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April - May 2006


Hydroquinone, the skin lightening ingredient: Not all badů

by Dr V Hubbard & Dr S Chopra

We read with interest the article ‘The Complexity of Complexion’ by Sujata Jolly, India Link International, February and March 2006 issue. Whilst we agree that hydroquinone, used to lighten the skin, can have adverse effects, we feel that these may have been overstated. We also believe that there are benefits of this treatment, when used by Dermatologists experienced in this field.

Hydroquinone can cause irritation of the skin. For this reason, dermatologists use it carefully, in combination with 2 other products. The triad of hydroquinone, tretinoin (a topical vitamin A derivative, useful in treating skin problems such as acne and used to reduce signs of photoageing of the skin) and a mild topical steroid can be very useful in treating a select group of skin conditions. The commonest indication for this combination treatment is melasma. Melasma is a common condition that produces hyperpigmentation of the face or neck. Several factors contribute to the development of this discoloration, including pregnancy, use of the oral contraceptive pill, sun exposure and genes. Melasma is much more common in asian skin than in white skin. Melasma can have a severe adverse psychological and emotional effect on affected individuals. Multiple studies have shown the benefit of treatment with hydroquinone, in combination with tretinoin and a topical steroid. One such study showed that 80% of patients with melasma, treated with this combination, showed a significant improvement in the appearance1. Furthermore, only 2.5% experienced adverse effects such as skin irritation, necessitating discontinuation of the treatment. Another study showed enhanced quality of life for the patients after using the triad of creams for 8 weeks2.

Other uses of hydroquinone, in combination with tretinoin and a topical steroid, are postinflammatory pigmentation, such as occurs after severe acne. Indeed, one paper describes this combination as ‘the gold standard’ for treating pigmentation changes after acne in asian skin3. In addition, hydroquinone is an important component of skin preparation before and after chemical peels when used to treat acne scars and facial wrinkles.

There is no doubt that hydroquinone has been linked to cases of exogenous ochronosis (asymptomatic paradoxical increased pigmentation of the skin caused by long-term use of bleaching creams). The risk of this however remains low. 1 large study in Senegal showed that less than 4 in 100 people using hydroquinone developed ochronosis4. Further studies have shown a lower prevalence of ochronosis in other countries. The reason for this difference is unclear, but it is speculated that it is either a racial variant or due to additional products being used5. We would advocate the use of hydroquinone in combination

We would advocate use of sunscreen (at least SPF 30) in all patients using hydroquinone in the above combination. The reason for this is to prevent the skin discoloration, such as melasma, from returning.

To our knowledge, there is no evidence that hydroquinone adversely affects wound healing.
In summary, we agree with Ms Jolly that hydroquinone can be dangerous when used in the wrong manner and we applaud her for her campaigning role in creating public awareness of this. The removal of hydroquinone from cosmetic creams has been an important milestone. However, we believe that the judicious use of hydroquinone, in combination with other products, by dermatologists experienced in this field, can be very useful for a select group of skin conditions.

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