Worldwide, a clear skin has become a standard

Transcription

1 I S T M 282 REVIEW The Practice of Skin-Bleaching for a Cosmetic Purpose in Immigrant Communities Antoine Mahé, MD Department of Dermatology, Hôpital Pasteur, Colmar, France DOI: /jtm Background. Using skin-lightening compounds for a cosmetic purpose that are normally restricted to medical use or forbidden has become a world-wide practice. Complications are numerous. Immigrant communities often import their practice from their original country. Methods. A review of the literature on the subject of complications of cosmetic skin-bleaching, with special focus on data concerning immigrants originating from highly endemic countries, was conducted. Results. Complications of cosmetic skin-bleaching are common, involving mainly the skin although some general complications are also reported with a growing incidence. Conclusion. The high frequency of this practice, added to the frequency of various complications, suggests it might be considered as a genuine public health problem currently. Worldwide, a clear skin has become a standard of beauty in some populations with dark skin, with the frequent use of skin-lightening compounds by many people from these areas. The high frequency of cosmetic, nonmedical use of skin-lightening products in populations over the world, added to the frequent occurrence of various local and systemic complications, suggests it has become a genuine public health problem. 1 3 Immigrant communities originating from countries where skin-bleaching is common often import their practice. It appears worthwhile raising awareness on this subject for medical practitioners who are likely to see travelers originating from these countries, as those complications may mimic other skin conditions, and be unrecognized. Methods A review of the medical literature since the late 1970s on the topic of epidemiology and complications of cosmetic skin-bleaching, with special focus on data concerning Corresponding Author: Antoine Mahé, MD, Department of Dermatology, Hôpital Pasteur, 39 avenue de la Liberté, F Colmar cedex, France. antoine.mahe@ ch-colmar.fr immigrants originating from highly endemic countries, was conducted. In concrete terms, we carried out research on PubMed with the following keywords: (skinbleaching OR skin lightening) AND (black skin OR dark skin OR Africa); only articles with original data were considered. In addition, relevant articles from Frenchspeaking medical literature (not all referenced through PubMed) were considered. A total of 75 articles were found relevant. Personal experience of the author was occasionally mentioned. Results Epidemiology Skin-bleaching is particularly common in sub-saharan Africa. 4 7 In Bamako (Mali), a prevalence study estimated that 25% of the adult female population currently used skin-lightening products. 4 In Dakar (Senegal), an even higher ratio was found (67%). 5 This practice is also common in the Middle East, Asia (eg, India, Philippines, and Hong Kong), as well as in Southern and Central America. 2,8,9 Not surprisingly, in Europe and in the United States, although no solid epidemiological studies are available, it is considered to be a quite common practice in various immigrant communities. 10,11 Women are the main users of such products as well as men from certain geographical 2014 International Society of Travel Medicine, Journal of Travel Medicine 2014; Volume 21 (Issue 4):

2 Cosmetic Skin-Bleaching 283 areas (such as Central Africa). Adult women are mostly interested, with age ranging from late teens to around 50; children have been occasionally said to be interested, but we were not able to find any objective data documenting that. Pharmacology Skin-lightening compounds used in the context of lightening are normally restricted to medical use, or forbidden. Indeed, the main active compounds today are hydroquinone (often found in high concentrations, above 5%), and 0.05% clobetasol propionate (which belongs to the highest potent topical steroids category); mercurial compounds are more rarely used today, 11 a striking change in practice when comparing