Hydroquinone and Tretinoin are the two most prescribed medicines for hyperpigmentation. However they do very different things and are not interchangeable. First of all these prescription only medicines work through different mechanisms which means they tackle hyperpigmentation differently. They also have different safety profiles which affects their use. All this means that Tretinoin and Hydroquinone have distinct uses, risks and limitations. The choice to use one or the other (or both) depends on the hyperpigmentation, skin condition and patient’s overall health. In this article we compare Hydroquinone vs Tretinoin for hyperpigmentation to understand how they work, their uses, safety, limitations and alternatives.
Types of Hyperpigmentation
Hyperpigmentation develops when the pigment producing skin cells (melanocytes) make excess melanin or distribute it unevenly. This occurs when Tyrosinase, the enzyme that drives melanin production, becomes overactive and slow cell turnover allows pigment to build up. This excess pigment may collect superficially, in deeper layers or in a mixture of depths in the skin depending on the cause of hyperpigmentation. Although the mechanism is similar, there are actually several types of hyperpigmentation including:
- Melasma: The main trigger for this is hormones and sun exposure. It is most common in women and relapses frequently especially in hotter or sunnier environments. Melasma most commonly presents as symmetrical patches of hyperpigmentation on the face. The pigment often deposits in deeper or mixed layers of the skin.
- Post-Inflammatory Hyperpigmentation (PIH): This usually follows acne, eczema, burns or skin injuries. It is usually superficial in depth and resolves quickly but can persist in darker skin tones.
- Sun-Induced Pigmentation: This includes sun spots (lentigines) and diffuse patches due to years of UV exposure. It is cumulative and often mixed in depth.
- Mixed Hyperpigmentation: This is actually the most common form. Most people tend to have a mixture of superficial and deeper pigmentation. They may also have a combination of hyperpigmentation conditions such as melasma, PIH and sun spots coexisting.
In addition to the type, the pattern and depth of hyperpigmentation also play a key part in dictating which treatment is effective. Pigment limited to the epidermis (superficial layer of skin) usually responds well to just topical treatments. Dermal (deeper layer of skin) pigmentation is harder to treat and often relapses. It may not completely respond to topical treatments. Mixed pigmentation may require a multi-layered approach that takes into account the depth and causes of the hyperpigmentation.
Hydroquinone for Hyperpigmentation Treatment
This prescription only medicine blocks tyrosinase enzyme activity to reduce melanin production. Hydroquinone is a topical treatment (usually available in cream form) that can clear stubborn dark patches relatively quickly even in as little as 3 months although this varies from person to person. It is popular for use in melasma, sun spots as well as persistent or treatment resistant post inflammatory hyperpigmentation.
Whilst Hydroquinone is a common hyperpigmentation treatment, you can only use it continuously for up to 6 months. This is because prolonged use and inappropriately high doses can cause irritation, rebound hyperpigmentation and even ochronosis. As such a typical course is usually for 3-6 months with a 2-3 month break before resuming another course if needed. Usually another treatment such as azelaic acid, retinoids or other pigment suppressor is necessary in the break or after the finishing the treatment to help maintain results. Your doctor may also advise a gradual withdrawal of Hydroquinone to reduce the risk of rebounding.
Tretinoin for Hyperpigmentation Treatment
Another prescription only medicine, Tretinoin is a vitamin A derivative that speeds up skin turnover which lifts up excess pigment and exfoliates it away over time. It also treats acne and skin ageing which makes it great for patients with overlapping concerns. Unlike Hydroquinone, it is possible to use Tretinoin continuously long term as long as you can tolerate it. As it does not directly suppress pigment production, Tretinoin is useful for milder more superficial types of hyperpigmentation and to prevent relapse. It is particularly popular for cases of:
- Diffuse pigmentation that affects large areas rather than discrete patches
- Pigmentation linked to acne, where treating acne also prevents new marks
- Patients who need a maintenance option after a Hydroquinone course to maintain and build on results
Tretinoin can cause irritation and purging so treatment usually starts at a low strength and frequency to allow the skin to adapt. Visible improvement can appear in 3-6 months and results usually build up with ongoing use. It doesn’t usually need gradual withdrawal if you choose to stop treatment. However, maintenance with at least an over the counter retinoid and sun protection is usually necessary.
Using Hydroquinone & Tretinoin Together
In resistant, severe or mixed hyperpigmentation, its not a simple matter of Hydroquinone vs Tretinoin. In these cases they are often used together. This may be as separate creams or compounded in a single product. They may also be formulated with other ingredients such as Hydrocortisone, Azelaic acid or Niacinamide. The aim of using Tretinoin and Hydroquinone is to combine pigment suppression with increased turnover. This amplifies each ingredients effects and also provides greater stability in terms of results. This can potentially allow patients to see faster results than with either medicine alone. It also provides seamless transition when Hydroquinone is withdrawn as you can just continue Tretinoin for maintenance. That being said, the risk of irritation is higher. As such, it may take time for skin to adjust to these two strong treatments. Strict sun protection is also extremely important.
