Dark spots, or hyperpigmentation, are a common skin concern that can occur due to various factors, such as sun exposure, acne, hormonal fluctuations, and trauma to the skin. Dealing with persistent dark spots can be a frustrating experience and naturally many people turn to skin-lightening creams, lotions and potions.
Your skin is precious and sensitive, so you must choose your treatment carefully. There are so many dark spot removal treatments on the market, but how does each work and what are the side effects? What precautions do you need to take? What natural alternatives are out there? You likely have a lot of questions about which treatment to choose, so read on to find out more in this comprehensive guide to effective dark spot removal treatments.
A promising combination treatment for dark spots consists of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone. Each ingredient works with the others to maximise dark spot removal. This article will explore how each works, their synergistic effects and how they compare to other dark spot removal treatments.
Hydroquinone is a well-known skin-lightening agent. Usually, a concentration of 1-5% is employed in cream or lotion formulations. It is frequently used in combination formulations with other skin-lightening treatments such as topical retinoids (to improve effectiveness) and low-strength topical steroids (to reduce irritation to the skin). In the combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone, hydroquinone is used at a higher concentration which can provide faster and more pronounced results in reducing dark spots. It should be used under a dermatologist’s supervision and for a short period, usually for no more than 2-3 months due to the increased risk of side effects.1, 2
How hydroquinone for effective dark spot removal works.
In the combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone, Hydroquinone works by stopping the function of enzymes essential for producing melanin in the pigment-producing cells in the epidermis, the outermost layer of the skin. As the pigment levels decrease, the area under treatment becomes noticeably lighter to the naked eye. Hydroquinone does not work in the dermal (middle) layer of skin, which means that it needs to be used in combination with other dark spot removal treatments to maximise effectiveness.2
Conditions suitable for dark spot removal with hydroquinone
Hydroquinone is used as a depigmentation treatment for a range of treatments such as
- Solar lentigines
- Post-inflammatory hyperpigmentation2
Hydroquinone for dark spot removal: side effects and precautions
When used in higher doses, hydroquinone can cause irritating contact dermatitis. A brief pharmacological break and/or combination use of a topical steroid generally resolves the problem, which is included as hydrocortisone (read more about it below).
Questions concerning the safety of hydroquinone have been raised due to research showing that high-dose oral hydroquinone caused cancer in rats, however, it is important to state that no incidences of cancer in people have been found after 50 years of usage on the skin of humans.1, 2
A rare condition called ochronosis, which is the staining of bone, cartilage, skin and nails can be caused by hydroquinone, but typically only after years of using high dosages, numerous times each day.2 Our 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone combination is for use for a period of non longer than 2-3 months, in line with American Association of Dermatology recommendations.
If you are diabetic, it’s worth noting that hydroquinone has been associated with higher finger prick glucometer readings.3 If you have been diagnosed with diabetes or impaired glucose tolerance (sometimes known as pre-diabetes) talk to your provider before starting this medicine.
Tretinoin is derived from vitamin A and is a widely used treatment for acne, photoaging, and hyperpigmentation.4 Tretinoin is also commonly known as all-trans retinoic acid (ATRA). In this combination, a 0.05% concentration of Tretinoin is used, which is a standard strength for treating dark spots although concentrations of up to 0.1% are used routinely.4
How tretinoin for dark spot removal works.
In the combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone treatment, tretinoin works by promoting rapid exfoliation, stimulating collagen and elastin in the skin and increasing the turnover of skin cells. For dark spot removal, this process helps to shed pigmented cells and allows them to be replaced by new, healthy cells. This leads to the appearance of smoother, fresh, evenly toned skin and reduced dark spot appearance.
Conditions suitable for dark spot removal with tretinoin
Tretinoin is FDA-approved for topical treatment of:
- Acne vulgaris5
- Facial mottled hyperpigmentation (i.e., ‘liver spots’)6
- Fine facial wrinkles
As well as used off-label for
- Early stretch marks.7
Tretinoin for dark spot removal: side effects and precautions
Tretinoin may cause side effects such as skin irritation, peeling, and redness, especially during the initial weeks of use. It is crucial to use sun protection while using Tretinoin, as it can make the skin more sensitive to UV radiation. Patients using tretinoin should wear protective clothing and use sunscreen with an SPF rating of 15 or higher even when outdoors on cloudy days.
Additionally, it is important to avoid the use of skin products that can irritate and dry out the skin. These include strong soaps, shampoos, hair chemicals, hair removal creams and skin products that contain alcohol, spices, astringents, or lime.
If tretinoin is administered during pregnancy, there is a significantly high risk of fetal death and malformations, especially during the first trimester.
