So Your Derm Prescribed You Hydroquinone. Now What?

A few years ago, after trying countless over-the-counter spot correctors to no avail, I took my stubborn dark spots to a dermatologist. “I don’t know what to do about this hyperpigmentation,” I told him, referring to the tiny post-inflammatory marks left behind by my hormonal acne. He examined my skin, then said the words I’d been waiting to hear: "I'm going to prescribe you a hydroquinone compound." Bingo. I’d given up on anything I could find on the shelves at Sephora and Target and was ready to give the medical-grade brightening mixture a spin.

This wasn't my first encounter with hydroquinone. Growing up, women in my West Indian family reached for tubes of Ambi Fade Cream and Nadinola containing 2% of the ingredient, the legal over-the-counter concentration, to fade spots on their skin. A topical skin-lightening agent, hydroquinone has been used for decades to treat hyperpigmentation. In the United States, dermatologists prescribe it frequently — but its global reputation is fraught.

Widespread use of the ingredient for skin-bleaching purposes and a thriving black-market pipeline have led to questions about its safety, and for good reason: Hydroquinone isn’t meant to be used at high levels or for extended periods of time, and when it is, there could be dangerous results. Currently, the ingredient is banned in the European Union, Japan, and Australia; African countries like Ghana, Rwanda, Côte d'Ivoire, Tanzania, and South Africa have also put restrictions in place. But with other countries limiting consumer access to hydroquinone, it leaves American consumers confused: Is it really safe?

According to Carlos Charles, MD, dermatologist and founder of Derma di Colore in NYC, hydroquinone is safe — when used correctly. “Hydroquinone has been in use for years for treating various types of skin hyperpigmentation. When used appropriately it can be a safe and effective topical agent for treating hyperpigmentation,” Dr. Charles says. Many medical professionals still consider the ingredient the “gold standard” for treating hyperpigmentation, because it works.

"Hydroquinone inhibits the tyrosinase enzymes that are necessary for darkening the skin," explains Corey L. Hartman, MD, a dermatologist at Skin Wellness Centre in Alabama. By blocking those enzymes and stopping the production of melanin in the skin, hydroquinone prevents dark spots from getting darker and helps fade those that already exist. "It’s a very effective ingredient for treating dark spots, and it is currently approved for professional use up to 4%," says Candrice Heath, MD. Dr. Charles also says that he prescribes the ingredient in his practice several times a week for things like acne, injury, melasma, and sun damage.

With American dermatologists standing behind the ingredient, why is it vilified across the globe?

“Hydroquinone has garnered a negative reputation for several reasons,” says Dr. Charles. “First, there has been a great deal of misuse of hydroquinone, which can lead to various problems, some of which are difficult to reverse.” The melanin-inhibiting capabilities of hydroquinone have made it a favourite for those looking to get lighter skin. However, dermatologists agree that it’s best used as a target spot treatment, not an all-over solution.

"Hydroquinone should be used for a short period of time with the intended use to lighten hyperpigmentation," Dr. Hartman says, "not to completely change your complexion." However, the reality is that in many cultures the notion that lighter skin is more desirable exists, often leading people to the use of harmful bleaching products in the first place.

"There is definitely a premium placed on fair and clear skin in some societies," Shingirai Mtero, lecturer & doctoral candidate at Rhodes University in South Africa, says. "It's why companies make so much money on products that promise a clear, even skin tone." This preference isn't only prevalent in African countries: In some southeast Asian nations, skin-lightening solutions are offered in the form of ingestible pills and IV-injectables containing glutathione and vitamin C, in addition to topical creams. "A lot of the lightening products sold in African states are also imported from Asia, where pale skin is deemed to be more beautiful," says Mtero.

In addition to being used off-label for skin bleaching based on cultural pressures, poorly-regulated markets also cause misuse of the chemical. "Many imported products aren't heavily vetted in African markets," Mtero explains. “The medicines we produce ourselves are heavily regulated, but in open-market systems where products are imported, there is room for distribution of questionable skin care.” That open-market system is how skin-lightening creams with dangerous levels of hydroquinone and other ingredients find their way into Africa.

Around the globe and locally, lack of access to dermatologists, education, and finances for safe products continues to further enable the use of these black-market creams. "Many of these dangerous topicals are also significantly cheaper in non-regulated markets," Mtero says, "whereas brand-name imports cost significantly more, making unregulated creams more attractive to some." As Mtero explains, not all of these consumers are looking to significantly lighten their complexions. Many of them are simply seeking a way to fade their dark spots but, in an effort to save money, wind up with products containing an excess of hydroquinone.

