Evaluation and Treatment for Sudden Under-Eye Changes (Hollowness, Creasing, Thin Skin Appearance) (Photos)

Question

About me: 34F, 5’2”, 113 lbs. Dry, acne-prone skin. Hx: high DHEAS, eczema. No weight loss (gained ~2–3 lbs). Historically looked much younger than my age BUT Over the past 2–4 months, I’ve noticed a sudden change in my under-eye area: increased creasing/wrinkles when smiling, more hollow/shadowed appearance, and overall a more fatigued look. This was abrupt & noticeable to others who’ve asked me if I’ve been in tu sun too much or not sleeping (negative). During this same timeframe, I started spironolactone (50–100 mg) for acne/DHEAS. It cleared my acne & improved menstrual pain, but caused frequent nighttime urination. I’ve since reduced to ~50 mg intermittently. I also use retinol a couple times a week (including an eye cream), sunscreen, and basic skincare. I don’t drink caffeine or much alcohol, mostly just drink water, and haven’t had major lifestyle stressors. I stopped working 3 months ago (previously high screen time), so eye strain should be less. Questions: - Could this be dehydration/skin barrier damage vs early volume loss (tear trough)? - Could spironolactone or retinol be contributing? - Best conservative treatment approach? - Am I a candidate for PRF vs very conservative tear trough filler? - Are lasers appropriate or too harsh for dry/thin under-eye skin? Goal: understand cause and safest, most effective treatment.

Anna Chacon, MD, FAAD · Answer

This is a very thoughtful and detailed history, and honestly, the timeline you described is important.

A few key possibilities here:

1. Skin barrier + dryness contribution (very likely):

Retinoids around the eye area, even a few times weekly, can thin the appearance of the skin temporarily
Eczema history also makes the under-eye more reactive
This often creates more creasing and “fragility” in movement

2. Functional volume shift (possible but mild):

Even small changes in hydration, fat padding, or muscle tension can make the under-eye look suddenly different
Spironolactone can indirectly contribute via fluid shifts and increased urination, especially at higher doses

3. True volume loss:

Less likely given your stable weight and age, but early tear trough changes can become more visible when skin quality changes
My clinical impression

This sounds more like a skin quality + hydration + barrier disruption issue, rather than true structural aging.

Treatment approach (I would be conservative here):
Temporarily reduce retinol use around the eyes
Focus on barrier repair (moisturizing, gentle routine)
Consider pausing or adjusting spironolactone dose with your prescribing physician if timing correlates strongly
If still persistent:
PRF is often a safer first step than filler in thin, reactive under-eyes
Tear trough filler only if carefully selected and very conservatively placed

Lasers:

Not necessarily off limits, but I would be cautious with aggressive resurfacing in dry/eczema-prone skin

Camille Cash, MD · Answer

Various medications can definitely cause skin changes but it's not possible to say that is what caused your concerns.  Ensure you are getting adequate sleep, good hydration and eating a balanced diet. To treat under eye hollowness you can consider HA fillers.  The treatment is done in the office with some results seen immediately.  Always use an expert injector for optimal results.

Evaluation and Treatment for Sudden Under-Eye Changes (Hollowness, Creasing, Thin Skin Appearance) (Photos)

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