Unsupervised Hydroquinone Use: Beware of what you put on your skin
Hydroquinone (HQ) has long been regarded as effective for treating darkened skin (hyperpigmentation), having been used as a skin-lightening chemical for over 50 years. It has been prescribed by doctors and used by patients to treat facial spots (e.g.freckles) and patches (e.g.melasma), a blotchy complexion due to sun damage, and discoloration or dark scars due to trauma and skin disease (e.g. acne or chickenpox).
However like any other drug, HQ does have its share of side effects. In the 1980’s, the most commonly reported complication was disfiguring exogenous ochronosis or pseudo-ochronosis which presents as dark discolorations and grey-blue bumps on sun-exposed areas of the skin. Other reported side effects include loss of skin elasticity, poor wound healing, skin nodules appearing especially on the upper back and nail discoloration. Most, if not all of these side effects, stem from the improper use and the use without the supervision of a dermatologist of HQ on large areas of the face and body for a prolonged period of time.
What has largely contributed to the misuse of HQ? Consumers in their desire to have that flawless, fair skin have resorted to applying high concentrations of HQ over large areas of the face and body for a period of several months to years. Unethical practices by some manufacturers compounded the problem such as the lack of ingredient labeling or inaccurate concentrations of HQ indicated in the product. From the usual concentrations of 2 – 4 %, HQ concentrations of 6- 8.5% have been used. Also, to disguise the incorporation of HQ in a skin product, synonyms like “1,4-benzenediol” or “p-diphenol” were used instead. The lack of regulating bodies or clear guidelines in some countries has also resulted in cosmetic and toiletry products containing HQ to flood the retail shops and market places aggravating its unsupervised use.
All these have unfortunately compromised the safety of using HQ which has been part of the therapeutic armamentarium of physicians in treating hyperpigmentation. There now exists a real health concern of new side effects being noted more in patients if these practices would be allowed to continue and proliferate.
It is for this reason that in the Philippines, the PDS recommends the regulated use of HQ as proposed by the Bureau of Food and Drugs (BFAD). All preparations containing less than or equal to two percent (2%) HQ can be dispensed without the supervision of a licensed pharmacist. Preparations containing more than two percent (2%) but less than or equal to four percent (4%) HQ must be dispensed under the supervision of a licensed pharmacist. Preparations containing more than more than four percent (4%) but less than five percent (5%) HQ must be dispensed only by licensed pharmacists of registered drug outlets upon the presentation of a proper prescription. Furthermore, to help prevent the abuse of HQ usage, the PDS supports efforts moving for a stricter regulation on HQ-containing products as proposed by the BFAD, such as making all concentrations of HQ available only upon the presentation of a proper prescription.
REFERENCES
Ly, Fatimata, Anta Soumare Soko, et al. “Aesthetic problems associated with the cosmetic use of bleaching products.” International Journal of Dermatology 46 (2007): 15-17.
Olumide, Yetunde M., Ayesha O. Akinkugbe, et.al. “Complications of chronic use of skin lightening cosmetics.” International Journal of Dermatology 47 (2008): 344-353.
Westerhof W., T J Kooyers. “Hydroquinone and its analogues in dermatology- a potential health risk.” Journal of Cosmetic Dermatology 4 (2005): 55-59.
McGregor, Douglas. “Hydroquinone: An Evaluation of the Human Risks from its Carcinogenic and Mutagenic Properties.” Critical Reviews in Toxicology 37 (2007): 887-914.
Toombs, Ella L. “Hydroquinone-what is it’s future?” Dermatologic Therapy 20 (2007): 149-156.
Nordlund,JJ, PE Grimes, JP Ortonne. “The safety of hydroquinone.” Journal of the European Academy of Dermatology and Venereology 20 (2006): 781-787.
Levitt, Jacob. “The safety of hydroquinone: A dermatologist’s response to the 2006 Federal Register.” JAAD 10.1016 (2007):854-872.
Draelos, Zoe Diana. “Skin lightening preparations and the hydroquinone controversy.” Dermatologic Therapy 20 (2007): 308-313.
The Importance of Using a Sunscreen Everyday
Evelyn R. Gonzaga, MD, FPDS, FAAD
Sunlight and exposure to the elements can cause damaging and unwanted stresses on the skin. In fact how old our skin looks is often dictated by environmental aspects especially ultraviolet light radiation (UVR).
So what is UVR and where does it come from? Sunlight is composed of a continuous spectrum of electromagnetic radiation that is divided into three main parts: ultraviolet light (UV) 5%, visible light 50% and infrared 45%. UV light is further divided into three subgroups namely UVC, UVB and UVA. UVC is absorbed by the ozone layer and does not reach the ground. UVB is the primary cause of sunburn and skin cancer. UVA, on the other hand, represents 90% of the total UVR reaching the earth’s surface, penetrates deeper into the skin to cause skin darkening, and penetrates most deeply into the eyes and can cause retinal degeneration. UVA is twenty times more abundant than UVB, and is present all day and throughout the year and can reach the skin even through windows.
Consequences of sun exposure include sunburn, tanning, darkening of freckles, premature aging or photoaging of the skin like coarse wrinkling, yellow hue, laxity, thickening and furrowing of the skin, telangiectasia, solar keratoses, cataracts, and skin cancers. (Fig. 1).
Photoaging accounts for most age-associated changes in skin appearance and affects lighter skinned individuals most severely and it accounts for 90% of the unwanted changes in appearance in skin. The face, neck, dorsum of the hands and forearms are most commonly affected.
Clinical Picture of Photoaged Skin includes: wrinkles, yellow hue, laxity, telangiectasia, leathery appearance and skin cancer (Fig.1)
So how do we protect our skin from Photoaging? Photoprotection is the single most cost-effective therapy for photoaging. It includes sun avoidance, wearing protective clothing and the use of sunscreens. Sun avoidance includes limiting exposure during peak UV times, particularly between 10am and 4pm, avoiding UV- reflective surfaces such as the sand and water. Physical protection includes wearing photoprotective clothing such as a broad-brimmed hat 4 inches or greater, wearing long sleeves clothes, use of dark colored umbrellas and use of UV-blocking films on windows.
The use of sunscreen products has been advocated by the dermatologists as a means to reduce skin damage produced by ultraviolet radiation from sunlight.
What sunscreen should you use? Sunscreens prevent photodamage and allows repair of the skin. These products represent an extension and an increase of the skin’s natural defense mechanisms against UVR. The term “sunblock” is commonly used to refer to sunscreen and their active ingredients. Today the US Food and Drug Administration sunscreen monograph does not sanction the term because the consumers might be misled into thinking that the product completely blocked all sunlight.
Is SPF enough in a sunscreen?
The Sun Protection Factor (SPF) scale specified in a sunscreen product applies solely to UVB protection – so it provides inadequate photoprotection.as it does not give you enough protection against UVA rays as well. Below are the SPF guidelines:
4 Categories of UVB sunburn protection products:
Low SPF 2 to <15
Medium SPF 15 to <30
High SPF 30 to 50
Highest SPF >50
The ideal sunscreen should contain organic or inorganic ingredients that act as UV absorbers and UV reflectors. The combination of UVB and UVA filters contained in the sunscreen will provide broad-spectrum photoprotection. Your dermatologist can provide you with this information.
The UVA Sunscreen Rating is the Star System. The rating is as follows:
UVA Rating Persistent Pigment Darkening
Low 1* 2 – < 4 hours
Medium 2** 4 – < 8 hours
High 3*** 8 – < 12 hours
Highest 4**** 12 or above
Good Protection is 4 Stars
In short, when choosing a sunscreen – look for one that has both UVB and UVA protection. It is best to consult your dermatologist when making this choice.
How much sunscreen should you apply?
Most people only use 0.5mg/cm2 to 1mg/cm2 , which is 25% to 50% of the recommended dose. The ideal dose of application is actually 2mg per cm2 (square centimeter) of the body. and a simple way of making sure you have the right dose is called the “Teaspoon Rule of Sunscreen Application” (Fig. 2)
Fig 2. Teaspoon Rule of Sunscreen Application
Sunscreens containing both UVA and UVB filters should be used daily. The amount to be applied should be more than half a teaspoon each on head and neck and each arm, and more than a teaspoon each on anterior torso, posterior torso and each leg.
When should sunscreens be applied?
Sunscreens should be applied to exposed areas 15 to 30 minutes before going out into the sun. Reapply to exposed sites 15 to 30 minutes after sun exposure begins and further reapplication is advised every 2-4 hours after vigorous activity that remove sunscreen such as swimming, toweling or excessive sweating and rubbing.
What are the sunscreen preparations available for your use?
Sunscreens are available in a variety of preparations. Lotions are the most popular preparations. Creams are more water resistant and provide higher SPF protection. Gels are non-greasy, good for oily skin or when sweating. Sticks are the most water resistant, good for the lips or around the eyes and best for sensitive skin. Aerosols are best on the body.
In light of the numerous benefits of broad-spectrum photoprotection, daily use of sunscreens is advocated by members of the Philippines Dermatological Society as well as by the dermatologists worldwide.
In summary, the Regimen of Overall Photoprotection includes
Sunglasses to protect the eyes
Protective clothing
Avoid midday sun
Regular use of broad spectrum (UVB & UVA) sunscreens – everyday, even if you will stay indoors!
References:
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12. Lim HW, Naylor M, Honigsmann H, Gilchrest BA, Cooper K, Morison W, Deleo, VA. American Academy of Dermatology Consensus conference on UVA protection of sunscreens: summary and recommendations, J Am Acad Dermatol 2001, 44(3):505-508
13. Svobodova A, Walterova D, Vostalova J. Ultraviolet light induced alteration to the skin, Biomed Pap Med Fac Palacky Olomouc Czech Repub. 2006, 150(1):25-38
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