the reports from the 1970s that might be linked to a better tolerance of the skin to topical steroids and hydroquinone. All products are used as milks, creams or gel creams, or soaps. Caustic compounds (lemon juice, high concentration acid salicylic preparations, etc.) are sometimes used on certain areas that are more difficult to lighten (such as hands and feet).the compounds are commonly applied on the entire surface of the body, once or twice daily, often for decades because of the rapid reversibility of the lightening after stopping the use of the product. No tachyphylaxis has been described so far. Legally, bleaching products might be drugs that are misused; however, more often, their presentations are those of true cosmetic brands, which are numerous. 12 The active ingredients might be indicated on the packages, which could give the true information or not, 13 but are often withheld. These products appear to be available in every country where they are used, including Northern countries, through well-organized networks of distribution. A list of compounds commonly used in French-speaking African countries, and some of them in France as well, has been published and is reproduced in Table Complications The most common complications involve the skin. For instance in Dakar, the dermatological complications following the use of skin-bleaching products represented half of the reasons for adult women seeking dermatological advice. 14 General complications are less commonly reported, perhaps partly because of misknowledge. With a longer use of bleaching products obviously complications appear more frequently although some of them might present relatively early. Skin Disorders Disorders Linked to Steroid Use Infectious disorders either de novo or aggravated by the immunosuppression of the skin induced by steroids are especially common: superficial mycoses (Figure 1A), scabies (Figure 1B), superficial bacterial pyoderma, Table 1 List of bleaching products used with a cosmetic purpose collected in some French-speaking countries 12 Active principle Brand name (concentration when known) Galenic Charme Clobetasol propionate (0.05%) Cream Civic Clobetasol propionate (0.05%) Cream, gel Clovate Clobetasol propionate (0.05%) Cream Dermogel plus Fluocinonide (0.075%) Gel Dermovate Clobetasol propionate (0.05%) Cream, gel Diana Clobetasol propionate (0.05%) Cream Edguard Clobetasol propionate (0.05%) Cream Fashion fair Clobetasol propionate (0.05%) Cream L Ivoirienne Clobetasol propionate (0.05%) Cream Lemonvate Clobetasol propionate (0.05%) Cream Lumière Clobetasol propionate (0.05%) Cream Maxim Betamethasone dipropionate (0.05%) Gel Movate Clobetasol propionate (0.05%) Cream Neomat Clobetasol propionate (0.05%) Cream, gel Néoprosone Betamethasone dipropionate (0.05%) Gel Niuma extra-cream Clobetasol propionate (0.04%) Cream PC Clobetasol propionate (0.05%) Gel, cream Plaisir Clobetasol propionate (0.05%) Cream Prosone Betamethasone dipropionate (0.05%) Gel Skin Success Clobetasol propionate (0.05%) Cream Topgel Fluocinonide (0.025%) Gel Topifram Clobetasol propionate (0.05%) Cream Akagni Hydroquinone (5%) Cream, milk Bicu Hydroquinone Cream Blackstar Hydroquinone Milk Body clear Hydroquinone Milk, cream Carolight Hydroquinone (2%) Milk CBL Hydroquinone Milk Charms Hydroquinone (4%) Cream Clairliss Hydroquinone Milk Clear Essence Hydroquinone (2%) Milk Clear skin Hydroquinone (4%) Cream DD dynamy Hydroquinone (3%) Cream Dear Heart Hydroquinone Cream Emos Hydroquinone Cream Fair white Hydroquinone (8.7%) Cream, milk HT 26 Hydroquinone Milk Immédiat clair Hydroquinone Cream, milk Makari Hydroquinone (4%) Cream Métic ée Hydroquinone Cream MGC Hydroquinone Milk Niomré Hydroquinone (3%) Cream Niuma Hydroquinone Milk Peau claire Hydroquinone Cream, milk QEI+ Hydroquinone (4%) Cream Sivoclair Hydroquinone Cream, milk, soap Skin light Hydroquinone (6.7%) Cream, milk, soap Top-tone Hydroquinone (6.5%) Cream Vénus de Milo Hydroquinone (5%) Cream Asepso Iodide mercury (2%) Soap Idole Iodide mercury Jaribu Iodide mercury (3%) Mekako Iodide mercury (2%) Movate Iodide mercury Neko Iodide mercury (1%) Niuma Iodide mercury (2%) Rico Iodide mercury (3%) Sukisa Bango Iodide mercury Roberts Iodide mercury (2%)

