rebound pigmentation Archives - WLC (2023)

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Part2: Pulse Therapy

When used properly, under the guidance of a physician, 4% hydroquinone is a safe and effective means of managing pigment disorders. So, what constitutes as proper use of hydroquinone? Dr. Zein Obagi, a pioneer in the concept of total skin health and creator of ZO Skin Health & ZO Medical, recommends a “pulsed” approach to avoid the adverse events associated with long-term hydroquinone use.

Dr. Obagi, whose name is synonymous with pigment correction, founded Worldwide Medical, Inc (makers of the original Obagi Nu-Derm & Obagi Blue Peel) in 1988. Nearly 10 years later, in 1997, Obagi Medical Products (OMP) acquired Worldwide Medical and the Obagi® trademark and continued to produce the Obagi Nu-Derm system… the same, relatively unchanged Nu-Derm system that we know today. In 2006, Dr. Obagi left his position with OMP as he worked to improve and evolve his original concept of total skin health. It was in 2007 that ZO Skin Health was born, and then, after years of research and clinical studies, in 2012, ZO Medical launched as the alternative to OMP’s Obagi Nu-Derm.

In addition to his involvement with introducing hydroquinone to the masses, Dr. Obagi is a practicing board-certified dermatologist. His in-office clinical experience, combined with decades of research, has convinced him that a “pulsed” approach to treating pigment disorders with hydroquinone is not only safer than the “bigger, better, faster, more” approach of the late 1980’s – early 1990’s, but also more in tune with his philosophy of total skin health.

The “pulsed” approach to hydroquinone is a simple one: limit use of hydroquinone to no longer than 5 months at a time. Then, give your skin a break; allow it to rest and stabilize for 2-3 months as you use NON-hydroquinone pigment control products to prevent rebound pigmentation. After the break, your physician can decide if another 5 month course of hydroquinone is appropriate for you.

Hydroquinone is an inflammatory agent that can become allergenic after 5 months of use. Hydroquinone-induced inflammation can cause rebound hyperpigmentation and reduced tolerance to hydroquinone itself. Pulsing hydroquinone use can prevent this, but quitting ‘cold turkey’ can trigger rebound pigmentation as well. That’s one of the reasons medical supervision is so important: your physician and/or skin care clinician can custom-tailor a pigment control regimen based on dosage and frequency that minimizes risks and maximizes efficacy.

For over a quarter of a century, 4% hydroquinone has been the dermatological gold standard for topical treatment of pigmentation disorders ranging from melasma to photo-damage to post-inflammatory hyperpigmentation.

Hydroquinone works to correct, reduce, and prevent hyperpigmentation (dark spots) by inhibiting the activity of tyrosinase, the enzyme needed to make pigment. When tyrosinase activity is limited, production of pigment is decreased and the skin’s ability to break down existing pigment is increased. The result is the gradual bleaching of existing dark spots and the suppression of future dark spots.

While the outward effects of hydroquinone are cosmetic and it is generally treated as “skincare,” consumers tend to forget that it is a prescription medication and, as such, needs to be used under medical supervision. As with the medication we use to control blood pressure, treat infection, and manage diabetes, dosage, frequency of use, and duration of hydroquinone treatment are decisions that should be made under the direct guidance of your healthcare provider.

Long-term, self-directed treatment with hydroquinone (often purchased through internet pharmacies or skincare sites) can have disfiguring, life-altering, and most importantly, preventable side effects. Some of the most common adverse events stemming from unsupervised use of hydroquinone include:

