Pharmacology and Therapeutics

Combination of topical and oral glutathione as a

skin-whitening agent: a double-blind randomized
controlled clinical trial
Siswanto Wahab, MD, PhD, Anis I. Anwar, MD, PhD, Andi N. Zainuddin, MD,
Emma N. Hutabarat, MD, Asvina A. Anwar, MD and Ivan Kurniadi, MD, BmedSci (Hons)

Department of Dermatology and Abstract

Venereology, Faculty of Medicine, Background The antimelanogenesis effect of topical and oral glutathione has been shown
Hasanuddin University, Makassar,
in several in vitro and clinical studies. However, whether combination of topical and oral
Indonesia
glutathione is superior to topical or oral monotherapy is unknown. This study aimed to
Correspondence compare the skin-whitening effect of topical and oral glutathione combination therapy
Siswanto Wahab, MD, PHD against topical and oral monotherapy.
Department of Dermatology and Methods This double-blind randomized controlled study was done on 46 participants who
Venereology
were divided into two equal groups. Each group received oral placebo and oral glutathione,
Faculty of Medicine
Hasanuddin University
respectively. All participants were also instructed to apply topical placebo and glutathione
Jl. Perintis Kemerdekaan Km. 10 to each facial side, respectively. Colorimeter examination was done biweekly using
Makassar mexameter and chromameter for 8 weeks. One-way ANOVA test was used to compare the
South Sulawesi results of all groups.
Indonesia
Results The combination group showed significantly lower melanin index (MI) and L*
E-mail: siswantowahab64@gmail.com
score to placebo (P < 0.05). The mean MI and L* score of the combination group were the
Conflict of interest: None.
highest of all groups. Statistical significance of difference in L* score was reached when
the combination group was compared to the oral placebo and topical glutathione group
Funding source: None. (P < 0.05).
Conclusion This study showed that topical and oral glutathione were effective skin-
lightening agents. Furthermore, combination of topical and oral glutathione might be
doi: 10.1111/ijd.15573 superior to monotherapy.

Glutathione is a tripeptide that consists of cysteine, gluta-

Introduction
mate, and glutamine that is well-known for its antioxidant
Fair and flawless skin is often the standard of beauty in many effect.7 It protects cells from oxidative stress and damage such
countries and cultures, especially in people with skin of color, as drug and hydrogen peroxide detoxification.8 In addition,
making the skin-whitening products market a vast growing mar- in vitro studies have shown that glutathione alters melanogene-
ket which continues to expand.1 This desire has led to a sis9 through several proposed mechanisms such as increased
plethora of skin-whitening products, both in topical and oral pheomelanin production, tyrosinase inhibitory effect, and indi-
preparations that flood the market. rectly through its antioxidative effects.10,11
In terms of topical agent, hydroquinone is still regarded the Despite the popular use of this agent in countries such as
gold standard treatment.2,3 However, its use has been associ- Singapore, Thailand, Malaysia, and Indonesia in various prepa-
ated with adverse effects such as irritation, leukoderma, and rations, the evidence is still limited. To our knowledge, only two
malignancy,4 resulting in its ban as a cosmetic agent in Europe, and three studies are available on topical12,13 and oral6,8,14
5
the Unites States of America, and some Asian countries. Oral preparations, respectively. Furthermore, the efficacy of a combi-
tranexamic acid, on the other hand, is popular among those nation of topical and oral therapy, despite its widely advertised
who aim for a generalized whitening effect. However, the long- use, has never been assessed and compared to monotherapy.
term safety profile of this plasmin inhibitor is yet to be clearly This study aimed to assess the whitening effect of a combination
elucidated.6 Thus, new agents with a good safety profile con- of topical and oral glutathione on otherwise healthy, unaffected skin
tinue to need to be developed. and how it compared with monotherapy and placebo. 1

ª 2021 the International Society of Dermatology International Journal of Dermatology 2021

2 Pharmacology and Therapeutics Combination of topical and oral glutathione as a skin-whitening agent Wahab et al.

assessment of the reflected light resulted in melanin index (MI),

Methods
which corresponded with the skin melanin level.15
Study design
This double-blind randomized controlled clinical trial was done Chromameter
at Hasanuddin University Hospital, Makassar, South Sulawesi, The fundamental principle of this device is to emit three
Indonesia, between January and March 2020. wavelengths of 450, 560, and 600 nm to the skin surface
which, upon reflection, were absorbed by the probe of the
Participants device and produced three scores, one of which was the L*
Healthy females aged 25–50 years with Fitzpatrick skin type IV score, which represented skin brightness and ranged from 0
and V were included in this study. Subjects with a history of (black) to 100 (white).16
skin cancer, especially melanoma, glutathione intake in the past
1 month, presence of dermatoses on the face, pregnancy, Safety profile assessment
those who smoked, and breastfeeding mothers were excluded Participants were asked to report the occurrence of erythema,
from this study. In addition, subjects were required to work stinging sensation, pruritus, or any discomfort experienced
indoors or avoid intense sun exposure for a minimum of during the study. In case of severe effects, participants were
8 hours per day. encouraged to contact the researchers anytime.