3 284 Mahé A B C D Figure 1 (A) Widespread dermotophytosis related to potent topical steroid use. (B) Scabies aggravated by potent topical steroid use. (C) Cellulitis of the leg in a potent topical steroid user. (D) Steroid-induced acne of the anterior chest. (E) Prominent striae of the chest related to potent topical steroid use. cellulitis (Figure 1C), sometimes life-threatening. 15 The clinical presentation of these disorders is often severe, with unusually widespread lesions. Steroid-induced acne, as well as definite striae, are also very common (Figure 1D and E). Skin atrophy is linked with longterm use of steroids and might facilitate complications of surgical wounds. Disorders Linked to Hydroquinone Use A periorbital hyperpigmentation is very common and is seen quite early (Figure 2A); it is attributed to a phototoxic property of hydroquinone that, in medical use, is associated with photoprotection. Exogenous ochronosis is another cause of paradoxal hyperpigmentation; it appears to be secondary to the long-term use of hydroquinone; 16 it is characterized by the occurrence of deeply hyperpigmented plaques on certain photo-exposed areas (chin, malar areas, neck, upper back, and limbs; Figure 2B and C), with secondary infiltration, and is considered to be definitive; on pathology, there is a characteristic dystrophia of conjunctival bundles in the upper dermis. Vitiligo-like lesions, typically distributed in a confetti-like pattern, are less common (Figure 2B). Pseudo-lupus eruptions are rarely seen but might be confusing; 17 they occur after several months of hydroquinone use, and involve mostly the face (chin and malar areas, Figure 2D), with an annular and E papular aspect that might mimic lupus erythematosus; itching is however common; pathology shows dermoepidermic junctional features that might further mimic lichen planus or lupus; regression is rapid after cessation of hydroquinone use, leaving only post-lesional hyperpigmentation. Others Dermatitis, either caustic or allergic, is possible. The active ingredient that is responsible is often difficult to determine (hydroquinone, mercurials, perfumes, etc.). Two cases of skin epidermoid cancer have been reported in very long-term users (more than 10 years of practice) of bleaching products. 18 The occurrence of the carcinoma at the base of the neck, a very unusual topography in people with dark skin, made the relationship between skin-bleaching and cancer likely. Skin-lightening might also hide unrelated disorders whose typical features could be missed because of depigmentation. 19 General Complications Glomerulonephritis and neurological complications related to topical mercurials are well known and occasionally still observed Intoxication of a neonate through the use of mercurials by the mother during pregnancy and/or lactation has also been reported. 23

4 Cosmetic Skin-Bleaching 285 A B C D Figure 2 (A) Peri-orbital macular hyperpigmentation. (B and C) Exogenous ochronosis of the face and upper back (concomitant confetti-like achromia in Figure 2B). (D) Pseudo lupus-lichen of the face induced by hydroquinone use. Clobetasol propionate creams are used at very high dosages that are known to have systemic repercussion. 24 A negative feed-back on the endogenous secretion of cortisol has been established during the cosmetic use of bleaching products. 25 Cases of induced hypercorticism and adrenal insufficiency have also been reported. 26,27 A case-controlled study identified skin-bleaching as a risk factor for hypertension and diabetes mellitus; 28 interestingly, the frequency of diabetes was clearly correlated with the length of the bleaching practice. A study in pregnant women in Dakar showed that bleaching practice was very common in that context (reported by two thirds of questioned women), and that clobetasol propionate use was associated with a lower weight in newborn children. 29 Finally, altered blood glucose and ketone fast-measurements have been observed in diabetic persons because of the presence of residual hydroquinone on their fingers. 