Cosmeceutical alternatives to hydroquinone
Growing evidence suggests alternative agents may have good efficacy for melasma, hyperpigmentation with fewer side effects (1,600 words, 8 minutes)
The most popular option for treating hyperpigmentation has long been hydroquinone, Dr. Heather Woolery-Lloyd said during the 7th Annual Skin Spectrum Summit. However, promising findings from research on cosmeceuticals are providing valuable options, she said.
Dr. Woolery-Lloyd said that the research is “driven by a need for an alternative to hydroquinone,” Dr. Woolery-Lloyd said.
“There is increased regulation of hydroquinone around the world. In the U.S., the two per cent [formulation] is no longer available over the counter.”
Dr. Woolery-Lloyd is the Director of the Skin of Color Division in the Department of Dermatology and Cutaneous Surgery at the University of Miami in Florida.
In her presentation, she listed several topical cosmeceuticals with growing bodies of research supporting their use as treatments for melasma.
Topical vitamin C: Evidence suggests this agent has lower efficacy than hydroquinone or topical tranexamic acid, but it also has fewer side effects than hydroquinone. Microneedling or iontophoresis may be ways of improving its efficacy.
Licorice extract: A 4% formulation of a specific extract of licorice root, liquiritin, was shown in one study to be better at treating melasma than 4% hydroquinone. Other research has shown improved results with a combination of liquiritin and vitamin C.
Niacinamide: This is a popular choice as it is widely available and inexpensive. However, studies have shown to be less effective at treating facial pigment changes than hydroquinone, though niacinamide does have fewer side effects.
Azelaic acid: Dr. Woolery-Lloyd said she frequently uses azelaic acid to treat hyperpigmentation and melasma. She has not found it superior to hydroquinone in her practice, but it is very effective.
Silymarin (Milk thistle): This has shown promising results in early research, she said. A study comparing silymarin at two different formulations and hydroquinone cream at 4% showed no difference in therapeutic response.
Thiamadol: A study of this tyrosinase inhibitor showed significant improvement in hyperpigmentation, particularly when dosed on a four-times-a-day schedule.
Cysteamine: One study has shown this more effective than a modified Kligman formula cream for treating epidermal melasma.
Topical tranexamic acid: Some studies have shown efficacy comparable to hydroquinone with topical tranexamic acid for treating melasma, particularly when combined with microneedling.
Supporting topical cosmeceuticals
Dr. Woolery-Lloyd noted there had been research into incorporating biocompatible microneedle-like particles into topical formulations to improve penetration of active agents into the skin, which she said is especially important in patients of colour.
“This is something very new, very cutting edge,” she said. “Hopefully, we will see these come to market because the key [to improving hyperpigmentation] with our skin of colour patients is [enhancing] penetration of our topicals because these patients are much more challenging to treat when it comes to hyperpigmentation.”
Dr. Woolery-Lloyd also recommended using Polypodium leucotomos and Pinus pinaster plant extracts as adjunct oral agents to help provide systemic photoprotection.
Bottom Line: Alternatives to hydroquinone as a treatment for hyperpigmentation are becoming more important. Vitamin C, cysteamine, tranexamic acid, thiamadol, azelaic acid, licorice extract, niacinamide and silymarin may all be alternatives. Combining ingredients, changing delivery systems and adding oral agents to improve photoprotection may all help improve treatment efficacy.
From the literature on cosmeceuticals and pigment disorders
Natural cosmeceutical ingredients for the management of hyperpigmentation in Hispanic and Latino women
This systematic literature review identified seven clinical studies, including six randomized clinical trials, that evaluated the topical management of hyperpigmentation using natural ingredients with specific reference to women of Hispanic or Latino race and ethnicity.
The authors identified seven natural ingredients that demonstrated efficacy and safety as depigmenting agents in this cohort from those studies. Those ingredients included niacinamide, soy, azelaic acid, ascorbic acid, licorice, Phyllanthus emblica, and Bellis perennis.
However, the authors note the paucity of studies in this setting and the limitations of many trials of natural ingredients. They write that more research is needed to determine long-term safety and efficacy and the best formulation of natural ingredients for the topical management of hyperpigmentation in Hispanic and Latino women.
Microneedling as an adjuvant to topical therapies for melasma: A systematic review and meta-analysis
The authors of this paper review 12 studies comprising 459 patients from seven different countries that compared topical therapies for melasma and evaluated the benefit of the addition of microneedling. Topical therapies included topical tranexamic acid, vitamin C, platelet-rich plasma, non-hydroquinone-based depigmentation serums, and hydroquinone-based depigmenting agents.
Overall, the investigators found that topical therapy with microneedling improved melasma severity compared to topical treatment alone. The microneedling was also well tolerated.
