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Skin Discolorations with Normal to Dry Skin
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Skin Discolorations with Normal to Oily Skin
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Causes of DiscolorationRegardless of your ethnic background or skin color, eventually most of us will struggle with some kind of brown or ashen pigmentation problem. Skin will either appear lighter or darker than normal in concentrated areas, or you may notice blotchy, uneven patches of brown to gray discoloration or freckling. Skin pigmentation disorders occur because the body produces either too much or too little melanin. Melanin is the pigment produced by specific cells (melanocytes). It is triggered by an enzyme called tyrosinase, which creates the color of our skin, eyes, and hair. (Melanin actually has two major forms that combine to create varying skin tones. Eumelanin produces a range of brown skin and hair color, while pheomelanin imparts a yellow to reddish hue.)
As far as skin is concerned, depending on how much is present, melanin does provide some amount of sun protection by absorbing the sun's ultraviolet light. This explains why darker skin colors are less susceptible to sunburn and the overall effects of sun damage. But less susceptible doesn't mean immune from problems.
Increased melanin production —also known as hyperpigmentation —is often referred to as melasma, chloasma or solar lentigenes. Melasma is a general term describing darkening of the skin. Chloasma is generally used to describe skin discolorations caused by hormones. These hormonal changes are usually the result of pregnancy, birth control pills or estrogen replacement therapy. Solar lentigenes is the technical term for darkened spots on the skin caused by the sun. Solar refers to sunlight and lentigene describes a darkened area of skin. These spots are quite common in adults with a long history of unprotected sun exposure.
Aside from sun exposure and hormones, hyperpigmentation can be caused by skin damage, such as remnants of blemishes, wounds or rashes (Source: Cutis, August 2005, pages 19-23). This is especially true for those with darker skin tones.
By far, for all skin colors, the most typical cause of darkened areas of skin, brown spots or areas of discoloration is unprotected sun exposure. Once incorrectly referred to as liver spots, these pigment problems have nothing whatsoever to do with the liver. In fact, these discolorations wouldn't have appeared in the first place if skin was diligently protected from the sun over the years.
On lighter to medium skin tones, solar lentigenes emerge as small- to medium-sized brown patches of freckling that can grow and accumulate over time on areas of the body that receive the most unprotected sun exposure, such as the back of the hands, forearms, chest, and face. For those with darker skin colors, these discolorations can appear as patches or areas of ashen-gray skin. Regardless of how or why these benign discolorations occur, the thought is the same worldwide: this is something women want to get rid of and prevent from recurring (or ever taking place).
Sunscreen
Store shelves are lined with products claiming to lighten skin. But without question, the first line of defense is smart sun behavior (meaning avoidance) along with the daily use (365 days a year) and liberal application (and, when needed, reapplication) of a well-formulated sunscreen. Diligent use of a sunscreen alone allows some repair as well as protection from further sun damage, which is what created the problem in the first place (Source:
Journal of the American Academy of Dermatology, May 2005, pages 786-792;
American Journal of Epidemiology, April 2005, pages 620-627; and
The British Journal of Dermatology, December 1996, pages 867-875). No other aspect of controlling or reducing skin discolorations is as important as being careful about exposing your skin to the sun and the use of sunscreen, SPF 15 or greater (and greater is usually better), with the UVA-protecting ingredients of titanium dioxide, zinc oxide or avobenzone. Using skin-lightening products, exfoliants, peels or laser treatments without also using a sunscreen will prove to be a waste of time and money. Sun exposure is one of the primary causes of melasma, and other treatments can't keep up with the sun's daily assault on the skin. Before you look at any other option for brown or ashen skin discolorations, applying sunscreen and reducing sun exposure are the most practical steps to start with.
