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Caution required: patients on anticoagulants (bleeding risk at injection sites), patients with a history of herpes simplex around the eyes (treatment may activate a flare), patients with unrealistic expectations or those expecting a single session to fully resolve long-standing dark circles, and patients whose dominant cause is pure tear trough volume loss (where filler is the more appropriate first-line treatment)

Adv Med Sci 2014;59:256260

J., Ayalon-Dangur I., Ayalon-Dangur R., Naamany E., Gafter-Gvili A., Koren G., et al

5.1.1 DNA methylation alterations 5.1.1.1 Aberrant imprinting and global hypomethylation Critical imprinting regions undergo substantial methylation changes following EED exposure

2025 Feb 24;8(1):299

Much of the safety data comes from animal studies, where researchers report on tolerance and effects in those models