Stains are not welcome whether on cloth or skin. When you get a stain in a treasured quilt, it is important to try to figure what caused the stain (blood, coffee, grease, etc). Some stains are better off left alone. Keep in mind you may damage your item irrevocably. It is recommended that products containing the ingredient Sodium Percarbonate be used. This is a white, free flowing granular chemical used in the formulation of laundry products and many other cleaning products. Sodium Percarbonate consists mainly of hydrogen peroxide and soda, and functions as a bleaching agent, alkali provider and water softener at the same time. It contains a high percentage of active oxygen which provides an excellent washing and bleaching effect. It is environmentally compatible as it will break down into water, oxygen, and soda ash. Unlike chlorine based bleaches, sodium percarbonate is non-toxic and biodegradable. For a complete guide see: Stain Removal Guidelines for Textiles and Other Items by Kris Driessen.
Mandibular--rami of the mandible (15% of cases)
Hydroquinone (HQ) 2-4%--It inhibits the conversion of dopa to melanin by inhibiting the activity of tyrosinase. It has been proposed that it may also interfere with DNA and RNA synthesis, degrade melanosomes, and destroy melanocytes. It is applied in a thin layer over the affected areas twice daily for up to 12 weeks. It should not be used longer than 12 weeks, as there are no studies regarding safety in long term use. Side-effects include irritant and allergic contact dermatitis, PIH, nail bleaching and rarely ochronosis-like pigmentation. Toxicity studies have shown HQ is capable of inducing renal adenoma in rats and is fetotoxic in animals. Because of these studies, HQ is banned in many countries including Japan, the European Union, South Africa, and Australia. In August of 2006, the FDA issued a proposal to remove it from any OTC products. Currently, the only FDA-approved prescription form of HQ is Tri-Luma (Galderma Laboratories).
Retinoids-- Tretinoin 0.05%-0.1% reduces pigmentation by inhibiting tyrosinase transcription and by interrupting melanin synthesis. It typically takes at least 24 weeks to see clinical improvement in melasma reduction using tretinoin. It may also increase pigmentation secondary to the irritation. It commonly causes erythema and peeling.
Azelaic acid (15%-20%) is a C9 dicarboxylic acid. It is a reversible inhibitor of tyrosinase. It may have cytotoxic and antiproliferative effects on melanocytes. It has been shown to be as effective as HQ 4% wibut without the side effects. Used in combination with 0.05% tretinoin or 15%-20% glycolic acid, it may produce earlier, more pronounced skin lightening. Adverse effects include pruritus, mild erythema, scaling, and burning.
Kojic Acid (KA) 2% is produced by the fungus Aspergilline oryzae. KA is a tyrosinase inhibitor. It is generally as effective as the other therapies, but may be more irritating. Generally, it is used in combination with GA 10% for 3 months.
Glycolic Acid (GA) 5%-10% is an alpha-hydroxy acid. It decreases pigment by thinning the stratum corneum, enhancing epidermolysis, dispersing melanin in the basal cell layer of the epidermis, and increasing collagen synthesis in the dermis. Mild irritation is a common adverse effect.
HQ 5% + tretinoin 0.1% + dexamethasone 0.1%--The addition of tretinoin to HQ eliminates pigment and increases keratinocyte proliferation by preventing the oxidation of HQ and improving the epidermal penetration. The addition of topical corticosteroids reduces the irritative effects of hypopigmenting agents, and inhibits melanin synthesis by decreasing cellular metabolism. This combination was first introduced in 1975 by Kligman.
Topical Treatments for Melasma and Postinflammatory Hyperpigmentation by C.B. Lynde; J.N. Kraft, MD; C.W. Lynde, MD, FRCPC--MedScape Article
Skin Lightening and Depigmenting Agents by Alaina James, MD--eMedicine Article
Melasma by Deborah Zell, MD--eMedicine Article