Under-eye Dark Circles: Looking at the Literature

With thin skin and little subcutaneous fat, the area around the eyes is one of the first places that people notice the signs of aging. There are a lot of ideas floating around regarding under-eye dark circles. Here we review some the recent literature to shine light on the topic.

Sleep: evidence shows sleep is unrelated to dark circles

A recent study from Case Western Medical School published in the journal Clinical & Experimental Dermatology compared the under-eye circles of good and bad sleepers. They found no difference between the groups, consistent with another study of 500 Brazilian women whose under-eye circles also showed no correlation with their sleep. Sleep was important for other aspects of skin health & appearance, however, with poor sleep causing accelerated skin aging, and worse healing (in particular healing UV-induced damage). You can read the article here.

What causes under-eye circles then?

A recent article in the journal Clinics in Plastic Surgery reviews the current thinking on what causes dark circles under the eyes. They identify three major contributors for most people. It should be noted that this article was very procedure-focused and that the authors collect consulting fees from the makers of Juvederm (a major hyaluronic acid filler).

1. Hollowing & Shadowing: As we age, the fat under our eyes breaks down. The loss of volume results in more shadows from other parts of the face, which results in the appearance of dark circles. This volume can be improved with the injection of hyaluronic acid fillers.

2. Excessive Pigmentation: Certain factors like UV light and estrogen can cause melanocytes in the skin to proliferate, resulting in more pigment and a darker appearance under the eyes. The gold standard treatment of hyperpigmentation of the skin is the prescription drug hydroquinone. It can also be treated with laser treatments that break down pigment.

3. Prominent Blood Vessels: Because the skin of the eyes is so thin, it is easy for underlying blood vessels to become visible through the skin, resulting in a dark blue or purple hue under the eye. This can be targeted with laser treatments that break down red blood cells & small blood vessels. These blood vessels also become engorged in several conditions (crying, sleeping without the head elevated). Sleeping with the head elevated and avoiding emotional stress may be helpful.

Full article here.

Caffeine: A popular cosmetic with little evidence base

Many cosmetic companies market caffeine gels for the treatment of dark under-eye circles, and several dermatologists have endorsed this approach. The data behind this recommendation, however, appears to be weak. Recent articles tend to cite a small study from Thailand that showed no statistical difference in the improvement in eye puffiness between base gel & caffeine-containing gel.

Clinical trial can be found here.

Anti-oxidants: Vitamin C has little to no effect on under-eye dark circles

The majority of studies looking at topical anti-oxidant creams (often containing vitamins E & C) are not controlled, making it difficult to study their efficacy. One trial from Japan used vitamin C on one eye and a control gel on the opposite eye. They showed no improvement in under-eye pigmentation, but a small improvement in under-eye erythema (a measure of the blood-vessel component to under-eye circles) with certain vitamin C formulations. Overall, the effect was not dramatic.

Clinical trial can be found here.

What should I do about it then?

Unfortunately, the literature behind over-the-counter cosmeceuticals for dark under-eye circles & puffiness is weak. There is very little data to suggest that these products (caffeine gels, anti-oxidant creams) will do much to help the problem. Some prescription products (hydroxyquinone for hyperpigmentation) and procedures (laser therapy & injectable hyaluronic acid) seem to do a better job. In terms of home care, avoiding expensive under-eye creams and focusing on regular skin care (daily sunscreen use, regular moisturizing) appears to be the best approach – reducing the signs of facial skin aging more generally. Although there is limited evidence to support the practice, sleeping with the head elevated may decrease the congestion of blood vessels under the eyes, and this logical technique is easy to implement.

Dark under-eye circles are not related to sleep or caffeine. Over-the-counter creams don’t have strong efficacy data. Image Source: Friedman et al. (2015) Dark Circles: Etiology & Management Options. Clin Plastic Surgery 42: 33-50.

Wear Sunscreen, Bro.

A new study from the Center for Disease Control (CDC) in the Journal of the American Academy of Dermatology showed that Americans are not following CDC guidelines regarding sunscreen use. Men were the worst.

Sunscreen protects against UV radiation from the sun, which is classified as a World Health Organization (WHO) class I carcinogen (the same grade as cigarette smoke). Proper sunscreen use prevents skin cancer, wrinkle formation, and aging of the skin.