30 Sociocultural Considerations Unfortunately, there are very few data regarding sociocultural aspects. We conducted a study in Dakar on claimed motivations by users; there appeared to be a strong social pressure for lightening their skin, mainly through peers and aggressive advertising. 31 In addition, a lighter skin was commonly considered as a sign of a higher social level. Therefore, socially important events, such as baptism or wedding, were especially invested. On the other hand, some women declared using the products with a primary medical intention (eg, bleaching dark spots). Individual Management of Cases There is often a tendency to dissimulation by bleaching product users. Rather than aiming at obtaining a definite confession, seeking for the list of compounds used with comparison to a reference list of the most commonly used products might be more efficient. 12 The treatment of the complications depends on the disorder that is considered, and is similar to the treatment of the more serious variants of each of them. Some are reversible when adequately treated (eg, topical and/or oral antimycotics for dermatophytosis, oral cyclins for acne). On the contrary, macular periorbital hyperpigmentation is generally definitive; hydroquinone is contraindicated here. Stopping bleaching practices will moderately attenuate the contrast with normal skin of hyperpigmented plaques of exogenous ochronosis; lasers do not appear to be helpful here. 32

5 286 Mahé Above all, discontinuing of bleaching practices appears mandatory in every situation; unfortunately, in addition to the fact that the practice of bleaching might be hidden by users and therefore missed by health care agents, discontinuing appears quite often difficult to maintain during long periods of time because of social pressure. Hydrating compounds can be largely proposed. Propositions for Public Health Actions Although it might appear rather unrealistic in certain aspects or areas, a public health strategy might be proposed. Repressive Actions Some countries have decreed laws focusing at reducing that practice, however without noticeable success. The cosmetic use of compounds such as hydroquinone, topical steroids, and mercury compounds is forbidden in many countries; unfortunately, the composition of the brands is often withheld, and difficult to determine. In areas where adequate control structures exist, declaration of adverse effects to labelled authorities should be encouraged. Prevention Rather than a rude condemnation of the practice and stigmatization of users, we suggest that neutral information for women on the dangers of the practice especially during pregnancy would be a more reasonable solution (eg, through posters in community areas, counselling through peer education). Such strategies have been occasionally conducted, although with nonevaluated or limited success. 11 Conclusion The high frequency of cosmetic skin-bleaching across the world, including immigrant communities, added to the high frequency of various complications, suggest that every physician including those in Northern countries should be aware of the relevant data. Declaration of Interests The author states he has no conflicts of interest to declare. References 1. Druce M, Goldstone AP, Tan TMM, Meeran K. The pursuit of beauty. Lancet 2008; 376: Easton A. Women have deadly desire for paler skin in the Philippines. Lancet 1998; 352: Del Giudice P, Raynaud E, Mahé A. L utilisation cosmétique de produits dépigmentants en Afrique. Bull Soc Path Exot 2003; 96: Mahé A, Blanc L, Halna JM, et al. Enquête épidémiologique sur l utilisation cosmétique de produits dépigmentants par les femmes de Bamako (Mali). Ann Dermatol Venereol 1993; 120: Wone I, Tal-Dia A, Diallo OF, et al. Prévalence de l utilisation de produits cosmétiques dépigmentants dans deux quartiers de Dakar (Sénégal). Dakar Med 2000; 45: Del Giudice P, Pinier Y. The widespread use of skin lightening creams in Senegal: a persistent public health problem in West Africa. Int J Dermatol 2002; 41: Traore A, Kadeba JC, Niamba P, et al. Use of