Other cases in which precautions with tretinoin should be taken include
- Hypersensitivity to the drug or any vitamin A derivate
- Caution if hypersensitivity to fish products
- Caution if eczema
Niacinamide, also known as nicotinamide, is a derivative of vitamin B3, an important component whose lack is associated with skin disorders. It is a versatile skincare ingredient with various benefits, including reducing inflammation, improving skin barrier function, and lightening dark spots. Since niacinamide is non-irritating to facial skin, chemically stable, and compatible with other skincare treatments, it is ideal for use in cosmetic products.
It’s important to note that niacinamide is not the same as niacin, although the body can use excess niacin to create niacinamide. Niacinamide is used to prevent vitamin B3 deficiency and its related condition known as pellagra. It has also been used for acne, ageing skin, skin discolouration, and other conditions unrelated to the skin.
How niacinamide for dark spot removal works
Used as part of a synergistic treatment of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone, niacinamide is an antioxidant with several beneficial properties that make it a great choice for dark spot removal treatments.
One of its key actions is preventing the transfer of pigment from melanocytes (pigment-producing cells) to the surrounding skin called keratinocytes. A study found that a 5% niacinamide moisturizer could reduce this process by around 70%, leading to reduced pigmentation.8 Additionally, niacinamide is believed to strengthen the skin’s barrier function, making it more resistant to environmental irritants and reducing redness.9
Lastly, niacinamide has antioxidant properties, blocking protein oxidation, glycation, and which normally lead to the production of yellowish-brown substances that accumulate in the skin as we age.10 By inhibiting these processes, niacinamide can help keep skin looking fresh.
Conditions suitable for dark spot removal with niacinamide
Niacinamide has been examined in studies for the treatment of facial hyperpigmentation in ageing skin. In a 12-week study with 50 Caucasian women, applying 5% niacinamide twice daily significantly improved fine lines, wrinkles, hyperpigmentation, redness, yellowing, and skin elasticity11. In another 8-week trial of Asian women, 5% niacinamide significantly lightened hyperpigmentation compared to a control.12
Studies have found Niacinamide to have the following benefits.
- Reduced skin yellowing11
- Reduced facial hyperpigmentation11
- Reduced redness and blotchiness of the skin
- Reduced size of pores13
Niacinamide for dark spot removal: side effects and precautions
Niacinamide is generally safe and well tolerated, however, it can cause redness, acne, skin flushing, or excessively dry skin. If you experience these side effects, discuss with your healthcare provider if continuing this treatment is right for you.
Hydrocortisone, a low-potency corticosteroid, is included in the combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone to help manage potential skin irritation and inflammation caused by the other active ingredients. Topical corticosteroids play a major role in the treatment of many dermatologic conditions. In this preparation, a 2.5% concentration of Hydrocortisone is used to provide relief from redness, itching, and discomfort.
How hydrocortisone for dark spot removal works.
Steroids can also contribute to the lightening of the area of skin to which they’re applied, by decreasing the number of melanocytes or altering melanocyte function. This reduces the presence of pigment in the treated area of the skin and leads to a lightened appearance.11
Hydrocortisone for dark spot removal: precautions and side effects
While generally safe for short-term use, extended use of Hydrocortisone can lead to side effects such as skin thinning and increased sensitivity to infections. It is essential to follow a dermatologist’s guidance when using Hydrocortisone in a combination treatment.
Steroid side effects can be split into local and systemic side effects. Systemic side effects with low-potency topical steroids are rare14.
Common local side effects include.15
- Skin atrophy (thinning of the skin)
- Striae (streaks on the skin)
- Rosacea (visible blood vessels and small pus-filled pimples)
- Purpura (A rash of purple spots)
Synergistic effects of the combination treatment
The combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone provides a multifaceted approach to treating dark spots. As we have talked about in each section, Hydroquinone and Niacinamide work together to reduce melanin production and transfer, while Tretinoin accelerates skin cell turnover to reveal a more even complexion. Meanwhile, Hydrocortisone helps manage the potential irritation and inflammation caused by the other ingredients making the treatment more tolerable for most users. This combination treatment can be highly effective for various types of dark spots, including melasma, post-inflammatory hyperpigmentation, and age spots.
Other dark spot treatments
While the combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone is a powerful treatment for dark spots, it’s essential to consider other skin-lightening treatments as well. These include chemical peels, laser-based therapies and over-the-counter treatments.
Chemical peels and exfoliators
Pros: Non-invasive, effective.
Cons: Designed to cause redness, irritation and peeling and leave the skin sensitive.
Chemical peels are a solution applied to the skin, causing it to exfoliate and eventually peel off. This process reveals a new layer of smoother, more evenly pigmented skin. Chemical peels can be performed at various depths, ranging from superficial to deep, depending on the severity of the dark spots and the desired results. While chemical peels can be effective in treating dark spots, they may also cause temporary redness, irritation, and peeling. In some cases, they can even lead to scarring or infection. Chemical exfoliators include alpha hydroxy acid (AHA), azelaic acid, beta hydroxy acid (BHA), lactic acid, mandelic acid, and salicylic acid.
