kind of results you want,” he added.
Melanozyme (lignin peroxidase) is another treatment effective at reducing pigment. “This is sometimes used in conjunction with hydroquinone right away, since Melanozyme breaks down existing melanin rather than trying to prevent melanin from forming,” Dr. Kopelman stated. There is no delay in activation with the use of Melanozyme, as opposed to the use of HQ, which usually takes several weeks to have a suppressive effect on pigment generating cells. He recommends an initial therapy regimen of a phenolic bleaching agent with or without the use of Melanozyme, and the substitution of nonphenolic compounds in a long-term therapy regimen.
Fractionated lasers also can be used to apply these drugs, he reported. The protocol involves creating a channel of predetermined depth and density, which allows for immediate application and penetration of topical drugs. Dr. Kopelman recommends applying medication immediately after delivering the fractionated laser treatment to the pigmented area, which will allow the medicine to better penetrate into the deeper layers of skin.
Chemical peels and laser resurfacing can be used as a secondary level of therapy, but “these can induce postinflammatory hyperpigmentation, so I’m very cautious about using anything that delivers heat or strong chemicals, as they can make things worse,” he warned. Laser treatment can be used as a tertiary level of treatment to disrupt melanin production. “But using lasers around the eyelids can be dangerous, so you have to be very cautious,” he added.
Patients must understand that the process of treating dark undereye circles takes time, and realistic expectations are a central part of the process, Dr. Kopelman emphasized. Often, multiple modalities are necessary to achieve an improvement, so patients must commit to long-term treatment, be compliant with applying medication on a daily basis, avoid sun exposure, and wear polarized sunglasses and sunblocks to prevent the sun from stimulating melanin production and achieve improved aesthetic outcomes.
Dr. Kopelman reported no relevant financial disclosures.