  • Resistance: overuse of 4% hydroquinone can cause the skin to become resistant to the bleaching effects. This generally occurs at the 4-5 month mark. Consumers notice that the medication is no longer working and discontinue use. Discontinuation without a proper “weaning” period can lead to rebound pigmentation—pigmentation actually becomes worse and can be further exacerbated by treatment with hydroquinone.
  • Photosensitivity: some consumers choose to use hydroquinone indefinitely under the mistaken impression that it will prevent any and all future pigmentation. In actuality, this extended use decreases the amount of melanin (our body’s natural defense against the sun) in the skin creates photosensitivity. This photosensitivity accelerates UV damage and intensifies the signs of photoaging. Further, without daily use of an SPF 30 sunscreen, photosensitivity leads to inflammation, which, in turn, stimulates melanin production, resulting in the creation of more pigment.
  • Exogenous Ochronosis: Exogenous Ochronosis (EO) is a pigmentary disorder caused by the unsupervised, long-term use of hydroquinone. The disease manifests itself in patches of blue-black pigment, localized to areas that have been both over-treated by hydroquinone and exposed to the sun. While EO is more prevalent in skin of color (Fitzpatrick types IV-VI), there has been an increase in documented cases among the Caucasian population which could be associated with the proliferation of online “pharmacies” and the rise of self-directed treatment. Numerous treatment modalities (e.g., steroids, retinoic acid, laser therapy, cryotherapy) have been proven clinically ineffective in reversing the signs and symptoms of EO.

rebound pigmentation Archives - WLC (2)

Exogenous Ochronosis caused by long-term use of hydroquinone

As with any medication, serious side effects may arise from the misuse and abuse of hydroquinone. However, a properly supervised course of treatment can be safe and life-changing to those who have suffered the low self-esteem and social anxiety that can stem from pigmentary disorders.

Stay tuned for Part II, a discussion on the benefits of a pulsed hydroquinone regimen.

This series of postsis adapted from Obagi, Z. (2013). Taking the Pulse of Hydroquinone Therapy: A Plea for Caution. Practical Dermatology, 39-42.


What is rebound pigmentation? ›

The pigmentation rebound was defined as melasma improvement after the end of laser treatment. 16. Nevertheless, at the follow-up period, the degree of pigmentation was equal or higher than baseline for 33% and 60% at 1-month and 3-month follow-up period, respectively.

How do you treat rebound pigmentation? ›

Topical therapy is typically effective for epidermal postinflammatory hyperpigmentation; however, certain procedures, such as chemical peeling and laser therapy, may help treat recalcitrant hyperpigmentation.

Does alpha arbutin cause rebound hyperpigmentation? ›

Alpha arbutin is safer and non-irritating, unlike Hydroquinone, and also does not lead to rebound hyperpigmentation (which means pigmentation comes back after you stop using Hydroquinone).

Does pigmentation come back after stopping hydroquinone? ›

Discontinuation without a proper “weaning” period can lead to rebound pigmentation—pigmentation actually becomes worse and can be further exacerbated by treatment with hydroquinone.

Does hydroquinone lighten skin permanently? ›

Does hydroquinone lighten skin permanently? No, the results of any skin lightening that hydroquinone brings about are not permanent. The effects can be seen within a couple of months or a few years at the maximum.

Does hydroquinone make spots darker first? ›

Hydroquinone is an organic compound that is highly effective in skin lightening. They have a whitening effect and treat hyperpigmentation on the skin. However, if used incorrectly, hydroquinone compounds can still make skin darkening and hyperpigmentation more severe and lasting.

How do you prevent hydroquinone rebound? ›

While transitioning off hydroquinone, continued stimulation with a retinoid is beneficial to prevent rebound pigmentation. Treatment should never stop abruptly! Using a non-hydroquinone tyrosinase inhibiting skin brightener after a hydroquinone cycle can also help enhance results.

How do you stop pigmentation from coming back? ›

How to prevent hyperpigmentation
  1. Avoid direct sunlight. Try to stay out of the sun during the peak hours of 10 am to 2 pm. ...
  2. Use a hat. Shade your face and scalp with a wide-brimmed hat.
  3. Incorporate Vitamin C into your beauty routine. ...
  4. Apply SPF. ...
  5. Limit touching your skin.