Topical Treatments
Topical hydroquinone is the next step in reducing or eliminating skin discolorations. In fact, topical application of hydroquinone is considered by many dermatologists to be a safer, as effective (if not more so), and far less expensive option than lasers or deep peel treatments. Topical hydroquinone in 2% (available in cosmetics) to 4% concentrations (available from a physician or by prescription), alone or in combination with tretinoin 0.05% to 0.1%, has an impressive track record. Research has repeatedly shown hydroquinone and tretinoin to be powerful tools against sun- or hormone-induced melasma (Source:
Dermatologic Surgery, March 2006, pages 365-371).
Some research has shown topical azelaic acid in 15% to 20% concentrations to be as efficacious as hydroquinone with a decreased risk of irritation. Tretinoin by itself has also been shown to be especially useful in treating hyperpigmentation of sun-damaged skin. Kojic acid, alone or in combination with glycolic acid or hydroquinone, also has shown good results due to its inhibitory action on tyrosinase (though kojic acid has had its share of problems in terms of stability and potential negative effects on the skin and is rarely being used nowadays). Several plant extracts and vitamin C also have some research showing them to be effective for inhibiting melanin production (Sources:
Journal of the American Academy of Dermatology, May 2006, pages S272-S281;
International Journal of Dermatology, August 2004, pages 604-607; and
The American Journal of Clinical Dermatology, September-October 2000, pages 261-268). The most reliable and best ones by far to look for are reviewed below.
Hydroquinone
Hydroquinone deserves more discussion because it has long been established as the most effective ingredient for reducing and potentially eliminating melasma. Over-the-counter hydroquinone products can contain 0.5% to 2% concentrations of hydroquinone, while 4% (and sometimes even higher) concentrations are available only from a physician.
In medical literature, hydroquinone is considered the primary topical ingredient for inhibiting melanin production. Using it in combination with the other options listed in this section —especially tretinoin—can greatly reduce and even eliminate skin discolorations (Sources:
Cutis, March 2006, pages 177-184;
Journal of Drugs in Dermatology, September-October 2005, pages 592-597;
Journal of Cosmetic Science, May-June 1998, pages 208-290; and
Dermatological Surgery, May 1996, pages 443-447). Interestingly, hydroquinone is not only a hero for those with sun- or hormone-induced melasma, but its components have potent antioxidant abilities (Source:
Journal of Natural Products, November 2002, pages 1605-1611).
Hydroquinone is a strong inhibitor of melanin production (Source:
Journal of Dermatological Science, August, 2001, supplemental, pages 68-75), meaning that it prevents skin from making the substance responsible for skin color. Hydroquinone does not bleach the skin, which is why calling it a bleaching agent is a misnomer as it can't remove pigment from the skin cell. Hydroquinone can only disrupt the synthesis and production of melanin hyperpigmentation, which is actually true of any skin-lightening ingredient. When you prevent melanin from being generated, as new skin cells are formed and move to the skin's surface, they do not contain the excess pigment (melanin), therefore reducing or eliminating these darkened areas.
Some concerns about hydroquinone's safety on skin have been expressed, but the research when it comes to topical application indicates negative reactions are minor or a result of using extremely high concentrations or from other skin-lightening agents such as glucocorticoids or mercury iodine. This is particularly true in Africa where adulterated skin lightening products are commonplace (Sources:
British Journal of Dermatology, March 2003, pages 493-500 and
Critical Reviews in Toxicology, May 1999, pages 283-330).
According to Howard I. Maibach, M.D., professor of dermatology at the University of California School of Medicine, San Francisco, "Overall, adverse events reported with the use of hydroquinone... have been relatively few and minor in nature.... To date there is no evidence of adverse systemic reactions following the use of hydroquinone. and it has been around for over 30 years in skin-care products." Maibach also has stated that "hydroquinone is undoubtedly the most active and safest skin-depigmenting substance..." Research supporting Maibach's contentions was published in the
Journal of Toxicology and Environmental Health (1998, pages 301-317). Concern about hydroquinone having carcinogenic properties is mostly from industrial-grade materials and uses. For cosmetic use there appears to be no similar evidence.
