Triple combination therapy
Dr. Levine: Do you use that combination treatment which is already pre-formulated, or do you divide it up and pick and choose which of the agents you wish to use at one time?
Dr. Desai: The triple combination therapy is really in the literature as first-line, which is the hydroquinone, retinoid and steroids all-in-one.[i] However, I don’t always do that, as availability of the branded product had become an issue, and often cost plays a significant role for our patients. I actually make my own compound of the hydroquinone, retinoid, and steroid. But I add kojic acid in addition to that. So mine is actually a four-ingredient compound.
The reason I started doing this is was that the branded triple combination was discontinued for an extended period of time, which led to issues of access to therapy and then to me doing some more creation of my own formulation. So I don’t use the branded ready-made mixture, I actually make my own mixture.
Now if you don’t want to do that or cannot access a compounding pharmacy, you can still use that triple combination that is back on the market. It is available; the problem is, it that it can be expensive. So for patients who can’t afford that, they could use a prescription for a generic retinoid and a generic hydroquinone and apply those one layer at time, starting with the retinoid first at night. The steroid then doesn’t have to be necessarily used at night and can be used the following morning. Sometimes it helps with the retinoid dermatitis if the patient is going to experience that.
Dr. Levine: Now there is an old-fashioned product, Groot’s Cream, which is a high concentration of hydroquinone. Is that good, bad or indifferent?
Dr. Desai: Believe it or not, that product actually works. You bring up an interesting point, which is higher-strength hydroquinone. I do use higher-strength hydroquinone in patients who have failed at least an 8-12-week course of 4% hydroquinone combination therapy along with an additional treatment option, which in my practice second-line is chemical peel treatments. I highly encourage practitioners to incorporate chemical peels for the treatment of melasma in combination with a topical agent. A number of studies support that.[ii]
If one fails 8-12 weeks of 4% combination of hydroquinone therapy and at least two rounds of chemical peels, then I increase the strength of hydroquinone to 8%. I’ve actually gone as strong as 12% in some patients. The problem is, it is highly irritating in that concentration, but it works. Of course the other issue is that, as you increase the strength, you are increasing your risk of exogenous ochronosis from hydroquinone, which is a problem. There was a really nice paper published in the European literature that discusses the supervised use of hydroquinone in a limited duration supervised use of prescription topical hydroquinone had no more than a theoretical risk of malignancy, developing ochronosis or other long term safety side effects. You get into trouble when it’s long-term use that’s unsupervised and in high concentration. So I would say that higher hydroquinone is not something to be afraid of if you use it the right way, short duration, in the right patient setting, and with extensive counseling.[iii]