How long does it take for hyper pigmentation to go away? ›

How long does it take for hyperpigmentation to fade? Once what's causing the dark spots or patches is found and stopped, fading can take time. A spot that is a few shades darker than your natural skin color will usually fade within 6 to 12 months. If the color lies deep in your skin, however, fading can take years.

Should I stop using alpha arbutin after 3 months? ›

Yes, arbutin is safe to use everyday. Depending on your skin's sensitivity, it can be used twice a day. Just remember, don't use arbutin more than 3 months at a time because that can be damaging to your skin.

What happens when you stop using alpha arbutin? ›

No sooner do you discontinue using the arbutin products than your skin reverts to its former condition. The beneficial effects of arbutin are temporary. As it merely inhibits the activity of the key enzyme, tyrosinase, and decreases melanin production. No permanent change or reaction is caused.

What ingredients make hyperpigmentation worse? ›

Ingredients in skin care products can cause photosensitivity, leading to hyperpigmentation:
  • Retinol/Retin A.
  • Alpha Hydroxy Acids / AHAs (glycolic acid, lactic acid, citric acid, etc.)
  • Benzoyl Peroxide.
  • Perfume and fragrance.
  • Vitamin C (products containing high amounts of L-Absorbic Acid, 20% or higher)

How many months should you take a break from hydroquinone? ›

Usage Recommendations. Hydroquinone can be used twice daily for up to five months consecutively. After five months, melanocytes should be allowed to stabilize during a two to three month break from hydroquinone.

What completely clears hyperpigmentation? ›

Dermatologists consider products with hydroquinone, alone or combined with other lighteners, to be the gold standard for fading dark spots because it slows the production of pigment. These are available by prescription, per the U.S. Food and Drug Administration (FDA).

How do you cycle off hydroquinone? ›

Weaning Off Hydroquinone

2 days using the Hydroquinone products, the remainder of the week use Non-Hydroquinone products. 1 day using the Hydroquinone products, the remainder of the week use Non-Hydroquinone products. You should now be only using Non-Hydroquinone products for three months.

What happens if you use hydroquinone too long? ›

In rare cases , hydroquinone has caused a condition called ochronosis. It's marked by papules and bluish-black pigmentation. This can occur after prolonged daily use. As such, you shouldn't use products with this ingredient for more than five months at a time.

What are the disadvantages of hydroquinone? ›

Many people using this medication do not have serious side effects. Stop using hydroquinone and tell your doctor right away if you have any serious side effects, including: blistering, skin cracking, blue-black darkening of the skin. A very serious allergic reaction to this drug is rare.

What not to mix with hydroquinone? ›

Chan both agree hydroquinone does not play well with benzoyl peroxide, hydrogen peroxide, or other peroxide products. Not only will pairing them cause irritation and dryness, but it can also temporarily stain your skin.

Why is my pigmentation getting worse? ›

What triggers hyperpigmentation? Triggers include sun exposure, hormonal changes, and trauma to the skin, for example, due to acne or an injury. Picking at scabs and spots may make it worse. Some face creams can irritate the skin, leading to further hyperpigmentation.

Why won't my pigmentation go away? ›

Some cases of hyperpigmentation may never go away completely. If hyperpigmentation is caused by injury, then as the skin heals the discoloration will lessen as melanin is absorbed into the tissue surrounding the injury.

How long does it take for hydroquinone to remove pigmentation? ›

It can take approximately 4-6 weeks of daily (or even twice daily) hydroquinone application before dark spots will begin to fade. After 8-12 weeks, optimal results should appear and overall skin tone will become more even.

Are the effects of hydroquinone reversible? ›

Hydroquinone is a topical skin-bleaching agent used in the cosmetic treatment of hyperpigmented skin conditions. The effect of skin lightening caused by hydroquinone is reversible when exposed to sunlight and therefore requires regular use until desired results are achieved.

Can I put retinol on top of hydroquinone? ›

Hydroquinone and retinols work well together because retinols help hydroquinone penetrate deeper into the skin to work more effectively. Retinols can also protect hydroquinone from oxidation, which can cause it to degrade.

Does hydroquinone worsen hyperpigmentation? ›

Hydroquinone may cause local skin irritation, however, and thereby leading to post-inflammatory hyperpigmentation, making the skin pigmentation worse.

Why does pigmentation keep coming back? ›

The biggest risk factors for general hyperpigmentation are sun exposure and inflammation, as both situations can increase melanin production. The greater your exposure to the sun, the greater your risk of increased skin pigmentation.

Why does my pigmentation come back? ›

Sun damage – spending too much time in the sun, can give you a greater risk of developing pigmentation or more serious conditions. While you expose your skin to sun light without protection, the damaged pigment cells will leak pigment into the deeper layers of your skin. As a result your treatment can take longer.

What is the fastest way to cure pigmentation? ›

Apple cider vinegar contains acetic acid, which may help in lightening the pigmentation on your skin. Mix apple cider vinegar and water in equal parts in a container. Then, apply it to your dark patches and leave on two to three minutes. Rinse using lukewarm water.

Can you reverse hyper pigmentation? ›

Chemical peels, laser therapy, microdermabrasion, or dermabrasion are all options that work similarly to rid skin of hyperpigmentation. These procedures work to gently remove the top layer of your skin where the dark spots lie.

Is hyper pigmentation reversible? ›

Early diagnosis can limit morbidity and inappropriate workups. Hyperpigmentation associated with vitamin B12 deficiency is completely reversible with treatment.

Does drinking water help with hyperpigmentation? ›

Improved Skin Tone

If you struggle with mild hyperpigmentation (dark spots and uneven coloring), you might benefit from focusing on hydration. Upping your water intake may be linked to more even-looking skin and less discoloration.

Do you need a break from Alpha Arbutin? ›

After this you can apply alpha arbutin twice a day if needed, just ensure you stop using it after 3 months and allow your skin to have a break whilst preventing any further, long-lasting damage.

How long does Alpha Arbutin take to fade hyperpigmentation? ›

It is not only known to reduce the appearance of sun spots but also helps in preventing them. In most cases, hyperpigmentation takes time to heal so don't expect overnight results with Alpha-Arbutin, give it 8-12 weeks to show significant results.

Do you need to take a break from arbutin? ›

Some experts recommend using AA for about three months at a time before taking a break. You can then reuse it as needed after giving your skin some time off. Which is better: alpha arbutin or vitamin C?

Why is arbutin banned? ›

The use of this ingredient in cosmetics has been banned since 2001 because of the high risk of carcinogenesis in case of prolonged exposure to hydroquinone [6,7]. Chemical structures of hydroquinone, arbutin (β-arbutin), and α-arbutin.

Is it safe to use the Alpha Arbutin for a long time? ›

Arbutin is a derivative of hydroquinone, which is banned in many countries. But arbutin itself is not banned in any countries, as it's linked to a lower risk of side effects than hydroquinone. Can you use arbutin every day? Yes, it is safe to use arbutin every day, and it's also okay to use it twice a day.

What not to mix with alpha arbutin? ›

The only product Alpha Arbutin shouldn't be mixed with is The Ordinary Niacinamide Powder due to its pH level. Apart from that, Alpha Arbutin has no other conflicts, so it's a really easy product to fit into your skincare routine.

What foods trigger hyperpigmentation? ›

Spicy and Fried Foods – inflammatory foods

Spicy foods and/or fried foods are also highly inflammatory in the body. Those foods should be limited as they can also trigger hyperpigmentation of the skin.

How I cured my hyperpigmentation naturally? ›

Pigmentation treatment at home
  1. Combine equal parts apple cider vinegar and water in a container.
  2. Apply to your dark patches and leave on two to three minutes.
  3. Rinse using lukewarm water.
  4. Repeat twice daily you achieve the results you desire.