The use of botanical extracts in East Asia for treatment of hyperpigmentation: An evidenced-based review
This article reviews the current evidence on the safety and efficacy of key ingredients used in Asian cosmeceuticals to treat hyperpigmentation disorders. The authors searched PubMed to identify hyperpigmentation-related research studies on eight popular ingredients used in Asian cosmeceuticals. These eight were green tea, soy, orchid, licorice, rice water, ginseng, bamboo, and aloe.
Of the ingredients reviewed, the authors found that soy and licorice had the most clinical evidence supporting their efficacy, while all other ingredients were supported by in vitro studies. They write that more research is needed to evaluate further the safety and efficacy of these cosmeceutical ingredients in the treatment of hyperpigmentation.
Efficacy and safety of topical isobutylamido thiazolyl resorcinol (Thiamidol) vs. 4% hydroquinone cream for facial melasma: an evaluator-blinded, randomized controlled trial
This study compared the efficacy and tolerability of topical 0.2% Thiamidol, a potent tyrosinase inhibitor, vs. 4% hydroquinone for facial melasma.
A total of 50 women with facial melasma participated in the study. They were randomized to apply either a double layer of 0.2% Thiamidol twice a day or 4% hydroquinone cream at bedtime for 90 days. Both groups also received tinted sunscreen.
The investigators found that melasma improvement did not differ between the two treatment arms. They conclude that Thiamidol can be a suitable option for melasma patients with poor tolerability or treatment failure with hydroquinone.
VIDEO: Doctor V’s how to treat hyperpigmentation for skin of colour | brown/dark skincare
At the intersection of skin and society
On February 23, 2022, The Portrait Gallery of Canada (PGC) premiered a new series of works by Indigenous artist KC Adams. The exhibit, GIIYAABI OMAA NINDAYAAMIN (WE ARE STILL HERE), showcases 12 portraits of Indigenous children.
“Children bring truth because their honesty demands it,” said Adams in a press release. “And they remind us of our responsibility to create a safe environment. I am taking control of the narrative of residential schools with these portraits. WE ARE STILL HERE speaks about my Indigenous community’s resilience and knowledge and the responsibility of children to bring joy and hope to our people.”
KC Adams is a contemporary artist of Cree, Ojibway and British descent who lives on Treaty 1 Territory in Winnipeg.
According to the release, inspiration for the collection came on July 1, 2021. The Canadian flag had been flying at half-mast for weeks following the identification of 215 unmarked graves at the former Kamloops residential school. Canada Day celebrations were cancelled out of respect for the victims of this horrific tragedy.
The release explains that KC Adams wanted to express a narrative beyond oppression and focus on her community’s survival through joy and hope. She took photographs of the beautiful, healthy and smiling faces of children from her community, aged five to 16 years. This is the same age range as those who attended residential schools.
She has also digitally enhanced each of the 12 photographs on view with seven layers to represent the importance of the seven generations.
“My intent is that our community will acknowledge and recognize the beauty, resistance and strength of our people,” Adams said. “The survival of our languages, ceremonies and culture are direct acts of resistance to these acts of genocide. We survive through our love for our children, through the continued prayers for the generations yet to come.”
Organized by PGC curator Ann Davis and presented in English, French and Anishinaabemowin, the exhibition is complemented by a series of teaching and learning bundles for K-12 teachers, produced by Indigenous educator Renée McGurry.
The exhibition can be viewed online at portraitcanada.ca/giyaabi-omaa-nindayaamin.
Vender on psoriasis: Episode six
The Chronicle Podcast System’s program about psoriasis with Dr. Ronald Vender, based on Dr. Vender’s popular column in The Chronicle of Skin & Allergy, continues. In this sixth episode, Dr. Vender talks about biologics use, biosimilars and the potential risk of incident venous thromboembolism and peripheral vascular disease in psoriasis.
Listen here:
This week
February 28 is Rare Disease Day in the U.S.
March is Nutrition Month in Canada
March 1 is Zero Discrimination Day
Something to think about in the week ahead…
Next week
Our first full week of March 2022 begins with coverage of Dr. Gary Sibbald’s talk on wound care in skin of colour from the 7th annual Skin Spectrum Summit. Dr. Sibbald spoke on detecting deep tissue injury in individuals with darker skin and the risk, prevention and management of keloids after wounding.
Coming soon
On April 23, 2022, Chronicle Companies will be presenting the 2022 Summit on Atopic Dermatitis. This will be a one-day virtual medical educational event. The conference seeks to address an unmet need for education on the incidence of and latest therapies for atopic dermatitis (AD) among dermatologists and general practitioners. Presentations are planned to discuss the most current treatments for all disease severities. The conference will also emphasize AD diagnosis in skin of colour and will provide resources for patient and caregiver support.
Registration for the Summit on Atopic Dermatitis is open and available at this link.