White alert: The skinny on hydroquinone

These days, whitening products are flying off the shelves of drugstores or beauty counters faster than you can say glutathione or hydroquinone. Filipino women with bright dreams of being fair must be familiar with glutathione. (But more on glutathione and hydroquinone a wee bit later.) It’s in the print ads when you pore over the papers and pour your coffee in the morning. It’s in the billboards staring starkly down on you as you drive down the traffic-choked highway.

You can say that’s a black-and-white proof of our obsession with being white. A visiting doctor from the US, speaking at a cancer forum, couldn’t help take notice of this. The bemused doctor asked, “Why do you Filipinos want to be white while we Caucasians like to get a tan?”

Certainly, there’s light at the end of the tunnel. To enlighten consumers on hydroquinone, as well as some “white lies,” skin experts answer some oft-asked questions.

What is hydroquinone?

Hydroquinone (HQ) is a chemical that’s also known by the following names: 1,4 dihydroxybenzene, 1,4-benzenediol and p-diphenol. Note that it’s found naturally in wheat, berries, coffee, and tea.

What is it for?

HQ is used to lighten the skin. It has long been regarded as effective for treating hyperpigmentation or darkened skin, having been prescribed by doctors as a skin-lightening chemical for over 50 years. It has been used to treat facial spots (like freckles), patches (like melasma), blotchy complexion (due to sun damage), and discoloration or dark scars due to trauma or skin disease (like the scars of acne or chicken pox).

White is right — or is it? Does HQ have any known side effects?

Just like any other drug, HQ does have its share of side effects. In the 1980s, the most commonly reported complication was disfiguring exogenous ochronosis or pseudo-ochronosis. That means dark discoloration and grey-blue bumps on sun-exposed areas of the skin, which are permanent. Other reported side effects are 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 use of HQ without the supervision of a dermatologist. Its improper application on large areas of the face and body for a prolonged period of time may lead to the skin changes mentioned above.

What has largely caused the improper use of HQ?

In people’s desire to have that flawless, fair skin, they have resorted to applying high concentrations of HQ over large areas of the face and body for a long period of time — meaning not just for several months but for years.

Unethical practices by some manufacturers compounded the problem through incomplete ingredient labelling or inaccurate information on the content of hydroquinone in their products. From the usual concentrations of 2-4%, HQ concentrations of 6-8.5% have been used. Also, synonyms like “1,4-benzenediol” or “p-diphenol” were used to disguise the incorporation of HQ in a skin product.

The lack of regulating bodies or clear guidelines in some countries has also resulted in the flooding of cosmetic/toiletry products containing HQ in the retail shops and market places, aggravating its unsupervised use.

Why was the use (or abuse) of hydroquinone included in the Philippine Dermatological Society (PDS) skin safety campaign?

The public should be made aware that the practices of using higher concentrations, applying on large areas of the body, and extending HQ’s use for prolonged periods have compromised the safety of hydroquinone use.  If these practices are allowed to continue and proliferate, there’s a real health concern of increased side effects being noted in people who use it.

If it is a public health concern, are there any regulations about the use and sale of HQ-based products worldwide?  How about in the Philippines?

Different countries will have different regulations on the sale of HQ-containing products. Here in the Philippines, the PDS recommends the regulated use of HQ as proposed by the Bureau of Food and Drugs (BFAD), which states that all preparations containing:

• Less than or equal to two percent HQ can be dispensed without the supervision of a licensed pharmacist.

• More than two percent but less than or equal to four percent, HQ must be dispensed under the supervision of a licensed pharmacist.

• More than four percent but less than five percent, HQ must be dispensed only by licensed pharmacists of registered drug outlets upon the presentation of a proper prescription.

Are the existing regulations enough? PDS dermatologists must get a lot of patients who have abused and misused HQ products.

To help prevent the further abuse of hydroquinone, the PDS supports efforts towards 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.

In addition, Dr. Georgina Pastorfide, president of the Philippine Dermatological Society, gives us the skinny on PDS’ skin safety campaign in an exclusive interview with The Philippine STAR. Excerpts:

PHILIPPINE STAR: What does the Skin Safety Campaign hope to achieve?