Despite hydroquinone’s impressive track record and efficacy, in September 2006, the Food and Drug Administration (FDA) recommended that products containing hydroquinone be sold only with a prescription due to their opinion that it posed certain health risks. The FDA asserts there are animal studies showing it may be a possible carcinogen, and studies from Africa showing risk of a skin disorder called ochronosis (Source: http://www.fda.gov/OHRMS/DOCKETS/98fr/E6-14263.htm).
More than 200 products containing hydroquinone are currently sold in the United States, and, according to Dr. Susan Taylor, founding director of the Skin of Color Center in New York City and assistant professor of dermatology at Columbia University, "Hydroquinone is the gold standard for treating pigmentation disorders and has been for many years. I consider it to be very safe and effective" (Source: Pittsburgh Post-Gazette, Wednesday, September 6, 2006).
I concur. There is abundant research from reputable sources that shows hydroquinone to be safe and extremely effective (Sources:
Cutis, August 2006, Supplemental pages 6–19;
Journal of Cosmetic Laser Therapy, September 2006, pages 121–127;
American Journal of Clinical Dermatology, July 2006, pages 223–230; and
Journal of the American Academy of Dermatology, May 2006, Supplemental, pages 272–281). Surprisingly, there is even research showing that workers who handle pure hydroquinone actually have lower incidences of cancer than the population as a whole (Source:
Critical Reviews in Toxicology, May 1999, pages 283–330). Research to the contrary was done either using products contaminated with other ingredients or was performed on mice using high concentrations of hydroquinone—and that doesn’t equate to the levels of hydroquinone used in topical, over-the-counter skin-care products. Further evidence that this proposed ban doesn’t make sense comes from the American Academy of Dermatology (AAD), who doesn’t agree with the FDA’s proposal—yet the AAD stands to gain the most if consumers can only obtain hydroquinone products with a dermatologist’s prescription.
The negative research about hydroquinone and the frightening assertions being levied in the media are not related to how this effective ingredient is used in skin-care products sold in the United States. It has been, and still is, the most effective topical agent for fading and/or eliminating sun- or hormone-induced brown skin discolorations.
Because of hydroquinone's action on the skin, it can be a skin irritant, particularly in higher concentrations of 4% or greater and predictably when combined with tretinoin. Some medications have been created that combine 4% hydroquinone with tretinoin and a form of cortisone. The cortisone is included as an anti-inflammatory. The negative side effect of repeated application of cortisone is countered by the positive effect of the tretinoin so it doesn't cause thinning of skin and damage to collagen (Source:
Drugs in Dermatology, July-August 2004, pages 377-381).
Hydroquinone can be an unstable ingredient in cosmetic formulations. When exposed to air or sunlight it can turn a strange shade of brown. Therefore, when you are considering a hydroquinone product, it is essential to make sure it is packaged in a non-transparent container that doesn't let light in and minimizes air exposure. Hydroquinone products packaged in jars are not recommended because they become ineffective shortly after opening.
Alternatives to Hydroquinone
Although hydroquinone has the highest efficacy and a long history of safe usage behind it, there are other alternatives that have shown some promise for lightening skin. But these have been far less researched and often pale in comparison to hydroquinone. It is interesting to point out that some of these alternative ingredients are, ironically, derivatives of hydroquinone. They include Mitracarpus scaber extract, Uva ursi (bearberry) extract, Morus bombycis (mulberry), Morus alba (white mulberry), and Broussonetia papyrifera (paper mulberry)—all of which contain arbutin (more technically known as hydroquinone-beta-D-glucoside)—which can inhibit melanin production. Pure forms of arbutin are considered more potent for affecting skin lightening (alpha-arbutin, beta-arbutin, and deoxy-arbutin).