"It's not that the chemical itself is bad," Mtero says. "It's the concentration that’s available in these unchecked markets that can become dangerous."

One of the most common risks of misuse is ochronosis, a skin condition that results in what Dr. Hartman calls a paradoxical reaction. "When you use hydroquinone at a high percentage, it can cause darkening of the skin, instead of the desired fading of a particular spot," he says.

As a dermatology resident, Janeen Chappel, MD, says she witnessed a patient suffer from leg ulcers after 10 years of using unregulated creams containing hydroquinone. “The cream was mixed with steroids, which the patient wasn’t aware of, and as a result, the skin on her legs became extremely thin,” Dr. Chappel says.

There is also the ongoing question of whether or not it puts humans at a greater risk for cancer. "There were some animal studies performed years ago that show that it was a carcinogen, but you need to take the dosage levels and delivery systems in the study into consideration," says Dr. Hartman. "There has yet to be a study that substantiates claims that it causes cancer in humans."

In 2006, the U.S. Food & Drug Administration proposed a ban on hydroquinone. The document stated that, while the risk of carcinogenicity in humans has yet to be confirmed, evidence of its carcinogenicity in animals does exist. “Under these circumstances, the use of hydroquinone as an active ingredient in OTC skin bleaching drug products cannot be justified," the researchers wrote. The FDA has yet to implement a ban on hydroquinone following the proposal.

In some black-market bleaching creams, potentially life-threatening ingredients are used in tandem with hydroquinone — including mercury, a toxic metal — in order to boost the effects. In a 2016 study, researchers found that bodily exposure to mercury can cause long-lasting neurological and kidney complications. "Mercury in bleaching preparations can be absorbed through the skin and accumulate in body organs, giving rise to severe toxicity," the study states.

In the United States, the FDA restricts the use of mercury in cosmetics and threatens “enforcement action” — including “seizure of products, injunctions, and, in some situations, criminal prosecution,” a release on the FDA website states — for anyone who sells or distributes skin whitening or lightening creams that contain mercury. Rwanda has taken a similar approach in the ongoing ban of all illegal skin-bleaching goods, including ones containing hydroquinone.

In a 2016 public service announcement made by the Rwanda Standards Board, officials declared that the chemical was restricted for medical use only — and even then the approved concentration is limited to 0.02%. “Some manufacturers have resorted to the use of alternative names of hydroquinone as an ingredient in their commercial daily used body cosmetics,” the statement reads. “As a consequence, unsuspecting customers have suffered as a result of the application of such ingredients.”

According to the local Rwandan news outlet The New Times, police confiscated over 5,000 skin-lightening products containing illegal amounts of hydroquinone in a December 2018 raid alone. "Unfortunately, the danger doesn't erase the demand," Mtero says. "With many open economies, there is still the possibility of supply. However, I do believe that the government's current approach is the most effective way to institute a ban on a dangerous ingredient."

Experts believe that there is a middle ground that can be met when it comes to treating hyperpigmentation. The first step is education. "I always tell my patients to use it for no more than two months at a time,” Dr. Hartman says. “I also require regular check-ins so I can monitor progress.” Alternatively, Ron Robinson, cosmetic chemist and founder of Beauty Stat, says that consumers who are wary of using hydroquinone should consider brightening alternatives. "You should only trust hydroquinone-containing items made by reputable manufacturers," Robinson says. "However, other ingredients like mulberry, vitamin C, licorice, kojic acid, and niacinamide are also effective and safe in treating skin discolouration." Dr. Charles adds that tretinoin, adapalene, and azelaic acid are also effective options for treating hyperpigmentation.

While the sanctioning of hydroquinone continues to be debated worldwide, its efficacy under doctor supervision means it’s still prescribed frequently today. Since being introduced to the ingredient by my former dermatologist and sticking to a consistent skin-care routine, my existing hyperpigmentation has drastically improved. I haven’t experienced any negative side effects as a result of using the ingredient, and it’s a spot treatment that I use occasionally, not as part of my daily beauty regimen.

Dermatologists are aware of the impact the idea of skin lightening has on society, and still urge patients — and professionals — to approach treating hyperpigmentation with care. "It's important to not throw these ingredients and treatments around liberally because I don't want to harm a patient, but, above all, I don't want to be a part of feeding the beast of insecurity instilled in our society," Dr. Hartman says. "Treating skin conditions like hyperpigmentation is delicate, and it should be treated as such."