by Jason Gomez

Jason Gomez is a third-year medical student at Stanford School of Medicine and an MBA candidate at Stanford Graduate School of Business pursuing a career in Dermatology. Email: jasngomzATstanford.edu

The first patient I saw as a third-year medical student on my dermatology elective requested skin lightening cream. She “hated” her dark skin, particularly the areas where her melasma left hyperpigmented patches. She wasn’t alone. Throughout my rotation, I witnessed to black, hispanic, and south Asian patients investing in skin whiteness. But I never had a white patient ask me for a product that would darken their skin. Even if one of them had, I’m not sure what we would recommend. Tanning? There is no product to darken white skin that is equivalent to the hydroquinone we prescribe to lighten skin of color. My patients of color had internalized the idea that white skin was the ideal, that lighter skin was an achievement to attain. And so had I.

Late in my first-year of medical school, I noticed a patch of depigmented skin on my belly. It did not itch. It did not burn or bleed. It was not painful. But it was bothersome, though not for the reason one might expect. One of the first thoughts I caught myself having was wishing that my beautiful brown skin looked uniformly like that singular, depigmented patch. How much easier would it be to assimilate into a predominantly white profession if my skin color did not identify me as a minority.

My dermatologist diagnosed me with vitiligo. We discussed treatment options with the goal of repigmentation: topical treatments with Tacrolimus and Calcipotriene. If that failed, we could try phototherapy or laser treatments. But I brought up depigmentation. Monobenzyl ether of hydroquinone is an FDA-approved agent to whiten skin; it completes the depigmentation process of vitiligo. I’m so grateful that my dermatologist of color counseled me toward repigmentation.

Dermatologists are uniquely positioned to address colorism. Calls to action and efforts to diversify the dermatology workforce and to improve skin of color education in dermatology training can help address the internalized prejudice and discrimination against skin of color, but they are not enough. We must question why an industry that profits off colorism and the internalized idolization of whiteness continues to exist. This is not to say skin lightening creams like hydroquinone should never be prescribed. The heterogeneity and color variegation of conditions like melasma or vitiligo can be harmful to one’s self esteem and confidence. Instead, hydroquinone-based topicals should be used under the supervision of a physician to avoid chronic continuous use and possible side effects, such as ochronosis.

While over the counter formulations of hydroquinone were banned in the U.S. as of September 23, 2020 by legislation included in the CARES Act, limiting access to over the counter preparations likely impacted the most vulnerable, particularly those who were unable to access a dermatologist in the first place. We may even see unregulated use of hydroquinone-based products from abroad. Many of the patients I saw who requested hydroquinone, including my first dermatology patient, had been using hydroquinone based topicals from their countries of ancestry, such as India or China. Alternatively, we could see the rise of an illegal cosmetic industry with skin lightening products containing concentrations of hydroquinone that reach up to twenty percent, as was the case in Europe after a similar over the counter preparation and prescription ban. While hydroquinone is the most commonly studied skin lightening product, the maximum concentration and body surface area that can and should be treated with this medication remains controversial.

Dermatologists must continue to be thorough in their history taking for patients of color who request skin lightening products, to be rigorous in their research of the products they prescribe, and to educate themselves about colorism so they can counsel patients in a culturally sensitive manner.

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Editor’s note: Colorism is a “hot-button” issue. Refer to the hullabaloo over  “In the Heights,” the Hollywood adaptation of the Broadway musical, that as been heralded as a step for more Latino representation in Hollywood, but a conversation has emerged about colorism and the casting of the film.  This probably came as a surprise to the film’s creators.