Hydroquinone is the gold standard for treating hyperpigmentation in dermatology. Its effectiveness and safety is so well-documented in clinical studies that almost all dermatology providers will recommend 4% hydroquinone as a first step for anyone with significant pigment concerns. This ingredient works by interrupting the same step of melanin synthesis that kojic acid and licorice extract do (2 ingredients mentioned in our previous blog post: Hyperpigmentation Part 1) however on a much more significant, medical-grade scale. It is important that anyone using hydroquinone consult regularly with a nurse practitioner or physician, because very rare cases of overuse or misuse have resulted in unsightly side effects. Oftentimes, your nurse practitioner will schedule you for a “hydroquinone vacation” during which you take time-off from using the drug.
Retinoids like tretinoin, tazarotene, and adapalene, are powerful synthetic versions of retinol which is a naturally-occurring vitamin that plays a role in maintaining many organs in the human body, including the skin. Numerous clinical studies have shown that when applied to the skin, retinoids are very successful at reducing freckles and sun spots. The effectiveness of retinoids results from their ability to interrupt multiple steps of melanin production. Furthermore, retinoids are an excellent choice for treating hyperpigmentation because they increase skin cell turnover and shedding, allowing for greater penetration of other active melanin-suppressing ingredients like hydroquinone. Although there are a handful of FDA-approved retinoids on the market, the most studied and well-vetted of all is tretinoin, which is why it is the prescription retinoid cream of choice for many dermatology providers. Topical over-the-counter retinol is also effective, however these formulations are not as stable and have a short shelf-life.
Now that we’ve discussed retinoids and hydroquinone, this brings us to another favorite tool amongst dermatology providers, Tri-Luma, a combination cream of hydroquinone, tretinoin, plus a small dose of fluocinolone which is a steroid anti-inflammatory. As we mentioned above, retinoids like tretinoin have the ability to act as a penetration-enhancer, augmenting the effectiveness of hydroquinone. Although this combo is quite powerful, both tretinoin and hydroquinone have the undesirable side effects of redness, irritation, and dryness. This is why the added anti-inflammatory is important – it counters these unwanted side effects, increasing patient comfort and convenience.
Even with the use of prescription-strength creams, improvements in pigmentation can take months, and not all pigmentation will always resolve. For more rapid improvement, in-office elective dermatology procedures are a wonderful supplement to any topical therapy. In fact, when high quality topicals are used in conjunction with procedures like chemical peels or microneedling (discussed in our next blog post Hyperpigmentation Part III), dramatic improvements in pigmentation can successfully be achieved.