In many countries worldwide including the Philippines, India and South America, lightening your entire face or large areas of your body is a common goal to make one’s self more competitive in the marriage or job market. A lighter complexion is often seen as a way to climb up the social ladder, make new contacts, find a spouse, get a job etc.
In late 2009 Dominican-born Chicago Cubs baseball player Sammy Sosa showed up at the Latin Grammies with skin lightened by several shades. Sosa admitted to using creams to lighten his skin as well as getting bleaching treatments.
Pigment cells in the skin called melanocytes produce skin pigmentation called melanin from the amino acid tyrosine. The reaction is stimulated by genetics, sun exposure, skin inflammation or irritation and the aging process. Hydroquinone, a molecule discovered in the late 1800s and initially used to develop photographs, can block this reaction. The ability of hydroquinone to depigment skin was first noted in 1940 in wearers of rubber gloves made with compounds related to hydroquinone. Skin discoloration (the opposite of depigmentation) from chronic over application of hydroquinone was first noted in 1960. We call this onchronosis.
Later it was discovered that the addition of vitamin A derivatives and topical steroids allowed patients to tolerate higher concentrations of hydroquinone and lighten skin more quickly. The combination was so effective that it could create complete white patches of skin on an Afro-American no matter how dark their baseline skin color was. The problem was application of 3 different creams a day was cumbersome. At that time if you combined them they would interact with room air and the resulting product (triple bleaching cream) had a very short shelf life. By the late 1990s that problem was solved so stable triple skin bleaching creams became available. I would use them to prepare patients for laser skin resurfacing and then restart the creams a week or 2 after the laser treatment. This regimen prevented the temporary increased pigmentation we used to see after laser skin resurfacing treatments.
In 1982, the FDA published a rule to propose that over the counter skin bleaching drug products containing 1.5 to 2 percent hydroquinone be generally recognized as safe and effective (GRASE). The higher concentrations of 4% or more required a prescription. In 2006 research revealed that hydroquinone taken orally by mice or rats could cause cancer. Note that humans only apply it to the skin surface at much lower doses. They do not eat it. It also has been linked with a medical condition in humans known as ochronosis (skin darkening and disfiguration) when applied topically. At that time the FDA requested more scientific testing on hydroquinone. Those tests began in 2009 despite a hydroquinone ban in Britain beginning in 2001.
Less than 10 years ago a commercially available triple bleaching cream called Triluma became available by prescription. On 11/17/10 the FDA recalled specific batches of Triluma, “Firm was notified by supplier of a subpotent active ingredient”. That is not the same as a complete ban and the product can still be used. It contains 4% hydroquinone and therefore requires a prescription.
Directions for usage of both over the counter and prescription strengths clearly state that hydroquinone is to be used for only short term (4-6 months) and should be stopped if no result is seen by that time.
With prolonged exposure to hydroquinone, even the weaker over the counter formulations, there is progressive sooty darkening, inflammation, irritation, thickening and hyperpigmentation of the skin (darkened bluish/gray patches of skin). This condition is called onchronosis and individuals with darker complexions are at higher risk of getting it after prolonged use. It can occur with frequent applications in less than a year. For this reason it is recommended that hydroquinone be used for spot treatment and not all over the skin and for short durations. Allergic reactions to hydroquinone can cause dermatitis, which may lead to dark or reddened, inflamed and scaly patches on the skin.
Episode of Dr. Oz highlighting the problems with the over use of hydroquinone containing products.
For this reason it is recommended that hydroquinone be used for spot treatment and not all over the skin and for short durations. Typically, skin lightening can be seen in about four weeks. Once the desired effect is achieved, the treatment may be used less frequently to maintain results.
Those with sensitive skin, should test the hydroquinone product on a small patch of skin before applying to large areas. If no adverse reactions are seen within 24 hours, the treatment can be continued. Mild side effects such as itching, stinging or slight redness are usually temporary. More serious side effects include: burning, itching, crusting or swelling, and unusual skin discoloration one should stop using the product immediately and see a doctor if any of these reactions occur.
Lumixyl™ is a non-toxic, non-irritating, synthetic that can also lighten skin color or even out skin surface pigmentation by blocking the melanin producing enzymes. Lumixyl is an over the counter product sold through professional channels, whereas Triluma requires a prescription from a doctor.
Studies show that Lumixyl™ can reduce melanin synthesis by as much as 40 percent compared to treatments with hydroquinone, which reduced production by only 7 percent in the same study.
Other skin-lightening options include:
* Arbutin: Derived from the leaves of blueberry, bearberry, cranberry or mulberry shrubs, or from certain genus of pear, arbutin contains the natural form of hydroquinone.
* Azelaic acid: Most commonly, this ingredient treats acne, but recent studies have shown it benefits skin discoloration, too. Azelaic acid is made from wheat, rye or barley, and is usually found in creams at a concentration of 20 percent.
* Kojic acid: Derived from fungus and fermented rice, kojic acid also inhibits melanin production. Kojic acid oxidizes quickly and will turn brown if left exposed to air. Check the expiration date and be sure to store kojic acid products in a cool, dark place, away from heat or light.
* Licorice extract: A tyrosinase inhibitor, licorice extract is a potent skin lightener that disrupts skin’s melanin synthesis and also has anti-inflammatory qualities.
* Mild alpha hydroxy acids like Malic acid act as exfoliants. By sloughing off dead skin cells, they take away extra pigment and pigment cells as well.
* Dermamelan is a mixture of mild chemical peels, sunscreen, vitamin C and a natural hydroquinone like substance (Kojic Acid, Phytic Acid, Ascorbic Acid, Titanium Dioxide, Arbutine and Retinyl Palmitate) that is first applied as a mask in the doctor’s office. The patient goes home with the mask in place and then applies a cream of the material on a daily basis for several months. Skin lightening is visible within 2 to 8 weeks.
Before and After Dermamelan Treatment
Anything that lightens the skin automatically makes it more sensitive to sun damage including sun induced skin cancers. Also sunlight exposure directly counteracts the effects of skin bleaching creams. So these products should always be used in conjunction with sunscreens. You can get more information about sunscreens at my blog Suntanning and sunscreens
Aaron Stone MD – Plastic Surgeon Los Angeles
Aaron Stone MD – twitter
