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Dr. Tarbox: Hello, and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Dr. Michelle Tarbox. I am a professor of dermatology and dermatopathology at Texas Tech ÑÇÖÞ×ÔοÊÓƵ ÑÇÖÞ×ÔοÊÓƵ Sciences Center and beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, everybody. This is Dr. Luke Johnson. I am a pediatric dermatologist and a general dermatologist with the ÑÇÖÞ×ÔοÊÓƵ of Utah.

Dr. Tarbox: So today, we're going to continue our discussion on cosmetic issues and what can be done about them. And we're going to start off things focusing on a complaint that's become more of the kind of focus of the beauty industry over the past couple of years, and that is dark spots or pigment issues.

Dr. Johnson: There are a lot of different reasons why you can have a dark spot on your skin. One of the most common reasons is there was something kind of inflamed on your skin, like an acne bump, for example, and it leaves a super aggravating mark after it goes away, which is sometimes even more annoying than the acne lesion itself.

There are some other reasons that you can have dark spots on your skin. For example, just hanging out in the sun for some decades can leave you with dark spots on your skin. Those are sometimes called solar lentigines.

And then again, as we age, or as I like to say, as we accumulate wisdom, there are other sorts of dark but benign spots that can commonly appear on the skin. And people generally are concerned about them on the face and people are generally . . . they understand that they're not dangerous for the most part, but the appearance can be really irksome.

Dr. Tarbox: Yeah, it's one of the complaints that I think I hear a lot of in my practice. So here, where I practice in West Texas, we have a whole lot of sun exposure. We basically have 270-something days of sunshine every year.

Our population is a little bit more heterogeneous. So just under half of our population is comprised of patients with skin of color of one or the other skin tone. And so we do get a fair bit of complaint about skin pigmentary disorders and dyspigmentation.

Another big category is something called melasma, which can happen predominantly to women following some kind of hormonal exposure. That might be birth control pills. That might be a pregnancy. But it's a very difficult-to-treat condition where hyperpigmentation occurs on the face.

Dr. Johnson: The good news is that there are things that we can do about it. The bad news is it is kind of hard to treat. But with diligence and the right products, we can help make those dark spots fade, and perhaps even fade away completely.

Dr. Tarbox: So there is hope. There are products that can be used over-the-counter at home, and they're available to treat different irritating situations that you have with pigmentation.

One of the things we've talked about a little bit previously that's helpful for dyspigmentation of the skin are retinoids. Retinoids are topical versions of vitamin A. And they can actually affect gene expression within the skin cells and help them to withstand damage, to repair damage, or to improve cell turnover. And so retinoids are a powerful class of medications.

There are a couple of myths that go around about retinoids, so I always like to address that when I'm discussing a treatment regimen with patients. Retinoids are a medicine that are active at the level of the skin and activate gene expression in the keratinocytes. They help the skin cells to act more robustly and also to replace themselves more frequently.

Now, retinoids do not thin the skin. Some people will think that, because the skin can peel when you first start to use a retinoid. That's just a sign that the gene expression is changing in those cells because of the topically applied vitamin A product, and that it's actually helping those cells turn over more quickly, which causes the skin to peel. But the skin is not thinning.

You do have to be careful about sun exposure when you use a retinoid, and you should be careful when you're treating pigment issues in general because retinoids do thin the very outside dead layer of the skin.

So we have a layer sort of dead skin cells on the outside of our skin that helps keep us waterproof and helps improve our skin barrier. And that layer, because the turnover is happening more quickly with vitamin A products used topically, is going to be a little bit thinner and you will have less natural sun protection. It equates to about a decrease in UPF or UV protective factor of about two to three.

Dr. Johnson: We've talked about this product before. They are prescription versions of them, like tretinoin, and there are also over-the-counter versions, like Adapalene. And it looks like you've got a couple that you've listed that you like, Michelle.

Dr. Tarbox: There are a couple that I do like over-the-counter that are easy to get. So over-the-counter, you can get the Neutrogena Rapid Wrinkle Repair. That is a retinol pro 0.5% serum. It's not terribly expensive, it's well put together, easy to find.

There's another one called Paula's Choice 1% retinol ointment that is purchasable over-the-counter.

We will prescribe some often as well. There are also easy-to-find ones in the RoC line, which has a topical retinaldehyde that is helpful.

Dr. Johnson: We should probably remind our listeners, as always, that we are not sponsored or paid by anybody. So the products that we recommend, they're just ones that we like. And I know we've hit retinoids before, so let's talk about something else. Michelle, does baby got Bakuchiol?

