During the height of the COVID-19 pandemic, the United States Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act to provide economic assistance for American workers, small businesses, and industries. It also included a provision banning the sales of over-the-counter hydroquinone.
Much like a Russian nesting doll, major legislation passed in Washington is often filled with smaller, less-publicized provisions. Instead of voting on each item individually, lawmakers can bundle multiple issues into a single piece of legislation.
For decades, dermatologists have referred to hydroquinone as the ‘gold standard’ when it comes to treating hyperpigmentation—which is more common on Black skin—including skin conditions like melasma. And studies have shown that when used under the supervision of a board-certified dermatologist, hydroquinone is more effective than other topical ingredients when treating hyperpigmentation.
So why was over-the-counter hydroquinone banned in the United States? “Hydroquinone was removed from OTC products as a result of concerns over safety and adverse effects,” explains Dr. Ryan Turner, board-certified dermatologist and co-founder of TRNR Skin.
The ingredient has a bad reputation, partly due to its presence in a robust, unregulated black market, as well as bans in the European Union. Ahead, I spoke with experts to uncover whether hydroquinone deserves the villain treatment it has received or if the truth about the ingredient is more complicated than meets the eye.
What is hydroquinone?
“Hydroquinone is a skin-lightening agent that can be used to treat dark spots and patches, such as hyperpigmentation, sun spots, melasma, and post-inflammatory hyperpigmentation,” explains Dr. Turner. “It’s also a potent antioxidant.” Hydroquinone works by blocking tyrosinase, an enzyme that “converts the amino acid tyrosine into the precursors needed to produce melanin,” adds Dr. Turner. By inhibiting tyrosinase, hydroquinone reduces melanin production and helps lighten areas of hyperpigmentation. It’s one of the most potent skin-lightening agents available.
With great power comes great responsibility. Under medical supervision, hydroquinone treatments are applied once or twice daily for up to three months. “Depending on what’s being treated and the response after three months or so, a dermatologist will typically swap out your hydroquinone for a different skin-lightening topical,” says Dr. Turner, “cycling it back in as needed.”
What are the side effects of using hydroquinone?
Hydroquinone’s potential side effects come into play when it’s overused or used without medical supervision. Allergic reaction, redness, irritation, and hypopigmentation are all potential side effects, explains Dr. Turner. “There’s also a more worrisome side effect of hydroquinone use known as exogenous ochronosis,” he adds. Exogenous ochronosis is a type of skin coloration where the skin darkens and thickens, often turning a blue-black or gray-black color. This happens when homogentisic acid builds up in the skin, says Dr. Turner.
Exogenous ochronosis is a rare skin condition that can happen when you use certain products, like hydroquinone, for a long time. It’s a type of skin discoloration where the skin becomes darkened and thickened, often turning a bluish or grayish color. This happens because the skin starts to build up a substance called pigment in an unusual way, which can be caused by using too much of some chemicals over time. “Again, this is why it is so important to only use hydroquinone under the supervision of a dermatologist,” adds Dr. Turner.
How is hydroquinone used in other parts of the world?
Outside the U.S., there have been reports of unregulated hydroquinone products with higher concentrations, often combined with mercury and steroids, explains Dr. Ryan. “However, the risks associated with hydroquinone are primarily due to misuse, overuse, or contamination of products.”
These potential risks are why Dr. Grace Ayensu-Danquah, an American-trained general surgeon and Borghese Skin Expert, does not recommend hydroquinone to her patients. “In Africa and Asia, hydroquinone is often used to brighten or lighten the skin,” says Dr. Ayensu-Danquah, who is based in Accra. Before the ban in the U.S., hydroquinone was available to buy in a 2% concentration. In regions where skin bleaching is prevalent, bleaching creams are often formulated with very high concentrations of hydroquinone, such as 8% or 10%. “It became the chemical of choice because it was more affordable than other skin-brightening ingredients,” she explains.”When you visit markets in Africa, you’ll often see women with large purple or black blotches on their faces. They’re buying unregulated creams and lotions containing hydroquinone and applying them daily for years.”
Hydroquinone also increases the skin’s sensitivity to the sun. Limiting sun exposure and following strict sun protection protocols are crucial for treating and preventing future hyperpigmentation, says Dr. Turner. However, maintaining these precautions can be challenging in the tropical climate of West Africa. The increased sensitivity to the sun and the serious side effects that come along with the fact that hydroquinone products aren’t regulated in Ghana is why Dr. Ayensu-Danquah tells her patients to stay away. “It does have a place when treating hyperpigmentation or melasma, but there needs to be strict medical advice and supervision.” Instead, Dr. Ayensu-Danquah typically recommends vitamin C to her patients as a safer, over-the-counter alternative to hydroquinone.
Why is hydroquinone banned in the EU?
The EU follows the “precautionary principle,” meaning that even if there is uncertainty about the potential risks of a chemical or ingredient, the governing body will restrict or ban its use until further research confirms its safety. There has been ongoing debate, particularly online, about whether hydroquinone poses a cancer risk.
Some evidence suggests that when taken orally, hydroquinone may cause kidney cancer and leukemia in rats. However, no link has been found between hydroquinone use and cancer in humans. Despite this, the EU determined that the potential for misuse, combined with safety concerns, outweighed the benefits of making hydroquinone widely available. The U.S. Food and Drug Administration (FDA) has not determined that hydroquinone poses a cancer risk to humans when used topically at appropriate concentrations.
The Final Word
While the ban on hydroquinone in OTC products has led many people to believe it is dangerous, Dr. Turner explains, “The risks associated with hydroquinone are largely due to misuse, overuse, or contaminated products.” Many regulated ingredients in OTC skin care that can have negative side effects if misused or overused. Once again, it’s all about moderation and medical supervision. “Hydroquinone is a very valuable and useful skincare tool when used correctly.”