What foods fight hyperpigmentation? ›

In this category of foods, the best options are citrus fruits like oranges and lemons, foods with beta-carotene (orange color) like sweet potatoes, pumpkin and carrots, and seafood rich in copper, manganese, selenium, and zinc.

Does hydroquinone damage your skin? ›

FDA has received reports of serious side effects including skin rashes, facial swelling, and ochronosis (discoloration of skin) from the use of skin lightening products containing hydroquinone.

Which vitamin removes hyperpigmentation? ›

Vitamin C, also known as ascorbic acid, is used as a treatment modality in depigmentation of hyperpigmented spots on the skin and gingiva.

What type of hyperpigmentation is hardest to treat? ›

Melasma treatment

Whereas some types of hyperpigmentation can be treated with topical creams, melasma is not treated so easily due to the hormones that contribute to its cause in the first place.

How is stubborn hyperpigmentation treated? ›

Topical Treatments For Hyperpigmentation
  1. A skin-lightening ingredient like hydroquinone or cysteamine hydrochloride. ...
  2. A brightening serum with vitamin C. ...
  3. A physical sunblock with at least SPF 30. ...
  4. A chemical exfoliant like salicylic, glycolic or lactic acid. ...
  5. Retinol.
27 Jun 2022

Does hyperpigmentation come back after using hydroquinone? ›

Excessive hydroquinone concentrations may induce toxic or shocking effects on melanocytes, forcing them to regroup and increase their melanin production (resulting in rebound hyperpigmentation).

Why my pigmentation is coming back? ›

The biggest risk factors for general hyperpigmentation are sun exposure and inflammation, as both situations can increase melanin production. The greater your exposure to the sun, the greater your risk of increased skin pigmentation.

How long does hyper pigmentation last? ›

How long does it take for hyperpigmentation to fade? Once what's causing the dark spots or patches is found and stopped, fading can take time. A spot that is a few shades darker than your natural skin color will usually fade within 6 to 12 months. If the color lies deep in your skin, however, fading can take years.

Can hyperpigmentation come back after treatment? ›

It depends on your treatment approach. If you've been experimenting with short term solutions rather than address the root cause. your pigmentation will keep coming back. That's why its super important that you seek advice from a trained professional or Dermatologist.

What are the 3 types of hyperpigmentation? ›

What are the types of hyperpigmentation? The three main types include age spots, melasma, and post-inflammatory trauma. Post-inflammatory trauma can result from an injury, sun exposure, or a skin condition, such as acne.

How can I reverse my pigmentation naturally? ›

A few home remedies for hyperpigmentation
  1. Apple Cider Vinegar. Apple Cider Vinegar. A very effective home remedy for hyperpigmentation is apple cider vinegar. ...
  2. Aloe vera. Aloe vera. Aloe vera has umpteen benefits for your skin and it is also a home remedy for hyper-pigmentation. ...
  3. Green Tea. Green Tea. ...
  4. Milk or curd. Milk or curd.

How long does it take to reverse hyperpigmentation? ›

For post-inflammatory hyperpigmentation (PIH), without any treatment at all it can take anywhere from three months to two years for the discoloration to fade, depending on how dark the patches are, and even then it may not disappear completely.

How can I permanently reduce melanin in my skin? ›

However, aside from wearing sunscreen and limiting sun exposure, you can't lower your body's overall melanin production. Permanent reduction isn't possible, since melanin formation is determined by genetics.

Can hyper pigmentation be corrected? ›

While usually treated topically at home, most hyperpigmentation also can be treated in-office with chemical peels; only certain mild cases can be treated with lasers, because light and inflammation can trigger more hyperpigmentation.

Does vitamin C help with hyperpigmentation? ›

Vitamin C protects skin cells from free radicals and inhibits melanin production in the skin, which helps to ease hyperpigmentation, brown spots, even skin tone, and improve skin radiance.

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