Pros: effective, targeted treatment
Cons: expensive, can’t be done at home, can cause swelling, redness, tightness and even infection
Laser employs concentrated light energy to target the pigment directly or to remove skin layers gradually, effectively burning off the darkened skin layers. Laser treatment offers faster results compared to topical products, but it does come with some risks. Possible side effects of laser skin lightening include swelling, redness, tightness, scarring, infection, and changes in the skin’s texture. It’s essential to weigh the potential benefits and risks of laser treatment against the combination treatment to determine the best option for your skin type and concerns.
Pros: Cheap, easily available and some evidence they are good for skin
Cons: Not known to be as effective as clinically tested products
Over-the-counter products containing naturally derived ingredients are also available. Though these have had some evidence to suggest that they are effective for lightening skin or reducing dark spots, they may not be as effective as the combination treatment. Over-the-counter products can include ingredients such as
Kojic Acid – is made from certain fungi and works by inhibiting the formation of an amino acid called tyrosine, which is necessary for the production of melanin.
Azelaic Acid – a naturally occurring acid found in grains such as barley and rye, azelaic acid shares its mode of action with Kojic acid
Vitamin C – also known as ascorbic acid, Vitamin C: A potent antioxidant, Vitamin C is known can help brighten skin and reduce the appearance of dark spots.16
The combination of 12% Hydroquinone, 0.05% Tretinoin, 2% Niacinamide, and 2.5% Hydrocortisone offers a comprehensive approach to treating dark spots, addressing various aspects of hyperpigmentation. This treatment can be highly effective for a range of pigmentation concerns, providing noticeable improvements in skin tone and texture. Consult with your provider to determine if this combination treatment is suitable for your specific needs, and always follow their guidance for optimal results.
- McGregor D. Hydroquinone: an evaluation of the human risks from its carcinogenic and mutagenic properties. Crit Rev Toxicol. 2007;37(10):887-914.
- Schwartz C, Jan A, Zito PM. Hydroquinone. StatPearls. Treasure Island (FL): StatPearls Publishing
Copyright © 2023, StatPearls Publishing LLC.; 2023.
- Choukem SP, Efie DT, Djiogue S, Kaze FF, Mboue-Djieka Y, Boudjeko T, et al. Effects of hydroquinone-containing creams on capillary glycemia before and after serial hand washings in Africans. PLoS One. 2018;13(8):e0202271.
- Yoham AL, Casadesus D. Tretinoin. StatPearls. Treasure Island (FL): StatPearls Publishing
Copyright © 2023, StatPearls Publishing LLC.; 2023.
- Rathi SK. Acne vulgaris treatment : the current scenario. Indian J Dermatol. 2011;56(1):7-13.
- Mukherjee S, Date A, Patravale V, Korting HC, Roeder A, Weindl G. Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety. Clin Interv Aging. 2006;1(4):327-48.
- Kang S, Kim KJ, Griffiths CE, Wong TY, Talwar HS, Fisher GJ, et al. Topical tretinoin (retinoic acid) improves early stretch marks. Arch Dermatol. 1996;132(5):519-26.
- Hakozaki T, Minwalla L, Zhuang J, Chhoa M, Matsubara A, Miyamoto K, et al. The effect of niacinamide on reducing cutaneous pigmentation and suppression of melanosome transfer. Br J Dermatol. 2002;147(1):20-31.
- Bissett D. Topical niacinamide provides skin aging appearance benefits while enhancing barrier function. J Clin Dermatol. 2003;32:9-18.
- Dyer DG, Dunn JA, Thorpe SR, Bailie KE, Lyons TJ, McCance DR, et al. Accumulation of Maillard reaction products in skin collagen in diabetes and aging. J Clin Invest. 1993;91(6):2463-9.
- Bissett DL, Miyamoto K, Sun P, Li J, Berge CA. Topical niacinamide reduces yellowing, wrinkling, red blotchiness, and hyperpigmented spots in aging facial skin. Int J Cosmet Sci. 2004;26(5):231-8.
- Tanno O, Ota Y, Kitamura N, Katsube T, Inoue S. Nicotinamide increases biosynthesis of ceramides as well as other stratum corneum lipids to improve the epidermal permeability barrier. Br J Dermatol. 2000;143(3):524-31.
- Gehring W. Nicotinic acid/niacinamide and the skin. J Cosmet Dermatol. 2004;3(2):88-93.
- Gabros S, Nessel TA, Zito PM. Topical Corticosteroids. StatPearls. Treasure Island (FL): StatPearls Publishing
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- Coondoo A, Phiske M, Verma S, Lahiri K. Side-effects of topical steroids: A long overdue revisit. Indian Dermatol Online J. 2014;5(4):416-25.
- Pullar JM, Carr AC, Vissers MCM. The Roles of Vitamin C in Skin Health. Nutrients. 2017;9(8).