The study showed that Americans in general do a bad job of applying sunscreen, but the data for men were particularly alarming. 44% of men reported never wearing sunscreen. Only 15% of men regularly wear sunscreen. The study’s authors suggest that this may be because men view sunscreen as non-masculine, messy, or inconvenient.

The CDC also reported that the incidence of melanoma has doubled in the past 30 years, highlighting how important it is for all Americans to use sunscreen regularly.

A few sunscreen tips:

– Use sunscreen with SPF 30 or greater for appropriate protection (increasing SPFs provided limited added benefit and are significantly more expensive).

– Make sure your sunscreen is broad spectrum with UV-A & UV-B coverage.

– Apply sunscreen 20 minutes before going into the sun.

– Reapply every two hours and after swimming / significant sweating.

– It is important to wear sunscreen when going out in the sun for an hour or more, but we are exposed to UV light in our daily lives. Applying SPF 30 to all sun exposed areas (don’t forget the ears!) every day can prevent the risk of skin cancer and reduce the signs of skin aging.

– The lips are sensitive to UV light too. Don’t forget to protect them.

Some important sun facts:

– On cloudy days, 80% of the suns rays still make it to your skin. Be sure to wear sunscreen even on overcast days.

– You do not need the sun to get vitamin D. Vitamin D can be safety supplemented through the diet and with over-the-counter supplements.

– UV from the sun is most intense between 10:00am and 2:00pm. Seek shade during these hours when possible.

Full article here: http://ac.els-cdn.com/S0190962215013523/1-s2.0-S0190962215013523-main.pdf?_tid=92faae04-0a01-11e5-ac13-00000aacb35d&acdnat=1433343938_2106a903a69a66fb3749d38a88bbd57a

This man applies SPF30 sunscreen every morning before leaving the house. He applies sunscreen every two hours when he goes to the beach. He is going to have younger-appearing skin, fewer wrinkles, and a dramatically decreased risk of skin cancer.
Image Credit: Bigstock

Do your genes make you want to tan?

A study from the Yale School of Medicine published in Experimental Dermatology compared 79 individuals with “tanning dependence” – people who are essentially addicted to tanning (for example continuing to tan despite skin cancer) – with 213 individuals who tan recreationally but who are not addicted. They found that people with tanning dependence were more likely to have a unique gene – the “patched domain containing 2” (PTCHD2) gene. The protein product of this gene is found throughout the brain, but scientists have yet to describe its exact function. You can read the full study here: http://onlinelibrary.wiley.com/doi/10.1111/exd.12503/pdf.

Another article in Archives of Dermatology from the University of Texas in Galveston describes this subset of patients whose tanning closely resembles alcohol abuse, applying the DSM-IV criteria for alcohol dependence to UV light dependence. With growing rates of skin cancer secondary to excessive tanning, this under-recognized addiction may have significant public health implications: http://archderm.jamanetwork.com/article.aspx?articleid=398011.

A study in the journal experimental medicine identified a novel gene (PTCHD2) that is associated with a psychological tanning dependence / addiction.

Human breast milk does not improve your baby’s eczema

Atopic dermatitis (commonly referred to as “eczema”) is a common chronic itchy skin condition. It is thought to be immune-mediated. Because human breast milk contains several immune compounds (IgA antibodies, lactoferrin, toll-like receptors), it could theoretically have some benefit in atopic dermatitis.

A small study from Norway in BMC Dermatology compared moisturizer alone to moisturizer + human breast milk on infants with atopic dermatitis. The study did not show that human breast milk improved atopic dermatitis. Interestingly, it did not increase the rate of infection of the lesions, suggesting that it is a safe but ineffective strategy.

The full article can be found here: ://www.biomedcentral.com/content/pdf/s12895-015-0027-9.pdf

This child has atopic dermatitis. Putting human breast milk on it probably will not help.

Some people put human breast milk on their eczema. This is strange, and a small study was not able to demonstrate any benefit to this practice.

Coffee Reduces Skin Cancer Risk

A new paper from the Yale School of Public Health shows a correlation that suggests that drinking four or more cups of coffee each day can reduce your risk of melanoma: http://jnci.oxfordjournals.org/content/107/2/dju421.full.pdf+html.

Another study in the New England Journal of Medicine a few years ago showed that drinking coffee reduces your chances of death! http://www.nejm.org/doi/pdf/10.1056/NEJMoa1112010.

Let this coffee emoji serve as a reminder that drinking 4+ cups of coffee per day may reduce your risk of melanoma and early death!