cutaneous de-pigmenting products by women in two towns in Burkina Faso: epidemiologic data, motivations, products and side effects. Int J Dermatol 2005; 44: Alghamdi A. The use of topical bleaching agents among women: a cross-sectional study of knowledge, attitude and practices. J Eur Acad Dermatol Venereol 2010; 24: Sin KW, Tsang HF. Large-scale mercury exposure due to a cream cosmetic: community-wide case series. Hong Kong Med J 2003; 9: Petit A, Cohen-Ludmann C, Clevenbergh P, et al. Skin lightening and its complications among African people living in Paris. J Am Acad Dermatol 2006; 55: Kass DE, Thier AL, Leighton J, et al. Developing a comprehensive pesticide health effects tracking system for an urban setting: New York City s approach. Environ Health Perspect 2004; 112: Groupe Thématique peau noire de la SociétéFrançaise de Dermatologie. Liste de spécialités utilisées dans un but cosmétique et ayant été signalées comme contenant des substances éclaircissantesmédicalementdangereuses. Ann Dermatol Venereol 2011; 138: Ake M, Oga S, Bony N, et al. Recherche et dosage du 17-propionate de clobétasol et du 17-, 21-dipropionate de bétaméthasone dans les crèmes et les gels vendus sur les marches publics d Abidjan (Côte d Ivoire). J Science Pharm Biol 2007; 8: Mahé A, Ly F, Aymard G, Dangou JM. Skin diseases associated with the cosmetic use of bleaching products in women from Dakar, Senegal. Br J Dermatol 2003; 148: Dieng MT, Diop NN, Niang SO, et al. Dermohypodermite bactérienne et dépigmentation. A propos de 60 cas observés au Sénégal. Nouv Dermatol 2001; 20: Findlay GH, Morrison JG, Simson IW. Exogenous ochronosis and pigmented colloid milium from hydroquinone bleaching creams. Br J Dermatol 1975; 93: Ly F, Dangou JM, Ndiaye B, Mahé A. Dermatoses pseudo-lichéniennes et pseudo-lupiques secondaires à l usage à visée cosmétique de produits contenant de l hydroquinone. Nouv Dermatol 2008; 27: Ly F, Kane A, Déme A, et al. Premiers cas de carcinomes épidermoïdes sur terrain de dépigmentation artificielle. Ann Dermatol Venereol 2010; 137: Mahé A,LyF,BadianeC,etal.Irrationaluseofskinbleaching products can delay the diagnosis of leprosy. Int J Lepr Other Mycobact Dis 2002; 70: Barr RD, Rees PH, Cordy P, et al. Nephrotic syndrome in adult Africans in Nairobi. Br Med J 1972; 2:

6 Cosmetic Skin-Bleaching MMWR. Mercury poisoning associated with beauty cream Texas, New Mexico, and California, Arch Dermatol 1996; 132: Soo YO, Chow KM, Lam CW, et al. A whitened face woman with nephritic syndrome. Am J Kidney Dis 2003; 41: Lauwerys R, Bonnier C, Evrard P, et al. Prenatal and early postnatal intoxication by inorganic mercury resulting from the maternal use of mercury containing soap. Hum Toxicol 1987; 6: Keane FM, Munn SE, Taylor NF, du Vivier AW. Unregulated use of clobetasol propionate. Br J Dermatol 2001; 144: Perret JL, Sane M, Gning S, et al. Freinage hypothalamohypophyso-surrénalien lié à l usage de cosmétiques dépigmentants au Sénégal. Bull Soc Pathol Exot 2001; 94: Sobngwy E, Lubin V, Ury P, et al. Adrenal insufficiency and diabetes mellitus secondary to the use of topical corticosteroids for cosmetic purpose. Ann Endocrinol (Paris) 2003; 64: Goldstein RF, Teede HJ, Allan CA. Skin lightening cream: an emerging medical challenge. Med J Aust 2012; 196: RaynaudE, CellierC, PerretJL. Dépigmentation cutanée à visée cosmétique. Enquête de prévalence et effets indésirables dans une population féminine sénégalaise. Ann Dermatol Venereol 2000; 128: Mahé A, Perret JL, Ly F, et al. The cosmetic use of skinlightening products during pregnancy in Dakar, Senegal: a common and potentially hazardous practice. Trans R Soc Trop Med Hyg 2007; 101: Bihan H, Fysekidis M, Harbuz V, et al. False-positive blood glucose and ketone values with lightening cream. Ann Intern Med 2011; 155: Mahé A, Ly F, Gounongbé A. L utilisation cosmétique de produits dépigmentants à Dakar (Sénégal): facteurs socio-économiques associés et motivations individuelles déclarées. Sciences Sociales et Santé 2004; 22: Bellew SG, Alster TS. Treatment of exogenous ochronosis with a Q-switched alexandrite laser. Dermatol Surg 2004; 30: