Having spots and patches that are darker than the surrounding skin can be distressing. In the Latino community, many consider visibly darker areas of skin disfiguring. When 100 women of color (Asian, black, and Latina) were surveyed, 86% said that dark spots on their skin concerned them.

As this is a common concern for their patients with skin of color, dermatologists, fortunately, have many effective treatments. The key to effective treatment is finding the cause.

Causes
Darkening of the skin frequently develops in skin of color when the skin heals after an injury or trauma. Common skin injuries and traumas that can lead to dark spots and patches include:

• Break out: Acne or pimples

• Burn, bruise, cut, or scratch

• Cosmetic procedure (chemical peel, dermabrasion, laser therapy)

• Irritation caused by a skin care product

• Rash

• Razor bumps

• Rubbing or scrubbing to get skin clean

• Sunburn

• Surgery

When a dark spot or patch appears after injury or trauma to the skin, dermatologists call the reaction postinflammatory hyperpigmentation.

Another frequent cause of dark spots and patches is melasma, a common skin condition. Producing brown to grayish-brown patches on the face and occasionally the neck and forearms, melasma is most common in women between the ages of 21 and 40 who have brown skin tones. Sun exposure often triggers melasma. Pregnancy and taking birth control pills are other common triggers.

Dermatologists Recommend Early Treatment
Early detection and treatment of the underlying cause tend to give patients the best results. To find the cause, a dermatologist will examine a patient’s skin and ask questions.

Anyone who is taking medication, even for a few days, should tell the dermatologist. Some medications can cause skin discoloration. These include medications used to treat high blood pressure, diabetes, and heart disease. Common medications such as aspirin, birth control pills, and some antibiotics can cause round, dark patches or grayish-blue discoloration on skin of color.

If acne or pimples are causing the discoloration, it is important to treat both the acne and dark spots. Without effective treatment for the acne or pimples, the dark spots normally continue to appear as the new lesions clear. This can result in long-lasting skin discoloration.

Treatment Options
There are several treatment options for postinflammatory hyperpigmentation and melasma. Products that contain hydroquinone (pronounced hy-dro-QUIN-own) are the most common treatment option for eliminating dark spots and patches. While prescription-strength products that contain hydroquinone tend to be more effective, several products containing hydroquinone are available at local drug stores without a prescription. This availability may soon change. For more information about the proposal that would remove many of these products from the market, read the facing article in this newsletter, “Favored Skin-Lightening Products May Soon Vanish.”

Other treatments that a dermatologist may prescribe to treat dark spots and patches are medications that contain azelaic acid or glycolic acid. For some patients with skin of color, a chemical peel or microdermabrasion treatment may be recommended. This treatment option is best performed in a dermatologist’s office. At-home microdermabrasion kits and chemical peels are best avoided for treating dark spots and patches. Dermatologists who specialize in treating skin of color tell their patients that these at-home products “often do more harm than good.”

Prevention
As the dark spots and patches fade, it is important to follow these dermatologists’ recommendations to help keep the skin looking its best:

• Apply sunscreen every day to control melasma and prevent other dark spots from becoming darker.

• Use gentle skin care products.

• Avoid vigorously washing, rubbing, and scrubbing the skin.

• Avoid treatments, such as chemical peels and microdermabrasion, unless prescribed by a dermatologist.

• Continue to treat acne.

• Apply hair oils and pomades carefully so that the oils do not touch the face and possibly cause acne.

References:
Baumann, L et al. “Natural Considerations for Skin of Color.” Cutis. Dec 2006;78(suppl 6):2-20.

Taylor, S. “Postinflammatory Hyperpigmentation.” Brownskin.net. Available at: http://www.brownskin.net/hyperpigmentation.html.
Last accessed January 25, 2007.

Taylor, S. “Melasma.” Brownskin.net. Available at http://www.brownskin.net/melasma.html.
Last accessed January 25, 2007.

Generations have relied on over-the-counter products to safely and effectively lighten dark patches — from melasma to age spots — on their skin. Many of these products contain hydroquinone (pronounced hy-dro-QUIN-own). Now a proposal by the U.S. Food and Drug Administration (FDA) would require products containing hydroquinone to be evaluated as new drugs. This means that more than 200 skin-lightening products — both prescription and over-the-counter — could soon vanish.

While this removal could be temporary, the proposal leaves many dermatologists concerned. The process for evaluating a new drug costs the manufacturer of the product millions of dollars; this process lasts two to four years. Many dermatologists believe most companies will simply stop offering these products. If a product receives approval, it will likely cost much more and require a prescription.

The FDA says this action is necessary because hydroquinone poses serious health risks. Topping the list of concerns are an increased risk of cancer and ochronosis (pronounced oh-kron-no-sis). The latter is a rare medical condition that causes pigment to accumulate in the skin with long-term use of hydroquinone creams. When ochronosis occurs, the skin exposed to hydroquinone develops a sooty darkening.

Evidence Does Not Support Proposal
Dermatologists point out that products made by reputable companies remain safe and effective. The increased risk of cancer has not been proven in humans. This data comes from studies conducted on mice and rats, not humans. Even in Africa where some dermatologists say use of skin-lightening products borders on abuse, reports of an increased cancer risk have not occurred.

As for the increased risk of developing ochronosis, the fact is that millions of people in the United States have used these skin-lightening products. About 200 cases of ochronosis have been linked to these products, making the risk extremely rare.

The American Academy of Dermatology (Academy) and other medical organizations disagree with this FDA proposal. The Academy says that this change would significantly limit access to treatments for many patients. In a letter to the FDA, Academy President Stephen P. Stone, M.D., wrote, “the proposed changes would harm dyschromia patients and disproportionately affect minority populations.” Dyschromia is a medical condition that causes patchy discoloration of the skin.

Alternatives Not Safe
Many dermatologists fear that people looking for an alternative to their favorite skin-lightening cream may turn to unsafe products. Imported skin-lightening products often do not accurately list their ingredients. Some products contain mercury, others high-potency steroids. While illegal, these products do find their way into the United States. Using a product that contains a high-potency steroid can cause paper-thin skin, steroid-induced acne, and stretch marks.

Other imported products contain much higher levels of hydroquinone than currently allowed in the United States. These high levels can cause skin irritation and visible, light-colored halos around the treated skin.

Few Products Will Remain
If the FDA’s proposal goes into effect, not one over-the-counter product will be available. The FDA indicates that only products having undergone the FDA approval process will remain. One such product, which is available with a prescription, contains 4% hydroquinone. This is much higher than the 2% concentration that most over-the-counter skin-lightening products now offer. This product will remain available by prescription because it recently underwent the new drug application process and was approved.

Some retinoids, acid-based peels, and a few other products also will be available to lighten skin, but these, too, are prescription medications. Consumers looking for over-the-counter remedies will find some natural skin-lightening products. Usually containing soy, licorice, or kojic acid, many dermatologists predict that the results will be disappointing.

Consult a Dermatologist
If you wish to continue lightening your skin should this proposal go into effect, be sure to speak with a dermatologist before trying a new product. While a consult can be expensive, the cost of treating unwanted side effects can be much higher.

References:
American Academy of Dermatology. “Academy Registers Disagreement with FDA's Proposed Hydroquinone Changes.” Academy e-News. January 2007.

Bates, B. “Derms React to Possible FDA Ban of Hydroquinone.” Skin & Allergy News. January 2007, p. 1+

Jesitus, J. “FDA Impact Felt by Derms.” Dermatology Times. December 2006. p. 1+