This article on skin brighteners is a follow up to my blog on topical retinoids for skin restoration. The primary focus will be the treatment of solar lentigenes (“liver spots,” “freckles”), melasma and post inflammatory hyperpigmentation. This article is not intended to address other pigmented lesions such as moles, seborrheic keratoses, or anything that could be cancerous. It is always best to seek the advice of a board certified dermatologist for the proper initial diagnosis and treatment plan.
Unwanted brown freckles or splotches typically appear in sun-exposed areas such as the face, upper chest, arms and hands. The foundation of any treatment program for unwanted skin pigmentation includes sun protection, and usually a topical retinoid. In addition to these, hydroquinone is the gold standard for treating brown spots. While hydroquinone is the subject of controversy regarding its safety, this article will not address these issues because it has a long-term record of safe use in the United States. Hydroquinone is available over-the-counter in a 2% formulation and by prescription in a 4% formulation. It can also be compounded in higher strengths by some compounding pharmacies. Adverse reactions to hydroquinone include skin rash in approximately 5% of users and exogenous ochronisis, a permanent idiosyncratic darkening of the skin.
Azelaic acid is another useful treatment for unwanted pigmentation. This naturally-derived substance has been shown to be beneficial for the treatment of acne vulgaris, acne rosacea, and melasma. The only FDA approved topical prescription formulations are Azelex (20% Azelaic acid cream, $413/30 gm) for the treatment of acne vulgaris, and Finacea (15% Azelaic acid gel, $330.49/50 gm) for the treatment of acne rosacea.
Azelaic acid is also useful for hyperpigmentation, although published information seems to favor its efficacy more for melasma and post inflammatory hyperpigmentation than for sun spots. The FDA has not approved it for over-the-counter use in concentrations of 15% or greater and no claims can be made for over-the-counter azelaic acid products for the treatment of acne. Glytone has a product, Glytone Enhance Brightening Complex, containing 12% azelaic acid with 3% glycolic acid which costs $70/oz. This combination of azelaic acid and glycolic acid should provide synergy for the treatment of unwanted pigmentation. The manufacturer cites internal studies showing benefit but does not permit dissemination of the details of this information.
Topical Vitamin C
Topical vitamin C is another treatment option. There are several research studies showing the benefits of certain formulations of topical vitamin C for the treatment of hyperpigmentation, restoration of collagen and elastic tissue, and reduction of fine lines. In my opinion, high-quality vitamin C products are less effective than topical retinoids for this purpose because of their high price (SkinCeuticals C E Ferulic 15% vitamin C $165/oz, Glytone Age-Defying Vitamin C + E Serum with 20% THD ascorbate $130/oz, Revision Vitamin C Lotion with 30% THD ascorbate $109/oz) relative to their efficacy. Still, for those who wish to spend the money, they do have utility when used with topical retinoids.
Effectiveness and Use of Skin Brighteners
Here’s how I rank these compounds in terms of cost effectiveness for skin brightening:
- Topical 4% hydroquinone
- Revision Vitamin C lotion 30% or Glytone Enhance Brightening Complex with 12% azelaic and 3% glycolic acid
I recommend starting with 4% topical hydroquinone and a topical retinoid. After a month or two, replace the hydroquinone with a topical vitamin C or an azelaic acid product.