Dark circles: when to worry about an underlying disease? Complete guide
Written and reviewed by Dr Bernard Hayot, ophthalmologist, RPPS 10003926226.
Dark circles
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Dark circles are among the most common aesthetic concerns in oculoplastic consultations.
These shadows under the eyes, often bluish or brownish, give a hollow, aged, sometimes even unwell appearance.
Yet very different causes lie behind this common symptom, and this is where it becomes complicated. Treating dark circles without understanding their origin is like treating a fever without taking the temperature: you miss the target.
Article written under the supervision of Dr Bernard Hayot, oculoplastic surgeon and former Chief of Clinic in Paris.
I often see patients who have tried everything: brightening creams costing two hundred euros a tube, laser sessions in beauty clinics, even poorly suited filler injections. The result? Temporary effects, irritation and, above all, growing frustration. Why?
Because dark circles are not a single condition but a symptom with many faces. Some are due to simple periorbital hyperpigmentation, others to a marked hollow beneath the eyelid, others still to venous stasis or age-related thinning of the skin.
This is why the diagnosis is key: a precise clinical analysis, sometimes supplemented by skin ultrasound or blood tests, helps avoid unnecessary treatments.
In this article, I therefore explain what I see in consultation, the pitfalls, the solutions that work and those that disappoint.
For example, a thirty-eight-year-old patient came to see me after three fractional laser sessions that had made her dark circles worse. The problem?
An undiagnosed chronic allergy, responsible for persistent inflammation. A simple antihistamine treatment combined with targeted lipofilling transformed her appearance in six weeks.
Conversely, a fifty-five-year-old patient believed his dark circles were due to tiredness. In reality, it was suborbital fat atrophy, impossible to correct without an autologous fat graft. These cases illustrate a simple truth: there is no single solution for dark circles, but several, each suited to the underlying mechanism.
This is the precision I champion in my eyelid & oculoplastic surgery practice.
Whether you have pathological dark circles related to an underlying condition, stubborn hyperpigmentation, or a hollow
that gives you a sad appearance, the aim is the same: to offer you a tailored strategy, with no miracle promises but with lasting results. Because beyond appearance, self-confidence is often what is at stake. And no tube of cream can replace that.
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Dark circles: when are they a sign of disease?
She describes persistent fatigue despite eight hours of sleep, morning headaches and a sensation of heavy eyelids. Clinical examination shows asymmetric periorbital hyperpigmentation, more marked on the left, with oedema of the lower eyelids.
Blood work confirms subclinical hypothyroidism as the cause. This case illustrates that dark circles are not always a simple cosmetic matter.
Benign and pathological dark circles: how to tell them apart?
Benign dark circles are often symmetrical, stable over time and worsened by tiredness or lack of sleep. They generally result from skin hyperpigmentation, increased transparency of the skin under the eyes, or local venous congestion.
A study published in the Journal of Cosmetic Dermatology (2019,
Conversely, pathological dark circles come with associated symptoms: persistent oedema, itching, pain or changes in skin texture.
Dark circles of medical origin may reveal underlying conditions. Periorbital hyperpigmentation, for example, is sometimes the first sign of an endocrine disease such as hypothyroidism or Addison’s disease.
Inflammatory skin conditions such as eczema or atopic dermatitis can also cause dark circles through chronic irritation of the skin. Finally, kidney or liver disease sometimes leads to a build-up of toxins, showing as a greyish or yellowish discolouration of the eyelids.
Warning symptoms not to ignore
Certain signs should raise concern and warrant a specialist consultation. If your dark circles worsen rapidly, become asymmetric or come with persistent swelling, this may indicate an underlying condition.
Here are the symptoms that should prompt a consultation:
– Persistent lower eyelid oedema lasting more than 48 hours, even after a restorative night’s sleep. – Itching or burning around the eyes, which may suggest contact dermatitis or an allergy.
– Abnormal colouring (yellowish, greyish or purplish) associated with intense fatigue or joint pain.
– Sudden worsening of dark circles with no obvious cause (lack of sleep, stress, dehydration). – A family history of endocrine or autoimmune disease, which increases the risk of pathological dark circles.
Decision tree: when should you consult a specialist?
When a face shows dark circles, the first step is to rule out benign causes. If your dark circles are symmetrical, stable and worsened only by tiredness.
Simple measures may be enough: improving sleep hygiene, hydrating the skin, or using brightening creams. However, if the dark circles come with unusual symptoms, a consultation with a dermatologist or an oculoplastic surgeon is necessary.
I systematically recommend a full blood workup if dark circles appear suddenly or worsen without explanation.
This workup generally includes TSH (thyroid hormone), ferritin (to detect iron deficiency), a full blood count and liver function tests.
This approach is not appropriate if your dark circles are isolated and without associated symptoms. In that case, aesthetic solutions such as fractional lasers or hyaluronic acid injections may be considered.
It should also be noted that certain conditions affecting the eyelids, such as cutaneous amyloidosis, are rare but serious. They present with purplish dark circles and thickened skin, and require a biopsy for confirmation. If you notice these signs, prompt medical attention is essential.
Diseases and conditions associated with dark circles
They sometimes reveal underlying conditions that I encounter in consultation.
I will explain which ones, and how to tell them apart.
Allergies and dermatitis: frequent and overlooked causes
Respiratory and skin allergies often make dark circles worse. Atopic dermatitis, for example, causes itching that leads to rubbing of the eyes.
This chronic friction irritates the thin skin of the eyelids and stimulates melanin production. In my allergic patients, I observe seasonal worsening of dark circles, particularly in spring.
Some colleagues treat these cases with antihistamines alone. I prefer to combine this with a full allergy workup.
Why? A simple skin test can identify the allergen responsible and tailor the treatment.
Thyroid problems: hypothyroidism and hyperthyroidism
Hyperthyroidism, by contrast, causes eyelid retraction. This exposes more of the white of the eye and gives the impression of more pronounced dark circles.
I never perform eyelid & oculoplastic surgery on these patients without a prior thyroid workup.
Anaemia and nutritional deficiencies: the role of iron and vitamins
Iron deficiency is the leading medical cause of dark circles that I encounter.
Poor oxygenation of the tissues gives the skin a bluish or purplish hue. A blood test is enough to confirm this diagnosis. In my anaemic patients, I often see a visible improvement after two months of supplementation.
Vitamin B12 and vitamin D deficiencies also worsen dark circles.
I routinely check these vitamin levels before considering any cosmetic treatment.
Liver and kidney disease: associated skin signs
Liver diseases such as hepatitis or cirrhosis cause toxins to build up in the blood.
This shows as a yellowish colouring of the eyelids, which can resemble dark circles. A 48-year-old patient had persistent dark circles despite every treatment. Her liver workup revealed non-alcoholic fatty liver disease.
Kidney problems such as chronic kidney failure cause under-eye bags and dull skin.
I often work with nephrologists for these patients. It is important to know that these dark circles will not disappear with creams or lasers. Treatment must target the underlying cause.
Protocols, dosages and fees are never published here: they are determined in consultation, after examination, and set out in writing in the estimate.
This page is for information. It does not replace a consultation: every situation is judged on examination.