Other options with some amount of research regarding their potential skin lightening abilities are licorice extract (specifically glabridin), azelaic acid, and stabilized vitamin C (L-ascobic acid, ascorbic acid, and magnesium ascorbyl phosphate). What has not been conclusively established for most of these hydroquinone alternatives is how much is needed in a cosmetic lotion or cream to obtain an effect.
There is also a small amount of research showing oral supplements of pomegranate extract, ellagic acid, vitamin E, and ferulic acid can inhibit melanin production. All of these options are worth considering and experimenting with. However, compared to the extensive research concerning hydroquinone's effect on inhibiting melanin production, these alternatives may very well disappoint, but their natural allure is hard for consumers to ignore (Sources:
Experimental Dermatology, August 2005, pages 601-608;
Bioscience, Biotechnology, and Biochemistry, December 2005, pages 2368-2373;
International Journal of Dermatology, August 2004, pages 604-607;
Journal of Drugs in Dermatology, July-August 2004, pages 377-381;
Facial and Plastic Surgery, February 2004, pages 3-9;
Dermatologic Surgery, March 2004, pages 385-388;
Journal of Bioscience and Bioengineering, March 2005, pages 272-276;
Journal of Biological Chemistry, November 7, 2003, pages 44320-44325;
Journal of Agriculture and Food Chemistry, February 2003, pages 1201-1207;
International Journal of Cosmetic Science, August 2000, pages 291-303; and
Anti-Cancer Research, September-October 1999, pages 3769-3774).
Arbutin
A bit more information on arbutin is warranted. As mentioned above, arbutin contains a form of hydroquinone derived from the leaves of bearberry, cranberry, mulberry or blueberry shrubs, and also is present in most types of pears. Because of arbutin's hydroquinone content it can have melanin-inhibiting properties (Source:
The Journal of Pharmacology and Experimental Therapeutics, February 1996, pages 765-769). Although the research describing arbutin's effectiveness is persuasive (even if most of the research has been done in vitro), concentration protocols have not been established. That means we don't know how much arbutin it takes to lighten skin when it is added to a cosmetic formulation. Moreover, most cosmetics companies don't use "arbutin" in their products because there are patents controlling its use for skin lightening. To get around this problem many cosmetics companies use plant extracts that contain arbutin. Unfortunately, there is little to no research showing the plant extract source of arbutin as having any impact on skin, especially not in the tiny amounts used in cosmetics.
The only products available with a rather high concentration of arbutin (about 5%) are Shiseido's Whitess Intensive Skin Brightener, Shiseido's Luminizing Night Essence, and Shiseido's Cle de Peau The Cream. Despite the pricing disparity, these formulations have far more in common than they do differences. Be forewarned: The Cream comes in jar packaging, which will not keep the arbutin stable for very long after opening.
Tretinoin
A great deal of research has shown that the use of tretinoin (also known as all-trans retinoic acid as found in the prescription medication Renova and Retin-A) can only be somewhat effective in treating skin discolorations (Sources:
Dermatologic Surgery, March 2006, pages 365-371;
Acta Dermato-Venereologica, July 1999, pages 305-310;
International Journal of Dermatology, April 1998, pages 286-292; and
Journal of the American Academy of Dermatology, March 1997, pages S27-S36). However, the skin's response to tretinoin is far more noticeable and impressive when it is used in combination with hydroquinone or azelaic acid. Because of this, tretinoin is generally not recommended as the only topical option for melasma but is best used for the purpose of reducing darkened areas of skin in combination with other effective topicals, particularly sunscreen and hydroquinone (Source: eMedicine Journal, www.emedicine.com http://www.emedicine.com, November 15, 2001).
Even though tretinoin by itself can be disappointing for skin lightening, this should in no way diminish its role in the improvement of skin's healthy cell production, collagen production, elasticity, texture, and dermal thickness. Tretinoin, combined with more effective skin-lightening treatments, is a powerful ally in the battle against sun-damaged and aged skin.