Study protocol Statistical analysis

Subjects were equally divided into two groups and were given Demographic characteristics for both groups were described
oral placebo and oral glutathione. Participants in each group descriptively by calculating mean, standard deviation, and
were then instructed to apply topical glutathione and placebo on percentage. One-way ANOVA test was conducted to assess
the right and left cheeks in a blinded manner. This divided the intergroup difference in each follow-up period. The MI and L*
participants into four groups: topical and oral placebo (group 1), scores of each group were plotted into graphs to visualize the
topical glutathione and oral placebo (group 2), topical placebo data pattern. All analyses were performed using SPSS version
and oral glutathione (group 3), and topical and oral glutathione 22 (SPSS Inc. Chicago, IL, USA).
(group 4). The oral preparation contained 600 mg glutathione,
50 mg alpha lipoic acid, and 4 mg zinc picolinate while the
Result
topical preparation was in a serum preparation containing 2%
glutathione and vitamin C. The oral and topical placebo Demographic data
preparations were indistinguishable from those containing active A total of 46 participants took part in this study and were ran-
ingredients. domly divided into two groups, each containing 23 participants
The oral preparations were taken twice daily in the morning (Table 1). There was no significant difference in age nor Fitz-
and evening with a 12 -hour interval, while each serum was patrick skin type between both groups.
applied on the right and left sides of the face, respectively, in
the morning and evening after face cleansing for a total of Efficacy analysis
8 weeks. Participants were instructed to avoid consuming any Melanin index analyses of all groups at baseline and each fol-
supplements or applying other topical preparations except for low-up meeting were expressed in Table 2. After 8 weeks of
an SPF 35 broad-spectrum sunscreen in the morning, which treatment, the highest MI was shown by group 1, while the
was applied one minute after the serum.
The skin brightness assessment was done at baseline and
every 2 weeks for 8 weeks (T0, T2, T4, T6, and T8) using Table 1 Demographic characteristics

Chromameter (Konica Minolta, Tokyo, Japan) and Mexameter

MX 16 (Courage+Khazaka, Electronic GmbH, Cologne, Characteristic Oral placebo Oral glutathione

Germany). Adverse events were recorded at each meeting.

Age (years)a
This study was done after ethical clearance had been Mean  SD 29.7  8.3 30.2  7.8
obtained from the local ethical board committee. The protocols Range 20–44 20–43
were done in line with the Declaration of Helsinki guideline. Gender (%)
Male 0 (0) 0 (0)
Female 23 (100) 23 (100)
Quantitative skin color examination Fitzpatrick skin type (%)a
Type IV 13 (56.5) 10 (43.5)
Mexameter Type V 10 (43.5) 13 (56.5)
The probe of this device emitted light at 568 (green), 660 (red),
and 880 (infrared) nm wavelengths. A computerized
a
No significant difference between both groups (P > 0.05).

International Journal of Dermatology 2021 ª 2021 the International Society of Dermatology

Wahab et al. Combination of topical and oral glutathione as a skin-whitening agent Pharmacology and Therapeutics 3

Table 2 Melanin index of each group

Group 1 Group 2 Group 3 Group 4

Topical and oral Topical glutathione and oral Topical placebo and oral Topical and oral
placebo placebo glutathione glutathione P-valuea

Baseline 378.83  85.33 370.87  85.00 353.87  80.44 347.09  78.49 0.535
Week 2 377.57  86.05 365.09  87.74 354.78  71.51 335.57  72.44 0.338
Week 4 382.57  87.29 359.13  92.40 345.30  77.97 320.04  74.27 0.086
Week 6 385.65  85.70 343.87  92.81 339.04  91.25 319.00  78.01 0.076
Week 8 385.69  94.38 330.69  87.90 347.00  81.77 314.35  70.13 0.033

Bold values represent statistically significant, P < 0.05.

a
Significant if P < 0.05 (one-way ANOVA).

Table 3 Melanin index comparison between all groups at week 8

Group 1 Group 2 Group 3 Group 4

Topical and oral Topical glutathione and oral Topical placebo and oral Topical and oral
placebo placebo glutathione glutathione

Group 1 0.029 0.122 0.005

Topical and oral placebo
Group 2 0.512 0.511
Topical glutathione and oral
placebo
Group 3 0.191
Topical placebo and oral
glutathione
Group 4
Topical and oral glutathione

Bold values represent statistically significant, P < 0.05.