Dr. Tarbox: So if you want to talk about Bakuchiol, Bakuchiol has everything. Just kidding. But it is a natural version of retinol. So this is from a plant called the Babchi plant, and it is a nicely active sort of natural product. It does have to be prepared properly for it to be safe for the skin. There can be some photosensitizing things in it if it is not prepared properly.

But the ones that are available over-the-counter include the Herbivore Bakuchiol serum. It's a very pretty container. The serum is easy to apply. Patients seem to like it. The active ingredient in that is Bakuchiol.

ISDIN Melantonik Recovery Night Serum is another one that has Bakuchiol, vitamin C, and melatonin in it. And then Burt's Bees Renewal Intensive Firming Serum with Bakuchiol is another alternative to retinol if you wanted to try Bakuchiol.

You should also be careful when you're using Bakuchiol or retinols because they can thin that dead layer of skin on the outside of the skin. The dead layer of skin cells, that it is our stratum corneum. So you always want to be careful with the sun.

Dr. Johnson: You mentioned that Bakuchiol is kind of like a version of a retinoid. Does that mean you don't think people should use both a retinoid and Bakuchiol?

Dr. Tarbox: That's a great question. I think you'd probably want to pick one or the other and just stick with that. Alternating those products potentially could be done properly in a well-selected patient, but it might be too irritating for everybody. So I would probably pick one and stick with it.

Dr. Johnson: Perhaps the most important thing you can do to make your dark spots go away is keep those dark spots away from further sun exposure. Sunlight really likes to fix pigment in place. So sometimes I tell patients, "All right, we're going to do these things to help make your dark spots go away, but if you go outside for one day in the sun without sunscreen, then you lose a month of the treatments that we tried." So you really have to be extra good about sun protection.

We've talked about sunscreen a lot in this podcast, so I don't think we need to hammer it too much, but if you really want to go after your dark spots, you'll put sunscreen on your face every morning regardless of what you're going to do that day, even if you're not really planning on going outside at all. And then I often recommend that people put it on over the lunch hour or something too.

So SPF 30, at least. Higher is better. And again, we've talked about this before, so I don't think we need to hit it anymore. We can move on to something called hydroquinone.

Dr. Tarbox: Yes. So hydroquinone is a product that sometimes gets a little bit of shade thrown at it, I would say, in the media. But it is actually a very helpful ingredient for dyspigmentation, and it's usually relatively easy to get in one way or another.

It helps by actually interfering with melanin production by the melanocytes, the cells in our skin that make pigment. So it actually helps to inhibit that by inhibiting an enzyme, which is kind of fun. So it's inhibiting the conversion of a precursor to melanin, our skin's pigment, into a closer end product. So it's a very useful medication.

It is safe in the concentrations that it's sold over-the-counter in the United States. It can be sold outside of the United States at a very high concentration. When it's used at that high concentration that is not approved by the FDA, it is likely in some patients to cause some dyspigmentation that can be more permanent. So you don't want to use high percentage hydroquinone that's purchased outside of the country.

Dr. Johnson: Weirdly, that can give you dark spots, even though the medicine itself is supposed to lighten dark spots. So pretty strange. When something like that happens, we say it's paradoxical. Very high potency hydroquinone that you can get across the border, for example, not really a good idea because it can leave you with dark spots, and that's exactly what you don't want.

Dr. Tarbox: Exactly. And unfortunately, the dark spots that can come from those high concentration creams that are generally not sold in the United States, those areas of dyspigmentation won't improve with anything, not lasers, not anything. So it's a sad situation when that happens, and we definitely want to avoid that for our patients.

So there are a couple of places you can get the hydroquinone-containing creams over-the-counter. One of the ones that's a nice one that a lot of patients really like is Paula's Choice Resist Triple Action Dark Spot Eraser. So that has a 7% alpha hydroxy acid along with glycolic acid and hydroquinone. So this is a product that helps to improve dyspigmentation and patients can do pretty well with it.

Another product that has been around for a long time and is not terribly expensive and is available over-the-counter is called Ambi Fade Cream. Now this kind of goes in and out sometimes of supply issues, but when it is available, it's a 2% hydroquinone along with the sunscreen.

So these are what the hydroquinone products do. There are other products that can help lighten the skin, including niacinamide. Do you use a lot of niacinamide in your practice, Luke?

Dr. Johnson: I do not, but perhaps I should.

Dr. Tarbox: I use it for a lot of things. Niacinamide is sort of a version of a B vitamin called niacin. Niacin is a very powerful B vitamin. When you take straight niacin by mouth, you can actually have quite an impressive flushing reaction. So niacinamide actually helps to protect against that, but you still get the benefits of the niacin in the treatment.

It can be used topically to help improve dyspigmentation. There are a couple of different product lines that make niacinamide-based topicals. One of the ones we've talked about a lot is the CeraVe AM and PM Lotions that have niacinamide in them. Their AM Lotion has a sunscreen. Their PM is more emollient with ceramides in it, but that's a good product for dyspigmentation.

There's also something called NIA24 that is also available over the counter and is a broad product line that has good concentration of niacinamide in it.

I use niacinamide in my practice as well for patients who make lots of skin cancer. It's a very safe B vitamin and can be taken twice daily at about 500 milligrams to help improve your skin health, decrease the risk of skin cancer that's not the melanoma type of skin cancer, and also it's good for your heart and your brain. So it's a nice thing to be around. It basically is helpful for both inflammation and dyspigmentation.

And then, of course, we like vitamin C. There are many different vitamin C products available over the counter. You do want to make sure it's made by a company that has processed it properly so that the vitamin C is actually active. Vitamin C, especially in certain forms, is more vulnerable to the light, making it deteriorate. So a lot of vitamin C serums, especially, will be in a dark bottle, either brown or blue glass. If it's in a clear container, you're probably dealing with something a little bit less active.

So Estee Lauder makes one. There's a Perfectionist Pro Rapid Brightening Serum with Ferment2 and Vitamin C that Estee Lauder makes. The Estee Lauder Perfectionist is that one.

Ferulic acid is available as a SkinCeuticals product called C E Ferulic Skin Serum. There's also something called Cellex-C Advanced-C Serum and BioBare Serum that has vitamin C in it, and those range at different price points.

But vitamin C can be very beneficial as a brightening agent to the skin, overall pigment evening. It's a very safe ingredient. You can actually use vitamin C products during the daytime and the vitamin A products at nighttime to maximize your benefit to those, or you can use the vitamin C twice a day.

Dr. Johnson: You mentioned ferulic acid for just a second. Ferulic acid helps to stabilize the vitamin C. So it's in a lot of these products too just to make sure they're working right.

Dr. Tarbox: Yeah, it's a good product add-on. It helps to make sure that that vitamin C is active and able to work.

Glutathione is another product that can be used to help improve skin pigmentation. There is a product by JJ Labs that is their Glutathione Super Skin Serum with Hyaluronic Acid in it.

So glutathione can help with the skin in a couple different ways. It's an Antioxidant, so it can neutralize and eliminate free radicals that can damage the skin and cause aging, can cause pigment changes. It is actually a very powerful antioxidant, and sometimes we even use it for medical reasons. It helps improve cell turnover, and it's just a generally healthy skin ingredient. So I do like that product. I like glutathione.

Dr. Johnson: Glycolic acid also works, and one of the ways it's used is in chemical peels. A lot of chemical peels you have to get from a doctor's office or an esthetician, but there are some that are available over the counter as well.

I give my mom glycolic acid peels, for example, that I just purchase on Amazon because they're helpful for dark spots. And if you do them over and over again, then they can cause some permanent changes.

And then they're also available in not so much chemical peels, but just sort of individual spot treatments. You've got a couple listed here, and I lean on your expertise as the more cosmetically inclined of the two of us. Glytone Dark Spot Corrector and Glytone Mild Cleanser with Glycolic Acid.

Dr. Tarbox: I do like that product. I think it's a great glycolic-acid-based moisturizer. There's also a glycolic acid product from Avene. It's a French brand. Many different companies will make an alpha-hydroxy-acid-based product for exfoliating the skin and increasing cell turnover.

Kojic acid is another option for dyspigmentation. Kojic acid works sort of similarly to hydroquinone that we discussed earlier. It sort of blocks tyrosine from forming, which is a building block that's used to make melanin. So when patients use the kojic acid, they have sort of a brightening effect on the skin. It works fairly quickly, in about two weeks, and it doesn't have that risk of the paradoxical skin darkening like the hydroquinone can.

So kojic acid can be found in the SkinCeuticals Discoloration Defense, which is a great product. La Roche-Posay has something called Mela-D Pigment Control Serum, and Neutrogena Rapid Tone Repair Dark Spot Corrector is also a great product with kojic acid.

Do you do a lot of cooking with . . . Oh, sorry. Go ahead, Luke.

Dr. Johnson: You were going to ask me if I cooked with turmeric.

Dr. Tarbox: I was going to ask you if you cook with turmeric.

Dr. Johnson: I don't, really. Maybe I should cook with more turmeric.

Dr. Tarbox: I mean, maybe you should, because it might help you have more even beautiful skin on your hands. Who knows?

So a couple different products have turmeric in it. Turmeric is a spice, but it also has anti-inflammatory properties through curcuminoids that are part of that spice. So Allpa Botanicals makes a turmeric face oil. Andalou Naturals also makes a turmeric serum that can be beneficial for skin dyspigmentation.

