Hydroquinone or Not? The Two Routes for Treating Melasma

中文摘要在文末

Once we've settled the sunscreen conversation — and it always comes first, because without it none of the rest holds — the medication discussion is essentially a fork in the road.

There are two routes. One is faster. One is gentler. Neither is wrong, and I let patients choose with the full picture in front of them rather than deciding on their behalf.

What I won't do is present one as the "real" treatment and the other as the consolation prize. I've had patients do well on each.

First, what we're actually trying to do

A reminder from the pillar article, because it frames everything below.

Melasma takes years to form. The pigment-producing cells in your skin have become overactive and have been depositing extra pigment quietly for a long time before you noticed anything.

So the medications aren't removing a stain. They're suppressing an ongoing process — slowing those cells down, interrupting the signalling that keeps them switched on. That's why results are measured in months rather than weeks, and why stopping everything the moment things look better leads straight back to where you started.

Realistically: a little change may be visible around one month. The assessment that actually means something is at three months and beyond. We reach a level of improvement, we plateau, and then we shift into maintenance.

Route one: with hydroquinone

This is the faster route, and it's what I offer patients who tell me speed matters to them.

What hydroquinone is. It's a topical agent that reduces pigment production. It's been used in medicine for a long time and it works — that's not really in dispute. In practice I use it as part of a combination prescription cream rather than on its own, because the combination is more effective than any single component.

How it's used. Thinly, at night only, for a defined period of around two months. Then off it, and into a maintenance phase using other agents.

Two details in there that patients routinely get wrong, so I'll be emphatic about both:

Thinly. More is not faster. A thick layer doesn't accelerate anything; it increases irritation, and irritated skin in a melasma patient can itself produce more pigment. That's a genuinely counterproductive outcome — you can make your pigmentation worse by being enthusiastic.

At night only. This isn't arbitrary. It's part of how the whole regime is designed to work alongside your daytime sun protection.

And then you stop. The on-off structure is the important part of this route, and it exists for a specific reason.

Why hydroquinone isn't used continuously

I explain this to every patient before they choose this route, because I think you're entitled to know what you're agreeing to.

Used continuously over very long periods, hydroquinone can cause a condition called exogenous ochronosis — a paradoxical darkening of the skin. The thing you were using to reduce pigmentation ends up producing pigmentation of its own, and it's difficult to treat once established.

I want to be measured here rather than alarming. In my own practice, this is less common than the internet would have you believe, and I don't see it often. The realistic risk comes from unsupervised, indefinite use — someone who found a cream that worked, kept buying it, and used it every night for two or three years with nobody watching. That's the scenario, and the on-off structure is specifically designed to avoid it.

So: two months on, then off, then maintenance. If you're on this route and you find yourself tempted to keep going because it's working nicely, that's exactly the moment to come and talk to me instead.

This is also, incidentally, why I care so much about what's in unlabelled products people buy online. If a whitening product is producing dramatic results, there's a reasonable chance it contains something like hydroquinone at an undeclared concentration — which means someone is on this route without the structure, the supervision, or the stopping point.

Route two: without hydroquinone

Slower, gentler, and entirely legitimate. This is the route for patients who aren't in a hurry, who've had trouble with irritation, or who simply prefer to avoid hydroquinone.

The main agents:

Azelaic acid — reduces pigment production, generally well tolerated, and has the useful side property of helping with acne, which matters more than you'd think given how often the two problems arrive together.

Tretinoin — a retinoid, which speeds cell turnover and helps disperse pigment. It's also the agent most likely to cause irritation in the first few weeks, so it's introduced carefully. Irritation is not a sign it's working; in melasma, irritation can be actively counterproductive.

Tranexamic acid, topically — a more recent addition to melasma treatment and a useful one.

Tranexamic acid, orally — for appropriate patients, after proper screening.

I want to be careful about that last one.

About oral tranexamic acid

It's a genuinely useful tool in melasma, and I do prescribe it. It's also a prescription medicine with real contraindications, and I'm deliberately not publishing a dose or regimen on a public page.

That isn't me being coy. It's because oral tranexamic acid is not something to source yourself and start taking based on an article. It requires screening beforehand — your medical history, clotting risk, what else you're taking, and other factors specific to you — and it requires monitoring once you're on it. Some people should not take it at all, and working out whether you're one of them is the entire point of the consultation.

What I can tell you about how I run it: I review you at around one month and again at around two months, both to assess how the pigmentation is responding and to check for side effects. And you're welcome to contact us in between if anything at all concerns you. You don't have to wait for the scheduled appointment — I'd much rather hear about something early.

If someone is offering you oral tranexamic acid without asking about your medical history, that should worry you.

Compounded preparations

For some patients I prescribe compounded preparations rather than off-the-shelf products.

The reason is practical. Sometimes the combination or the concentration I want for a particular person's skin doesn't exist as a commercial product. Someone needs a gentler concentration than anything sold; someone else needs two agents combined in a single application because their routine is already too complicated to be realistic.

