Skin

Under-Eye Concerns: Dark Circles, Hollowing, Lines and Bags

The under-eye area covers four distinct concerns that look similar but have different causes and require different treatments. Dr Shahe Boghossian explains how to distinguish them and what each responds to.

Published 21 May 2026

The under-eye area is one of the most requested and most frequently mismanaged areas in aesthetic practice. The reason is that what patients describe as “dark circles” or “tired eyes” can have four entirely different underlying causes and what works for one does not work for the others. The clinical assessment that distinguishes these is the most important step.

The four distinct under-eye concerns

1. Vascular dark circles. A bluish-purple discolouration caused by the underlying orbicularis oculi muscle and periorbital vasculature showing through the skin. This type is often genetic, worsens with fatigue and dehydration, and is not driven by pigmentation. It does not respond to pigmentation-targeting treatments.

2. Pigmented dark circles. A brownish discolouration that represents actual melanin in the periorbital skin. More common in patients with darker skin tones, with sun damage or with a genetic predisposition. This type does respond to pigmentation management.

3. Structural shadowing. This is not true dark circles at all. It is the shadow cast by a hollow or groove in the tear trough region. Volume loss creates a concavity that casts a shadow in any light. This type is structural, not chromophore-based, and responds to volume restoration.

4. Lower eyelid bags. Fullness or puffiness in the lower eyelid caused by herniation of orbital fat through a progressively laxer lower eyelid septum. This is a structural anatomical change. Non-surgical treatment can improve the skin quality of the area but cannot address the fat herniation itself. Significant cases require assessment for surgical correction.

What assessment involves

Under-eye assessment at The London Road Clinic begins with a detailed examination in natural and angled light, with the patient both resting and animated. The Observ 520 skin analysis is useful for distinguishing vascular from pigmented darkness and for assessing subsurface skin quality.

Treatment approaches by type

Vascular dark circles. The most limited type from a treatment standpoint. Improving the quality and thickness of the periorbital skin over time through polynucleotides can reduce vascular show-through by building a more substantial tissue barrier. Results are gradual and modest.

Pigmented dark circles. Topical management is the primary approach: daily broad-spectrum SPF, vitamin C, niacinamide and tranexamic acid. Lumecca IPL can be used cautiously in appropriate skin tones with specialist eye protection. For Fitzpatrick IV-VI, topical-first is strongly preferred.

Structural shadowing. Volume restoration is the most effective approach. Polynucleotides improve skin quality, provide structural support and reduce crepey texture. Profhilo can improve overall periorbital skin quality. Tear trough filler with a low-viscosity hyaluronic acid product, placed by an experienced injector, can restore volume to the hollow directly. This is one of the most technically demanding filler applications because of the thin skin, proximity to the orbital rim and the risk of the Tyndall effect.

Following an in-person consultation with our prescribing clinician, in line with current GMC, NMC, GPhC and GDC guidance.

Lower eyelid bags. For fluid-related puffiness, lifestyle and skincare approaches provide temporary relief. For structural bags caused by fat herniation, conservative in-clinic treatment can reduce appearance in mild cases. For moderate to significant structural bags, the honest recommendation is surgical assessment.

Realistic expectations for the under-eye area

The under-eye area is where expectation management matters most. Structural bags with significant fat herniation need surgery. Vascular darkness in very thin, fair periorbital skin has limited treatment options. What is achievable for most patients: meaningfully improved skin quality and texture, reduction in the hollowing component of shadowing, calmer and less crepey skin.

Frequently asked questions

Can polynucleotides replace tear trough filler?

Not directly. Polynucleotides improve skin quality, thickness and tissue support through collagen stimulation and anti-inflammatory signalling. Tear trough filler adds physical volume to a hollow. For patients with mild hollowing and a primary skin quality concern, polynucleotides may be sufficient. For meaningful volume restoration, filler is the more direct answer. Many patients benefit from both, sequenced at consultation.

What is the Tyndall effect and how is it avoided?

The Tyndall effect is a blue-grey discolouration that appears when hyaluronic acid filler is placed too superficially in thin-skinned areas, most commonly the tear trough. It is avoided through appropriate product selection, careful placement depth and conservative volume. Where it does occur, it is treated with hyaluronidase.

Do eye creams make a meaningful difference?

Some do, for specific concerns. Retinol-containing eye creams used consistently over months increase skin thickness and reduce fine lines. Vitamin C reduces pigmentation. Caffeine-containing products provide temporary vasoconstriction that reduces vascular darkness briefly. The most important topical is SPF, applied daily.

Is tear trough filler safe?

In experienced hands, with appropriate product selection and careful technique, yes. The tear trough is one of the higher-risk filler sites because of skin thinness and proximity to vascular anatomy. The considerations are: Tyndall effect, overcorrection, bruising and vascular complications. At The London Road Clinic, tear trough filler is only placed following full assessment and informed consent.

Are under-eye bags the same as tear trough hollowing?

No. Tear trough hollowing is a concavity, a loss of volume, that creates shadow. Lower eyelid bags are a convexity, a fullness, caused by fat herniation or fluid. They are structurally opposite problems. Sometimes they coexist: the hollow beneath the bag makes the bag more prominent by contrast.

Related advice

Injectables

Patient Guide: Polynucleotides

A comprehensive patient guide to polynucleotide injections at The London Road Clinic: how they work, what Croma Polyphil is, who they suit, and how they compare to other regenerative injectables. Written by Dr Shahe Boghossian, Medical Consultant, GMC 5204600.

21 May 2026