Treating “Brown Spots” With Bleaching Cream

Todd Minars, M.D.
Dermatology This is the first of a two part email about treating “brown spots”. This month we will discuss the treatment of “brown spots” with bleaching cream, and next month we will talk about the treatment of “brown spots” with lasers.“Brown spots” is an intentionally vague term. But most people do not know the medical term for the type of brown spots that they have. Some people are familiar with the term melasma, which is also called “the mask of pregnancy” (though you do not have to be pregnant to have it). Another very common form of “brown spots” is called post-inflammatory hyperpigmentation. Acne patients with darker skin are familiar with this form of “brown spots”. In these patients the inflammation from their acne leaves them with brown pigmentation on their face that can last from months to years. Any type of inflammation can leave this form of pigmentation: burns, irritation from shaving, plucking, or ingrown hairs. Both of these conditions: melasma and post-inflammatory hyperpigmentation are notoriously difficult to treat. In fact, they are even notoriously resistant to laser therapy, so we turn to bleaching creams.Bleaching creams come in many varieties. The most common ingredient is hydroquinone. Over-the-counter preparations contain up to 2% hydroquinone and prescription creams contain up to 4% hydroquinone. But most patients who I see have already tried these creams, and they are coming to see me because they have failed to improve.The most effective bleaching cream was developed many years ago by a dermatologist at the University of Pennsylvania named Albert Kligman. His cream is a mixture of three ingredients (one of them being 4% hydroquinone) and was used with great success by dermatologists for years.

The only problem was that a pharmacist had to compound (i.e. custom mix) the cream, and the art of compounding has been a dying art over the past few years due big chain pharmacies, poor insurance reimbursement, and the availability of pre-packaged creams. For example, Triluma came on the market a few years ago as a pre-packaged/ pre-mixed, prescription version of Kligman’s formula and is very effective for the treatment of hyperpigmentation (though also very expensive and usually not covered by insurance). Again however, being a specialist (and therefore often the last resort for some difficult cases) I will often see patients who have already tried Triluma, and failed to improve.

So the question is what kind of bleaching creams do I prescribe for my patients? As a specialist I have the unique opportunity to treat many patients with the same problem and I have tried just about every version of bleaching cream an (just as important) several pharmacies who compound these creams, and I now use one pharmacy to make my bleaching cream compounds based on Kligman’s formula, because they provide the following

advantages:

• We can use stronger concentrations than available in pre-packaged prescription creams. For example, Triluma has 4% hydroquinone, and we often like to use 6, 8, or 10% hydroquinone.
• We can use any combination of those three ingredients and can “fine tune” it according to your skin type or according to what stage of treatment you are in. For example, we may start with high concentrations of all three ingredients for two or three months to achieve initial clearing of the pigment, and then use lower concentrations of only one or two of the ingredients to maintain the results.
• Finally, we get all of these advantages at a significantly lower cost. Triluma usually costs about $90 to $100 for 30 grams. The pharmacy that we use will compound the same cream for $30 to $40. (please note: The pharmacy bills you directly. We in no way profit from this or any other prescriptions we write.)