Compounding means a licensed pharmacy prepares the formulation to prescription. It isn't exotic and it isn't a shortcut — it's just a way of getting a preparation that fits the patient rather than making the patient fit the preparation.

How to choose between the routes

The question I put to patients is essentially: how much do you value speed versus gentleness?

Choose the hydroquinone route if you want faster visible change and you're comfortable with a structured on-off regime with defined stopping points. Choose the non-hydroquinone route if you'd rather go gradually, if you've reacted badly to strong topicals before, or if you simply prefer avoiding it.

Some things that genuinely don't factor in: whether one is "natural" — neither is, and that isn't a useful category here. Or which one a friend used. Your friend's skin, mixture of pigmentation, and history are not yours.

There's also no rule that you must stay on your first choice forever. Routes can be changed. That's part of why I review you along the way.

What both routes have in common

Three things, and they're non-negotiable in either direction.

Sunscreen. Both routes fail without it. SPF 50+, PA++++, iron oxide, at least twice daily even indoors. Neither route is strong enough to outpace daily re-triggering.

Patience through the first month. The one-month mark is not the verdict. Judging at one month is how people abandon treatments that were about to start working.

Maintenance afterwards. Reaching a good level is the middle of the process, not the end. Melasma maintenance takes more discipline than most conditions, and everything you gained is reversible if the maintenance lapses.

Coming in

If you want to work out which route suits you, come and have the conversation. Bring what you've already been using — including anything unlabelled, since it may well contain something relevant to this decision.

Klinik Dr Tan (Skin & Acne), Lot 27, Ground Floor, Block D, Lintas Square, Kota Kinabalu.

WhatsApp 017-234 7328. Appointments preferred, because this discussion needs proper time.

I'm a GP with a strong interest in skin, not a dermatologist, and where a case needs specialist input I'll refer rather than persist.

Book a consultation with Dr. Tan — Book Online or WhatsApp 017-234 7328.

简要说明

我是陈医生，亚庇 Lintas Square 的 Klinik Dr Tan（皮肤与暗疮）。我是对皮肤有专长的普通科医生，不是皮肤专科医生。

先说清楚：黄褐斑是几年形成的，药物是在抑制持续进行中的过程，不是清除一块污渍。一个月可能看到一点变化，三个月以后的评估才有意义。

处理防晒之后，用药有两条路线，快一点的和温和一点的，两条都合理。

路线一：含对苯二酚（hydroquinone）

• 效果较快，我通常用复方处方药膏。

• 薄薄一层，只在晚上用，约两个月，然后停药进入维持期。

• 涂厚不会更快——只会增加刺激，而刺激本身在黄褐斑患者身上可能产生更多色素，反而弄巧成拙。

• 为什么要停：长期不间断使用可能引起外源性褐黄病（exogenous ochronosis），也就是皮肤反而变得更深，而且很难治疗。实际上我在临床上并不常见，真正的风险来自无人监督、无限期使用——找到有效的药膏就一直买、一直擦两三年。「用两个月然后停」这个结构，就是为了避开这个风险。

• 顺带一提：网购的美白产品如果效果特别快，很可能含有未标示浓度的类似成分——等于在没有结构、没有监督、没有停药点的情况下走这条路线。

路线二：不含对苯二酚

• 较慢、较温和，同样是正当的选择。

• 杜鹃花酸（azelaic acid）：耐受性好，同时对痘痘有帮助。

• A酸（tretinoin）：促进代谢、帮助色素分散，但初期较易刺激，需要慢慢加。刺激不等于有效，在黄褐斑反而可能有反效果。

• 传明酸外用。

• 传明酸口服：适合的患者、经过筛查后使用。

关于口服传明酸：这是处方药，有真实的禁忌症，所以我不会在公开文章里写剂量和疗程。这不是卖关子——是因为它需要事先筛查（病史、血栓风险、同时服用的其他药物等），有些人根本不适合服用。我的做法是一个月和两个月各复诊一次，评估效果也检查副作用，中间有任何不适随时可以联络我们，不必等到复诊。

如果有人不问你的病史就给你口服传明酸，那是需要警惕的。

调配药（compounded）：有时候我需要的浓度或组合市面上没有，就会由持牌药房按处方调配，让配方配合病人，而不是让病人迁就现成产品。

怎么选：主要看你更重视速度还是温和。朋友用什么不重要——他的皮肤、色素组合和病史跟你不一样。路线中途也可以调整。

两条路线的共同点：防晒（缺了都会失败）、第一个月要有耐心、之后必须维持。

Klinik Dr Tan (Skin & Acne)，Lot 27, Ground Floor, Block D, Lintas Square, Kota Kinabalu。WhatsApp：017-234 7328。建议预约。请把正在用的产品带来，包括没有标示成分的。

预约陈医生 — 在线预约 或通过 WhatsApp 联系 017-234 7328