Alpha Hydroxy Acids
Alpha hydroxy acids (AHAs)—primarily in the form of lactic acid and glycolic acid—are the most researched forms of AHAs because they have a molecular size that allows effective penetration into the top layers of skin. It is generally assumed that in and of themselves AHAs in concentrations of 4% to 15% are not effective for inhibiting melanin production and won't lighten skin discolorations in that manner. Rather, it is believed that their benefit is in helping cell turnover rates and removing unhealthy or abnormal layers of superficial skin cells (exfoliation) where hyperpigmented cells can accumulate. However, other research has shown that lactic and glycolic acids can indeed inhibit melanin production separate from their actions as an exfoliant on skin (Source:
Experimental Dermatology, January 2003, supplemental. pages 43-50).
Either way, there is a good amount of evidence that in combination with other treatments—such as hydroquinone, azelaic acid, laser resurfacing, and, of course, an effective sunscreen—AHAs can be very effective for improving the overall appearance of sun-damaged skin and possibly helping other ingredients better penetrate skin. While there is no comparative research in regards to salicylic acid (BHA) and its effect on melasma, it makes sense to assume that because salicylic acid exerts a similar action on skin as AHAs, it will have similar results for improving skin color.
Much like laser treatments, alpha hydroxy acid peels (using 50% concentrations or greater) have impressive results for removing skin discolorations (Sources:
Dermatologic Surgery, February 2005, pages 149-154;
Journal of Cutaneous Medicine and Surgery, April 2004, pages 97-102;
Cutis, February 2004, supplemental, pages 18-24;
Dermatologic Therapy, June 2004, pages 196-205; and
Dermatological Surgery, June 1999, pages 450-454). Only a physician should perform these types of facial peels.
Kojic Acid
Kojic acid is a by-product in the fermentation process of malting rice for use in the manufacturing of sake, the Japanese rice wine. There is convincing research—both in vitro (in a test tube) and in vivo (on a live subject)—showing kojic acid to be effective for inhibiting melanin production (Source:
Archives of Pharmacal Research, August 2001, pages 307-311). Glycolic or kojic acid, or glycolic acid with hydroquinone, are highly effective in reducing the pigment in melasma patients (Source:
Dermatological Surgery, May, 1996 pages 443-447). So why aren't there more products available containing kojic acid? Because it is an extremely unstable ingredient in cosmetic formulations. Upon exposure to air or sunlight it can turn a strange shade of brown and lose its efficacy. Many cosmetic companies use kojic dipalmitate as an alternative because it is far more stable in formulations. However, there is no research showing kojic dipalmitate to be as effective as kojic acid, although is it a good antioxidant. Further, some controversial research has shown kojic acid to have some carcinogenic properties (Sources:
Mutation Research, Genetic Toxicology and Environmental Mutagenesis, June 2005, pages 133-1450 and
Toxicological Sciences, September 2004, pages 43-49).
Azelaic Acid
Azelaic acid is a component of grains, such as wheat, rye, and barley. It is effective against a number of skin conditions when applied topically in a cream formulation at a 20% concentration. Azelaic acid is recommended to treat acne, but there also is research showing it to be effective for skin discolorations. For example, "The efficacy of 20% azelaic acid cream and 4% hydroquinone cream, both used in conjunction with a broad-spectrum sunscreen, against melasma was investigated in a 24-week, double-blind study with 329 women. Over the treatment period, the azelaic acid cream yielded 65% good or excellent results; no significant treatment differences were observed with regard to overall rating, reduction in lesion size, and pigment intensity. Severe side effects such as allergic sensitization or exogenous ochronosis were not observed with azelaic acid" (Source:
International Journal of Dermatology, December 1991, pages 893-895). Other research also indicates azelaic acid is an option for inhibiting melanin production (Source:
Journal of the American Academy of Dermatology, May 2006, supplemental, pages 272-281). However, additional research suggests that azelaic acid is more irritating than hydroquinone mixed with glycolic acid (Source: eMedicine Journal, www.emedicine.com, November 5, 2001). Regardless, azelaic acid is definitely a consideration for skin lightening if you have had problems using hydroquinone.