Figure 1 Melanin index in each group during the study

lowest MI was shown by group 4. One-way ANOVA analysis 8 weeks of treatment in all groups. Group 1 showed a stable
showed no significant MI difference among groups at baseline trend, while all treatment groups showed a decreasing trend,
and a significant difference at week 8 (P < 0.05). Post-hoc anal- with the lowest result shown by group 4.
ysis at week 8 showed significant difference between group 1 The L* scores of all groups at baseline and each follow-up
and group 2 and between group 1 and group 4 (P < 0.05) were expressed in Table 4. At the end of the study, the highest
(Table 3). Figure 1 shows the trend of MI change during and lowest L* scores were shown by group 4 and group 1,

ª 2021 the International Society of Dermatology International Journal of Dermatology 2021

4 Pharmacology and Therapeutics Combination of topical and oral glutathione as a skin-whitening agent Wahab et al.

Table 4 L* score of each group

Group 1 Group 2 Group 3 Group 4

Topical and oral Topical glutathione and oral Topical placebo and oral Topical and oral
placebo placebo glutathione glutathione P-valuea

Baseline 47.68  3.15 48.13  4.08 49.87  3.88 49.78  3.31 0.092
Week 2 47.71  3.45 47.83  5.12 49.03  3.26 49.62  3.31 0.269
Week 4 46.85  3.52 48.20  4.61 49.65  6.37 50.30  3.12 0.057
Week 6 46.78  3.54 48.59  4.73 49.68  3.99 51.01  3.29 0.040
Week 8 46.39  2.99 49.07  4.42 50.16  3.38 51.21  3.35 0.001

Bold values represent statistically significant, P < 0.05.

a
Significant if P < 0.05 (one-way ANOVA).

Table 5 Post-hoc analysis of L* score comparison among all groups at week 8

Group 1 Group 2 Group 3 Group 4

Topical and oral Topical glutathione and oral Topical placebo and oral Topical and oral
placebo placebo glutathione glutathione

Group 1 0.046 0.003 0.000

Topical and oral placebo
Group 2 0.301 0.045
Topical glutathione and oral
placebo
Group 3 0.324
Topical placebo and oral
glutathione
Group 4
Topical and oral glutathione

Bold values represent statistically significant, P < 0.05.

respectively. One-way ANOVA analysis showed no significant Analysis of the results showed that, compared to placebo, the
difference of L* score among groups at baseline (P > 0.05). A administration of glutathione, through topical, oral, or combination
significant difference started to appear at week 6 and was main- of both methods, resulted in a significant MI and L* score
tained at week 8 (P < 0.05). Post-hoc analysis at week 8 improvement after 8 weeks of treatment (P < 0.05). In contrast
showed significant difference between group 1 and groups 2, 3, with the placebo group, all treatment groups also showed consis-
and 4 and between group 2 and group 4 (P < 0.05) (Table 5). tently decreasing and increasing trend of the MI and L* score val-
All treatment groups showed a consistent increasing pattern ues, respectively, throughout the study. An exception was shown
throughout the study, while the placebo group showed a by MI of group 3 (topical placebo and oral glutathione), which did
decreasing pattern (Fig. 2). not show a statistically significant difference compared to pla-
cebo. However, the mean MI at week 8 of group 3 was consider-
Tolerability ably higher to that of placebo. These results were in line with
Erythema, edema, stinging, and pruritus were not observed nor previous studies on topical12,13 or oral6,8,14 monotherapy, which
reported by any of the participants. No systemic side effects all showed a consistent skin-lightening effect. An exception was
were observed nor complained during this study. shown by the study conducted by Weschawalit et al8 which did
not demonstrate beneficial effects of oral glutathione, both in
reduced and oxidized form, in most of the assessed parameters.8
Discussion
However, this result might be attributed to the significantly lower
This study evaluated the efficacy of topical and oral glutathione dose of glutathione administered (250 mg/day) as compared to
and combination of both in improving skin brightness of healthy the other two studies by Handog14 and Arjinpathana,6 which
Indonesian women. Both topical and oral glutathione were administered 500 mg glutathione.
effective skin-lightening agents and that combination of both To our knowledge, studies assessing the skin-lightening
agents might result in a superior outcome compared to effect of oral and topical glutathione combination therapy are
monotherapy. yet to be available. We attempted to take a step further by

International Journal of Dermatology 2021 ª 2021 the International Society of Dermatology

