While lightening treatments like tranexamic acid cream are gaining in popularity, hydroquinone remains the standard treatment for hyperpigmentation of various causes. Certain over-the-counter products like Porcelana cream contain hydroquinone in low concentrations – usually around 2%. The higher concentration creams with 6%, 8%, or 10% hydroquinone in combination with other ingredients can only be obtained from a compounding pharmacy. In addition, a compounding pharmacy can make customized creams with several active ingredients combined to better treat hyperpigmentation. A good example of this is a hydroquinone, tretinoin, corticosteroid cream, which is a first-line treatment for hyperpigmentation.

Combination Hydroquinone and Tretinoin Creams

Hydroquinone with tretinoin and a corticosteroid is the most commonly prepared combination skin lightening cream. Triamcinolone acetonide and hydrocortisone are two examples of corticosteroids that may be included to help reduce redness, itchiness, and swelling. This type of ingredient is almost essential when prescribing higher strength combinations of hydroquinone with other active ingredients.

Hydroquinone is a tyrosinase inhibitor that is sometimes called a “bleaching” or “brightening” agent. Used on its own, hydroquinone is effective, but not as effective as when it is combined with tretinoin. Hydroquinone’s brightening effects are reversible. This means that once treatment is discontinued, a trigger like sun exposure can reactivate the hyperpigmentation.

Tretinoin, also sometimes called retinoic acid, is a vitamin A derivative that has been shown to be an effective treatment for hyperpigmentation.

Hydrocortisone, triamcinolone, and other corticosteroids are used to help reduce inflammation that may occur when skin lightening agents are used.

What Are These Combination Creams Used For?

Combination skin lightening creams are used for treating various types of hyperpigmentation.

Melasma, for example, is a type of hyperpigmentation affecting the face in a symmetrical pattern. It is most common in women, especially those who are pregnant. It is triggered by sun exposure and sometimes hormonal changes. A skin lightening cream can help even skin tone to reduce the appearance of melasma.

Age spots, also called sun spots, are another type of hyperpigmentation. These dark spots on the skin occur when excess melanin is produced following exposure to UV radiation. In most cases it takes years of sun exposure to develop these spots but they can appear on anyone. Another word for hyperpigmentation changes due to UV radiation is “photodamage.” Photodamaged skin is one of the main reasons patients seek treatment with a combination lightening cream.

Post-inflammatory hyperpigmentation (PIH) is a discoloration resulting from injury or a skin condition. For example, patients with acne will often develop scarring along with darkened or reddish areas of hyperpigmentation. PIH can be the last reminder of acne even after flare-ups are completely under control. The term “cosmetic” in these types of cases can sometimes seem like a derogatory term. While PIH after acne does not necessarily cause any health issues for the skin, it can cause significant emotional distress. If a lightening cream can help reduce the appearance of PIH for a patient it can often improve their quality of life. This is true as well for melasma and age spots.

How is A Hydroquinone Tretinoin Cream Used?

It can take at least 4 weeks and even up to 8-12 weeks to notice results from using a hydroquinone tretinoin cream. Application is often done once daily at bedtime. A broad-spectrum sunscreen is recommended for daily use as well. Many patients will experience mild side effects like redness and itching. While more severe side effects are possible, they are not common. Treatment with these creams continues for a length of time determined by the patient’s dermatologist. Regular checkups help make sure the treatment is working and that there are no adverse effects.

In studies of hydroquinone and tretinoin, patient satisfaction rates have been high. A study in the Journal of Drugs in Dermatology with hydroquinone 4% and tretinoin showed that at week 24, 87.9% of patients were “satisfied” or “very satisfied” with their treatment. For higher strengths of hydroquinone, continuing treatment for two years may not be possible for all patients. Some doctors will use treatment courses lasting 3-6 months, with time in between treatment courses to allow the skin to adjust. Others may prescribe the cream to be used only two or three times a week.

Triple ingredient lightening creams can take time to work, so it is important for patients not to get discouraged if they do not see the results they want after a month of treatment. The skin needs time to replace the hyperpigmented skin cells with new skin cells for the results to be visible.

Example Formulations

	Hydroquinone	Tretinoin	Hydrocortisone	Kojic Acid
Compound 1	6%	0.05%	0.5%
Compound 2	8%	0.1%	0.5%
Compound 3	6%	0.05%	0.5%	4%
Compound 4	8%	0.05%	0.5%	4%

Sun Protection

Using a hydroquinone tretinoin cream makes your skin more sensitive to the sun. While melanin is inhibited, the skin is less protected from UV rays. Proper sun protection involves staying out of the sun when the sun is at its peak (usually between 10am – 4pm), wearing a sun hat, and regularly applying broad-spectrum sunscreen with an SPF of 30 or higher when outside. Some of the worst side effects of a hydroquinone cream occur when the sun is not protected from sun exposure. If you are using a hydroquinone tretinoin cream and notice swelling, crusting, or an allergic reaction, you should contact your healthcare provider immediately.

Alternatives for Skin Lightening

One of the reasons that hydroquinone tretinoin creams are popular for skin lightening is that they are cost effective. It has been in shown in some studies that hydroquinone combined with laser therapy can get faster results than when it is used alone. Laser therapy is expensive, though, as are other in-office treatments for hyperpigmentation. Some patients may want to use everything that their dermatologist has available including lasers, chemical peels, creams, and other treatments. However many patients will accept a slightly longer treatment time with a lower cost and no downtime.

Articles

Melasma and Post Inflammatory Hyperpigmentation: Management Update and Expert Opinion – Skin Therapy Letter (PubMed)

Combination of Hydroquinone and Fractional CO2 Laser versus Hydroquinone Monotherapy in Melasma Treatment: A Randomized, Single-blinded, Split-face Clinical Trial. – Indian Journal of Dermatology (PubMed)