Risks & Limitations
Hydroquinone and Tretinoin are widely prescribed treatments which are safe and effective if used appropriately effective. However, they are not for everyone. These include shared risks include:
- Irritation, redness and dryness (especially at the start)
- Increased photosensitivity and risk of worsening pigmentation without sunscreen
- Can not be used in pregnancy or breastfeeding
Additionally, Hydroquinone carries unique risks such as rebound pigmentation and ochronosis. Tretinoin also has its unique limitations such as causing temporary acne flare or purging when first started. It can also cause persistent peeling, dermatitis and post inflammatory hyperpigmentation especially in high strengths.
Skincare Tips for Using Hydroquinone or Tretinoin
Supportive skincare can help reduce some of the risks and side effects of these prescription treatments. Common skincare tips for using Hydroquinone or Tretinoin include:
- Always follow the instructions provided by your medical provider as these will be designed with your specific skin condition in mind
- Use a gentle hydrating cleanser to clean your skin but protect the skin barrier
- Apply a fragrance-free moisturiser morning and night to buffer irritation and prevent dryness
- Use a broad-spectrum sunscreen with at least SPF 30 daily regardless of the weather and reapply throughout the day
- Avoid introducing multiple strong actives at the same time as your treatment
Whilst results take time and patient is really important, don’t ignore irritation or anything abnormal. If you notice a negative change in the feel or appearance if your skin, contact your medical provider straight away. They may need to adjust your protocol.
Alternatives & Complementary Ingredients
Not everyone can use Hydroquinone or Tretinoin. Even those that can, may need alternatives for maintenance if they can no longer stay on prescription treatment. The below are ingredients that can be suitable alternatives or even complement Hydroquinone:
- Arbutin: This a gentler tyrosinase inhibitor that is useful for often used as an alternative to Hydroquinone or for maintenance. Arbutin is however not as effective in medium and deeper skin tones.
- Kojic acid: Another tyrosinase inhibitor, Kojic acid is helpful in patchy pigmentation especially across larger areas. It is suitable for a range of skin tones as a gentler alternative to Hydroquinone or for maintenance.
- Tranexamic acid: This is a useful alternative or complementary ingredient to Hydroquinone for melasma.
For patients who cannot use Tretinoin, the main over counter alternatives include:
- Retinol: This and Retinal are weaker retinoids that increase cell turnover like Tretinoin. They can be effective for very mild hyperpigmentation or for long term maintenance if it is not possible to continue Tretinoin.
- Bakuchiol: This is a plant-derived compound that mimics retinoid some benefits. Bakuchiol is safe for use during pregnancy, breast feeding and for those with very sensitive skin.
If you cannot use neieither Tretinoin nor Hydroquinone for any reason including pregnancy or if you need additional actives to complement there are a few option. The main alternatives include:
- Azelaic acid: This gentle exfoliant helps reduce hyperpigmentation and inflammation. It also has acne and rosacea benefits. In lower strengths, azelaic acid is safe for use during pregnancy.
- Niacinamide: In addition to pore reducing, hyperpigmentation fading and anti-acne benefits, Niacinamide also strengthens the skin barrier.
- Vitamin C: This antioxidant brightens skin and provides protection from oxidative stress. It is useful for skin brightening and anti-ageing especially when paired with sunscreen
Hydroquinone and Tretinoin are both effective prescription treatments, but they work in different ways and have limits. As such comparisons of Hydroquinone vs Tretinoin for hyperpigmentation should be approached with nuance. Whilst Hydroquinone can clear patches more quickly, it can only be used for short courses and over smaller areas. Tretinoin provides consistent slower and more gradual improvements but can be used long term. In resistant or more complex cases, they may be prescribed together. There are also a number of no prescription alternatives that can be useful when Tretinoin or Hydroquinone are not suitable or unavailable. As ever with skincare, the best treatment approach will tailor the plan to your skin condition, needs and goals. Your treating doctor will help you decide whether Hydroquinone vs Tretinoin (or both or neither) are best for your hyperpigmentation. Regardless of treatment, supportive skincare, strict sun protection, patience and consistency are also key to optimal results.
At City Skin Clinic, we are super passionate about personalised skincare. Through our online skin clinic, our doctors offer safe and effective treatments using ingredients like Tretinoin, Spironolactone, Azelaic acid and Hydroquinone where appropriate. We treat a range of skin conditions including acne, hyperpigmentation, melasma and skin ageing. To start your personalised skincare plan, book a virtual video consultation or use our online consultation form. The journey towards great skin starts here.