Wahab et al. Combination of topical and oral glutathione as a skin-whitening agent Pharmacology and Therapeutics 5

Figure 2 L* score of each group during the study

comparing the efficacy of combination topical and oral glutathione can be detected in its protein-bound form in human blood fol-
to monotherapy using two devices, the chromameter and mexam- lowing oral administration.22 This finding is further supported by
eter. Our results suggested that a combination of oral and topical the above-mentioned clinical trials. On the other hand, clinical
glutathione showed the most consistent result when compared to efficacy of topical administration is more well-established as
oral and topical glutathione monotherapy. The combination treat- topical preparation may directly penetrate the skin and exert its
ment group showed the lowest and highest MI and L* scores, effect on melanocytes.13 Thus, based on the results of this
respectively, and significantly higher L* score compared to topical study, we believe that the skin-whitening effect of combined
glutathione monotherapy after 8 weeks of treatment. Although topical and oral glutathione may be superior to topical or oral
based on L* score analysis, oral glutathione monotherapy glutathione monotherapy.
seemed to show a comparable efficacy to combination therapy, Although the colorimeter results improvement in this study
MI analysis showed less superior result of oral glutathione might not seem to be clinically apparent, it has to be emphasized
monotherapy when compared to combination treatment, where that the findings of this study were neither to confirm nor promote
oral glutathione monotherapy did not reach statistical significance the use of glutathione as a skin-whitening agent but rather pro-
when compared to placebo. Taken together, our results indicated vide additional supportive data on the melanogenesis inhibitory
that combination of both routes of administration might be supe- effect of glutathione. The seemingly not-so-intense difference
rior to monotherapy. In addition, the use of two different colorime- might occur as it is more challenging to drastically change the fac-
ters further strengthened and affirmed our findings. ultative skin color and hence this difference might have not been
The mechanism of skin-lightening effect of glutathione has clinically obvious in the course of our study. To the very least, if
been well documented and described. It has long been known the clinical effect of glutathione was not found to be clinically sig-
as an antioxidant7 and mediates its effect by scavenging free nificant, it still can be considered as an adjuvant or alternative
radicals during hydrogen peroxide and lipid peroxide detoxifica- therapy where conventional therapy does not result in an
tion process.17 Its melanogenesis inhibition activity is thought to expected outcome or a more optimal result is desired.
occur through tyrosinase inhibition, both directly by chelating Future studies with larger scale and longer follow-up duration
copper ions on the active site of tyrosinase and indirectly that incorporate patient perception are needed to better delin-
through the antioxidative property described above and by shift- eate the efficacy and safety of glutathione. In addition, the pres-
ing eumelanin, the darker pigment, to pheomelanin, the lighter ence of other antioxidants in the ingredient might have
pigment, production.14,18 The production of reactive oxygen contributed in the observed effect through ROS scavenging and
species and free radicals has been known to induce tyrosinase the possible tyrosinase inhibitory activity. However, this scenario
activity; glutathione has been shown to suppress reactive oxy- might better suit daily clinical practice setting where glutathione
gen species (ROS) production, thus preventing melanogene- is commonly combined with other supporting agents and we
sis.14,19 Production shift to pheomelanin occurs as a result of believe these data will be valuable for daily practice.
spontaneous conjugation of glutathione and cysteine (one of the
components of the glutathione tripeptide) with L-dopaquinone to
Conclusion
produce glutathionyldopa and cysteinyldopa, respectively, which
are precursors for pheomelanin.10,20 This study showed that topical and oral glutathione were
Although some studies were skeptical about the effectivity of promising skin-lightening agents. Furthermore, combination of
oral glutathione due to its reported low bioavailability based on topical and oral glutathione might be superior to monotherapy
whole blood examination,21 a study has shown that glutathione alone.

ª 2021 the International Society of Dermatology International Journal of Dermatology 2021

6 Pharmacology and Therapeutics Combination of topical and oral glutathione as a skin-whitening agent Wahab et al.

related protein-1 but not dopachrome tautomerase and Pmel17

Acknowledgments to melanosomes, which results in the attenuation of
melanization. Arch Dermatol 2014; 306: 37–49.
The authors thank all subjects for their participation in this
12 Etnawati K, Adiwinarni DR, Susetiati DA, et al. The efficacy of
study. The serum and oral preparations were manufactured by skin care products containing glutathione in delivering skin
PT. LipWih SynergyLab, Indonesia. lightening in Indonesian women. Dermatol Rep 2019. https://doi.
org/10.4081/dr.2019.8013.
13 Watanabe F, Hashizume E, Chan GP, et al. Skin-whitening
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International Journal of Dermatology 2021 ª 2021 the International Society of Dermatology