What are “bleaching creams” for the skin and are they safe to use?

Bleaching creams? A common question in the office particularly in the summer months when freckles and brown patches on the face begin to surface.  But winter and spring is a great time to prep the skin in advance of the deluge of the sun’s stimulating rays.  So, no matter the time of year, let’s talk bleaching creams.

While there are bleaching and lightening creams for hair on the skin, today we’re talking about lightening brown patches and freckles on the skin.  

Brown pigmentation is visible on the skin when our skin pigment cells called melanocytes overproduce pigment in confined areas.  When in small areas, they are often called “freckles”.  When in larger patches, the pigment patches are called “melasma”.  Melasma is most often seen on the face of women in areas like the upper lip, cheeks and forehead.

Traditionally, the active prescription ingredient in most “bleaching creams”, which are more aptly described as lightening creams, is hydroquinone.  Hydroquinone works to inhibit tyrosinase, an important enzyme in melanin production.  Melanin is produced by melanocytes in the epidermis, the outer layer of the skin.  So, hydroquinone works well to resolve superficial pigmentation.

Hydroquinone is available in OTC products in lower concentrations, but the prescription strength of hydroquinone is 4%.  Depending on the severity of pigmentation, it can be used once or twice a day.  While there are compounded products with higher concentrations, there is a risk of a condition called exogenous ochronosis (which appears as worsening pigmentation) with higher concentrations.

In addition to hydroquinone, there are a few other topical options that are used for melasma.  Nonprescription topical ingredients that can reduce pigmentation include Vitamin C, retinol, arbutin, azelaic acid, ferulic acid, turmeric and kojic acid.  Unfortunately, none of these work as well a topical hydroquinone.

Why do some sites recommend avoiding hydroquinone?  In the past many hydroquinone products contained harmful mercury, but this is no longer allowed by the FDA.  Some patients experience irritation from the sulfur preservative that is in most hydroquinone products, causing an allergic or sensitivity reaction in those allergic to sulfur.  While ORAL hydroquinone caused cancer in rats, there has never been any studies showing a risk of cancer from using hydroquinone topically.  Most dermatologists, including Dr Rosenberger, consider 4% hydroquinone to be very safe. 

Does hydroquinone permanently lighten spots?  Oh how I wish!  No, pigment cells are easily stimulated by sun and blue light and can easily begin producing pigment again even once the area seems normal in color.  Because of the temporary nature and relatively high cost, it is often not feasible to use a lightening cream in large areas such as the arms or legs. Other than hydroquinone, what other skin care products can have a lightening effect on brown spots?  Retinoids, in particular tretinoin, have been shown to augment the effectiveness of hydroquinone.  Because both tretinoin and hydroquinone can be slightly irritating, there is a prescription product called Tri-Luma cream that includes both ingredients as well as a topical steroid to prevent irritation. In addition, some formulations of hydroquinone such the ZO prescription strength Pigment Control+Blending are designed especially to be used with tretinoin at night for a great synergistic effect.  ZO does also offer some non-hydroquinone products such as the ZO Retinol Brightner.

What about sun protection?  I’m a dermatologist, so I would be remiss if I didn’t recommend wearing a sunscreen with zinc or titanium oxide EVERY SINGLE DAY.  Product with additional blue light protection also block the stimulating effects of blue light on pigment cells.  I encourage patients that it is a total waste to invest in a lightening cream and not use a daily sunscreen.  

Protect with sunscreen.  Calm the pigment cells with hydroquinone.  Stimulate the growth of new healthy skin with a retinoid.  It’s a prescription for success. 

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