Vitamin C
Magnesium ascorbyl phosphate, L-ascorbic acid, ascorbyl glucosamine, and ascorbic acid are various forms of vitamin C considered stable and effective antioxidants for skin. There are very few studies showing them to have benefit for inhibiting melanin production, but what little there is has been positive. The problem is that the concentrations of these ingredients were high (more than 5%), which is rarely used in cosmetic formulations. However, in combination with other treatments, vitamin C is an extra step that can help reduce skin discolorations (Sources:
International Journal of Dermatology, August 2004, page 604;
Dermatology, April 2003, pages 316-320; and
Journal of the American Academy of Dermatology, January 1996, pages 29-33).
Combination Treatments
Melanin is stimulated by a complex process partially controlled by an enzyme called tyrosinase. Most skin-lightening treatments are aimed at inhibiting this enzyme, which can reduce or block some amount of melanin production. There are many options to consider when searching for a solution. The most successful treatments use a combination of topical lotions or gels containing melanin-inhibiting ingredients along with a well-formulated sunscreen, and a prescription retinoid (such as Renova or generic versions containing tretinoin, a type of retinoid). Depending on how the skin responds to these treatments, exfoliants—either in the form of topical cosmetic or chemical peels—and lasers are also able to further affect pigment and can definitely enhance results (Sources:
Journal of the American Academy of Dermatology, May 2006, supplemental, pages 272-281;
Dermatologic Surgery, March 2006, pages 365-371;
Journal of Drugs in Dermatology, September-October 2004, supplemental, 27-34;
International Journal of Dermatology, December 2003, pages 966-972; and
Archives of Dermatology, December 2002, pages 1578-1582).
Laser Treatments
Both ablative and nonablative lasers can have a profound effect on melasma. However, the results are not always consistent, and problems can occur (such as hypo- or hyperpigmentation). Moreover, laser treatments of this kind often are a problem for those with darker skin tones. Nonetheless, when laser treatments work they can have a marked difference in the skin's appearance, especially when used in combination with the other topical treatments previously mentioned. The results can be startling, and though expensive, for stubborn discolorations, lasers are absolutely worth a try. There are many types of lasers that can be successful for this purpose. Which one is optimal for you is best determined by a skilled dermatologist who has a practice that incorporates a variety of different lasers (Sources:
Journal of the American Academy of Dermatology, May 2006, supplemental, pages 262-271;
Dermatologic Therapy, January 2001, page 46;
Journal of Cosmetic and Laser Therapy, March 2005, pages 39-43;
Journal of Cutaneous Medicine and Surgery, April 2004, pages 97-102;
Journal of Drugs in Dermatology, November-December 2005, pages 770-774;
Dermatologic Surgery, October 2005, page 1263; and
Lasers in Surgery and Medicine, April 2000, pages 376-379).
Paula's Choice Skin Care Solutions for DiscolorationsThese Paula's Choice Skin Care Solutions combine all the elements described above: Gentle cleansers, exfoliants, moisturizers and treatments loaded with antioxidants, ingredients that mimic the structure of skin, and cell-communicating ingredients.
Experimentation is key to finding the right combination of products that will work for you. For example, exfoliating with 1% beta hydroxy acid may not be enough and you would then want to consider trying a 2% concentration. For those allergic to aspirin, BHA may cause an allergic reaction and you should consider an alpha hydroxy acid-based exfoliant.
Based on the above recommendations, you may wish to consider these products for your skin type:
Step-by-Step Skin Care for Discolorations
- Skin Discolorations with Normal to Dry Skin
- Skin Discolorations with Normal to Oily Skin
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