She apologised for looking tired. That was the first thing she said when she sat down. She’d had a full eight hours, she told me, and still — she gestured at her face. The circles had been there for years, but they seemed darker lately, more sunken. She was forty-three.
I told her what I tell almost every patient who comes in describing this: dark circles are almost never about sleep.
Sleep affects them, yes — fluid redistribution during the night, reduced lymphatic flow when we’re upright, cortisol levels that impact inflammation. These are real mechanisms. But when patients ask about dark circles in their 40s, they are describing something structural and progressive, not something that will resolve with an extra hour in bed.
Three causes, rarely one alone
In my practice at SW1 Clinic, I’ve found that most dark circles in patients over 40 have three possible drivers — often operating simultaneously.
The first is pigmentation. This is particularly common in Fitzpatrick phototypes III to V — which includes most of my Southeast Asian and East Asian patients. Periorbital melanin hyperpigmentation is genetically determined and significantly exacerbated by chronic UV exposure. Singapore’s year-round sun, combined with the fact that most people stop applying sunscreen about two centimetres below the orbital rim, means this pigmentation accumulates over decades. The skin around the eye is the thinnest on the face — around 0.5mm in that zone — and any pigment change shows dramatically.
The second cause is vascular. The skin beneath the eye is thin enough that subcutaneous blood vessels are visible, giving a bluish-purple cast. This has nothing to do with melanin and does not respond to lightening treatments. It responds to treatments that either address the vascularity directly — certain laser modalities — or improve skin thickness, which reduces the visual impact of the underlying vessels.
The third cause is structural: volume loss and skeletal resorption creating a tear trough deformity. This is the one I see most in patients in their 40s and 50s. As the orbital fat pad descends and mid-face volume diminishes, a shadow forms. That shadow looks like a dark circle. No cream will address it because it’s not a skin problem — it’s a three-dimensional structural problem.
The reason patients are often confused is that the same feature — a dark, hollow appearance under the eye — can result from any combination of these three mechanisms. Treating pigmentation when the real driver is structural will achieve nothing. Treating the structure when pigmentation is the primary issue will also disappoint.
Why Asian patients present differently
I want to be direct about something that gets glossed over in most general skin literature: the dark circle literature is largely based on Caucasian patients.
Asian patients tend to present with a combination of periorbital pigmentation and structural hollowing earlier than their Caucasian counterparts. This is partly genetic — periorbital hyperpigmentation is highly heritable and has a higher prevalence in South, East, and Southeast Asian populations. It is also partly a consequence of the melanin-rich skin phototype responding more dramatically to any inflammatory trigger, including UV, rubbing the eyes, and even chronic allergies.
In Singapore, allergic rhinitis is endemic. I ask almost every patient with significant dark circles whether they suffer from nasal allergies. The venous congestion around the eyes from chronic nasal congestion — what dermatologists sometimes call the “allergic shiner” — is a frequently overlooked contributor that is entirely addressable once you identify it.
A study published in the Journal of Clinical and Aesthetic Dermatology reviewed the aetiology of periorbital hyperpigmentation and found that constitutional pigmentation was the most common cause in Asian patients, followed by post-inflammatory pigmentation and shadowing from prominent tear troughs [1]. This matches what I observe clinically.
The structural problem nobody wants to hear about
The tear trough conversation is the one most patients aren’t prepared for. When a patient shows me under-eye darkness and I explain that part of what they’re seeing is actually a shadow created by volume loss in the mid-face — not a skin problem at all — there’s often a pause.
The mid-face descends. The orbital fat pad migrates. The ligamentous support that keeps everything in position loosens with age and oestrogen decline. The result is a crease or hollow that begins at the inner corner of the eye and traces outward along the orbital rim. In darker phototypes, this shadow is visually indistinguishable from pigmentation until you assess it properly.
Treating this with hyaluronic acid filler placed along the tear trough — when done conservatively and precisely — can meaningfully reduce the apparent darkness without touching the skin at all. Revitalift is an approach we use at SW1 for patients where structural hollowing is a significant driver. But I always assess the full picture first, because overfilling the tear trough creates its own problems — the Tyndall effect, which produces a bluish discolouration from poorly placed filler, is something I regularly see in patients who’ve had this done too aggressively elsewhere.
What you can actually do
A proper assessment of your dark circles should include: an examination in good lighting, an assessment of skin quality (thickness, pigmentation, texture), and a three-dimensional evaluation of the undereye and mid-face structure.
If pigmentation is the primary driver: consistent daily application of SPF to the orbital area — actually to the orbital area, not stopping at the cheekbones — combined with a retinoid or vitamin C serum applied carefully to the periorbital skin over months. Expect slow progress. This is a years-long process, not a quick fix.
If vascularity is the driver: certain picosecond laser modalities and light-based treatments can be helpful. I also find that polynucleotide treatments in this region can improve skin thickness over time, which reduces the visual impact of underlying vessels.
If structure is the driver: the conversation shifts to volume, support, and potentially HIFU or radiofrequency tightening to address laxity in the surrounding tissues.
Most of my patients need a combination approach. I tell them this at the first consultation, because managing expectations is also part of the treatment.
You are not tired. Your face is simply telling a more complicated story than “get more sleep.” And like most complicated stories, it’s worth taking the time to understand properly before responding.
References
[1] Ranu, H., et al. (2011). Periorbital hyperpigmentation: A review of etiology, medical evaluation, and aesthetic treatment. Journal of Clinical and Aesthetic Dermatology, 4(2), 20–24. [VERIFY — confirm before publishing]
[2] Freitag, F. M., & Cestari, T. F. (2007). What causes dark circles under the eyes? Journal of the European Academy of Dermatology and Venereology, 21(2), 139–144. https://doi.org/10.1111/j.1468-3083.2006.01St.x [VERIFY — confirm before publishing]
[3] Sheth, P. B., et al. (2014). Periorbital hyperpigmentation: A study of its prevalence, common causative factors and its association with personal habits and other disorders. Indian Journal of Dermatology, 59(2), 151–157. [VERIFY — confirm before publishing]