Some of the products made with turmeric may have an orange hue to them, and it's possible that they might cause some staining. So you want to select those products carefully.

Dr. Johnson: Does taking turmeric by mouth, like heavy turmeric-containing foods, help my dark spots?

Dr. Tarbox: It helps, in general, with total body inflammation. So it could theoretically decrease the severity of acne and might decrease the spots based off of decreasing how much acne that you have. We know that it helps with psoriasis, so . . .

Dr. Johnson: Mostly, we're talking about getting some kind of product that contains turmeric and putting it on in your skin.

Dr. Tarbox: Yeah. That is generally what we're discussing here.

Dr. Johnson: And then you've got one more product listed on our list of things that can help with dark spots, tranexamic acid.

Dr. Tarbox: I know.

Dr. Johnson: That's something that doctors can prescribe as a pill. It's not FDA-approved for the treatment of dark spots here, and it does increase the risk of blood clots a little bit. But the medical data, I think, is pretty decent for it, that it's actually pretty safe and can help.

Dr. Tarbox: Yeah. So there are products that put the tranexamic acid together with it, over-the-counter topical preparation. As Luke was saying, orally, we sometimes use this as well. We do have to be a little bit careful when we use it by mouth because there's some risk for blood clots.

But topically, there's a great product that is made by SkinCeuticals. It's called Discoloration Defense. And so it has the tranexamic acid that can decrease the occurrence of discoloration. It also has kojic acid, which is produced by a fungus. Did you know that, Luke?

Dr. Johnson: I once did, but I had forgotten. So thanks for the reminder.

Dr. Tarbox: And then also niacinamide as well as some other anti-inflammatory products. So I think that that can be very helpful for dyspigmentation. We have a whole armamentarium of things that we can do to improve discoloration. Maybe next time we can talk about what we might do in the office for that, Luke.

Dr. Johnson: I hope so. We mentioned melasma. That's sometimes referred to as the mask of pregnancy. And one of the most important things you can do if you have melasma is to stop any medicines that you take that have hormones in them. So if you take birth control pills, for example, or hormone replacement therapy, that can definitely make that stuff worse.

So I'll admit, Michelle, that your list of stuff that can help with dark spots is way longer than I thought it was going to be, though it all has some medical data behind it. I primarily see ÑÇÖÞ×ÔοÊÓƵren, so that's perhaps why I'm not super familiar with a lot of these.

But with all this stuff available, give us just a sample regimen. Say we've got a listener who just has some sunspots on their skin that they don't like, and they say, "I don't really want to go to a doctor and get prescribed stuff." What would you recommend?

Dr. Tarbox: Well, of course, I would recommend at baseline all of the things that we talk to people about for a healthy skincare regimen. So getting plenty of sleep, drinking plenty of fluids, eating a nutritious diet with a rainbow of colors and lots of naturally occurring antioxidants and anti-inflammatories in those foods.

On top of that, I would make sure they add an excellent skincare regimen. Washing the skin carefully once or twice daily, at least, with a skin cleanser that agrees with their skin type. And in my personal opinion, I have a religion around sun protection almost, but I think that good regular sun protection is very, very important.

I would probably, for a normal person just kind of starting off with this, maybe have them use a vitamin C product in the morning with a sunscreen or a hydroquinone product that has sunscreen in the morning. I would make sure that they're using gentle products throughout the day to decrease any kind of blemish formation.

But I also would probably recommend Heliocare, which is that sun protection vitamin we've talked about before, that has the extract of that tropical fern in it and helps people deal with sun damage. So I like to use Heliocare as an oral supplement for patients who have dyspigmentation.

And then in their nighttime regimen, I would give them probably an alternating pattern of vitamin A medicine, either a retinol, like we discussed, by prescription or one of the over-the-counter products that I like, like the Neutrogena product. That's a very well-put-together vitamin A. Or if they wanted to try something more natural, they could use one of the Bakuchiol products like that Burt's Bees product.

I do like the alpha-hydroxy-acid-based cleansers if a patient's skin tolerates them well because they're good exfoliating agents.

And then I also would recommend that the patients have a mulberry silk pillow. The right kind of pillowcase can decrease skin breakouts and help improve skin health.

Dr. Johnson: I did not think I was going to hear about mulberries today.

Well, that's what we've got time for. Thanks for hanging out with us today, guys. Thanks, of course, to the ÑÇÖÞ×ÔοÊÓƵ of Utah and to Texas Tech.

And if you really like hearing Michelle and I talk, we've got another podcast. It's called "Dermasphere." It's intended for other dermatologists and people who are like dermatologists, and we get super nerdy about dermatology. So if you consider yourself a super dermatology nerd like us, go check that out. Otherwise, we will see you next time.