Use of skin lightening creamsBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6102 (Published 23 November 2010) Cite this as: BMJ 2010;341:c6102
Skin lightening (bleaching) cosmetics and toiletries are used to lighten the colour of darker skin. The practice, which is fuelled by racial prejudice, stems from the misconceptions that black skin is inferior and that someone with a fair skin is more attractive⇓.
By definition, cosmetics are meant to improve the appearance of the skin or enhance the attractiveness of users, not to alter the basic structure of the skin. Skin lightening creams alter the chemical structure of the skin by inhibiting the synthesis of melanin and should therefore be regulated as drugs not cosmetics.
The active ingredients include hydroquinone, mercury, and highly potent fluorinated corticosteroid ointments and creams such as fluocinonide, betamethasone valerate, and clobetasol propionate. The list of ingredients has expanded because some manufacturers have introduced new chemicals of unknown safety—such as niacinamide, oxybenzone, and triethanolamine—to circumvent the efforts of government regulatory agencies that prohibited the use of the above chemicals in cosmetics and toiletries.1 Some products do not have ingredient labelling or place of manufacture,2 3 and inadequate regulation has provided users with easy access to cheap, substandard, and misbranded toxic products.
These products are associated with serious and life threatening complications because they are used for long periods on a large body surface area and often under hot and humid tropical conditions, which promote percutaneous absorption. Complications such as exogenous ochronosis and colloid milium were initially reported in people with coloured skin in North America and South Africa in 1975.4 Exogenous ochronosis is related to the use of hydroquinone, and it presents as a dirty greyish brown waxy pigmentation on sun exposed areas of the skin. The primary lesion of colloid milium is a translucent flesh or cream coloured papule of 1 mm to 5 mm diameter on sun exposed areas. Pigmented forms of colloid milium are associated with hydroquinone induced exogenous ochronosis. Lesions often coalesce into nodules or plaques, and may rarely be verrucous.
A recent literature review of the adverse effects of skin lightening cosmetics found that the complications have become more complex and serious because of the nature of the additives and the methods of application.3 Exogenous ochronosis is a major complication. Topically applied phenolic intermediates such as hydroquinone may produce exogenous ochronosis. Hydroquinone specifically inhibits the enzyme homogentisic acid oxidase locally, resulting in accumulation of this substance on the collagen fibres at the site of application. Exogenous ochronosis shows identical histological changes on skin biopsy to those seen in alkaptonuria, an inherited disorder caused by lack of renal and hepatic homogentisic acid oxidase. Other complications are impaired wound healing and wound dehiscence; the fish odour syndrome5; nephropathy6; steroid addiction syndrome; predisposition to infection; a broad spectrum of cutaneous and endocrinological complications of corticosteroids, including suppression of the hypothalamic-pituitary-adrenal axis; and rarely skin cancer.3 7
The culture of bleaching has become common among black Africans. A study of market traders in Lagos, Nigeria, reported a prevalence of 27.6% in men and 49.7% in women.8 Another study among students of a tertiary institution in Enugu, Nigeria, reported a prevalence of 71.9% in women and 53.3% in men.2 Studies of women in Senegal and in Jordan reported a prevalence of 26% and 60.7%, respectively.9 10
This habit of bleaching has been driven by several factors. Women with lighter complexions are more often used to advertise a wide range of products including alcoholic beverages, toiletries, cosmetics (that are not even skin lightening creams), and clothing. Also, some highly visible women—for example, in the entertainment industry—bleach their skin. Therefore, the dominant signal being sent to undiscerning minds is that people with fair complexions are the beautiful and successful ones. Compared with non-users, people who use skin lightening products are more likely to believe that lighter skin tone has a positive role to play in self esteem, perception of beauty and youth, marriage, and employment opportunities compared with non-users.10 Some claim they use the cream to treat skin blemishes such as acne and melasma.2 3 9 10
Outside Africa, these products are not sold in the regular cosmetic section of department stores or pharmacies. They are either manufactured by international companies for export only or are manufactured in Africa for local consumption and export (largely through smuggling) to countries where the demand for these products is high. They are usually found only in local shops where ethnic foodstuffs are sold or in ghettoes colonised by black Africans and other people with coloured skin.
When should clinicians suspect the use of bleaching agents? The clinical presentation depends largely on the duration of use and the active ingredient in the cosmetic. The clinical history is usually inaccurate because patients may deny using the products or pretend not to know what their function is. Suspicion should be aroused in any black person whose skin appears unnaturally light. Patients often exude a rotten fish body odour because of the excretion of trimethylamine in the breath, urine, sweat, saliva, and vaginal secretions. The most common complications are exogenous ochronosis and colloid milium as a result of hydroquinone. If mainly corticosteroid creams are used patients may have extensive superficial fungal infections of the skin; extensive eruptive filiform (digitate) viral warts; severe acne vulgaris on a background of bleached facial skin; folliculitis, particularly around the axillary folds, and stretch marks (striae). The skin bruises easily, and wound dehiscence after surgery and delayed healing of wounds may occur.
Some grossly inadequate efforts have attempted to combat the problem. In 1995, the Nigerian Food, Cosmetics and Drugs Regulatory Agency prohibited the manufacture and sale of cosmetics containing hydroquinone and mercury,1 but it later endorsed a new cosmetic product―Venus Skin Toning Cream.
The international drug companies that manufacture corticosteroid creams are probably well aware of the misuse of their products as cosmetics. For financial reasons, some of them have chosen to turn a blind eye. Furthermore, the open trade between the borders of various African countries means that no country is immune, even if it tries to protect its own citizens through legislation.
Several efforts have been made by various people and corporate bodies—for example, the Medical Women’s Association of Nigeria, Nigerian Association of Dermatologists, the Nigerian Medical Students Association, and some religious organisations—to educate the public about the inherent dangers of these products, but the impact, if any, is yet to be documented.
Complications can be prevented only if there is a positive change in attitude among all stakeholders. Efforts should be made to change people’s unenlightened values and perceptions about beauty. The public needs to be told about the hazardous effects of these products. Skin lightening creams, especially potent fluorinated corticosteroid creams, should be available only as prescription drugs, as is the case in developed countries. Because of the open cross border trade between African countries, the various regional health communities in Africa must act in concert to enforce these regulations.
Cite this as: BMJ 2010;341:c6102
Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.