DR. GEORGINA PASTORFIDE: We’re passionate about this because we want to promote public safety on skin health through information dissemination and consultation with certified and competent PDS dermatologists. Our society is the only specialty society for dermatology that is recognized by the Philippine Medical Association (PMA) and the Philippine College of Physicians (PCP). People have the misconception that a dermatologist is not even a physician. They think it’s the same as a cosmetician, or a beautician, or what have you. So these we all label as pseudo-dermatologists. To even be a dermatologist, you have to be a physician — that means four years of a BS subject, then you go into four years proper, take one year of internship, and then you have to take the board to be licensed. That’s a good nine years. After you take the board, you’re just a general practitioner. Then you go into your specialization, which is your residency in dermatology, and that takes another three years. And we sometimes go into our sub-specialty training, like pediatric dermatology, dermatopathology, etc., and that may take anywhere between one and two years.

Are all the dermatologists in the Philippines members of the PDS?

All the recognized, certified dermatologists are members of the PDS. We’re recognized by PMA and PCP. A member would have the Skin Safety Campaign symbol either displayed on the clinic door or prominently placed inside it. As PDS members, we are guided by professional ethics. We don’t advertise right and left, we follow the guidelines of the PMA, PCP, and our own guidelines.

Which are the PDS-accredited institutions?

There are 11 of them: Davao Medical Center, East Avenue Medical Center, Jose R. Reyes Memorial Hospital, Makati Medical Center, Ospital ng Maynila, Research Institute of Tropical Medicine, Skin and Cancer Foundation, Inc., University of the East-Ramon Magsaysay Memorial Medical Center, University of the Philippines-Philippine General Hospital, University of Santo Tomas, and St. Luke’s Medical Center. Consultation in these institutions is free.

How do I find a good dermatologist?

Contact our office at St. Luke’s. We have fliers that we circulate around. Choosing a dermatologist is a matter of trust. Our number is 727-7309 or visit www.pds.org.ph.

In PDS’ info campaign, there was an article warning consumers to beware of the establishments derma-dermahan (pseudo-dermatologist). Can you share this with us?

There’s a well-documented case published in the PDS Journal involving an overseas Filipino worker who agreed to undergo body skin peeling offered by her manicurist to whiten her skin. Total cost of the procedure? Just her life. A significant amount of chemical was absorbed into her blood, interfering with the oxygen circulating in her whole body.

It’s a true and tragic tale. This doesn’t happen every day, of course, but losing one’s life in the attempt to achieve a lighter complexion is certainly not worth it. We have all heard of a lot of cosmetic procedures gone awry, of numerous sad tales regarding skin problems mismanaged by unqualified persons.

So where can you complain for a cosmetic procedure gone wrong?

You can always go to the Philippine Medical Association or PMA, that’s the umbrella society where all the other fields are under. I think they have an association of salons or something, where you can complain because apparently, they’re not trained to do their job correctly. You can complain to both associations.

What is the current stand of the PDS on glutathione?

The current stand of the PDS is that there is no randomized controlled study that supports glutathione as a whitening preparation. You can look through the Internet, there will no study supporting it. It is, indeed, used as an antioxidant, you see articles on that, but not as a whitening. Therefore, you will simply hear anecdotal reports, some patients’ claims. But you should hear the other side — other patients will say they spent so much, but nothing happened. Because it’s all media hype. And I try to tell patients not to have this colonial mentality. You don’t have to be white. Brown is beautiful, be proud of your skin. Fact is, the melanin in your skin protects you from skin cancer and this is something the Americans do not have. And they envy us, they sunbathe, they tan to have our color.

What’s the difference between glutathione and hydroquinone?

Chemically, they’re different. Hydroquinone really has been very effective in the treatment of hyperpigmentation for so many years already. Glutathione doesn’t have that same stature. We do use hydroquinone, but we advise patients to use it correctly — not to use it for a prolonged period and at a very high concentration. Because it does more harm than good. And you cannot use it to whiten everything, which is ridiculous.

And remember, we are Asians, and genetically, we’re born with melanocytes that produce melanosomes that are for Asian skin, not Caucasian. The melanosomes of Asian skin are more well-developed and more in number compared to the Caucasian’s.

The bottom line is genetically, you will never be a Caucasian. Many of us have this delusion. You just avoid the sun and you will become fairer or you will lighten up.

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