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Skin Bleaching- Highlighting the Misuse of Cutaneous Depigmenting

Skin Bleaching- Highlighting the Misuse of Cutaneous Depigmenting



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Published by: Marina Bessel on Dec 07, 2012
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 © 2009 The Authors
 , 741750Journal compilation © 2009 European Academy of Dermatology and Venereology
 DOI: 10.1111/j.1468-3083.2009.03150.x
 Skin bleaching: highlighting the misuse of cutaneous depigmentingagents
 OE Dadzie,
 * A Petit
Department of Dermatology, Chelsea and Westminster Hospital, London, UK 
Service de Dermatologie 1, Hôpital Saint-Louis, Paris, France
OE Dadzie.
 Hydroquinone and other cutaneous depigmenting agents are widely used by dermatologists to treat pigmentarydisorders. On 29 August 2006, the US Food and Drug Administration (FDA) published a monograph in the US FederalRegister proposing to ban all hydroquinone products that have not been approved via a New Drug Application process.Reports in the scientific literature on the occurrence of exogenous ochronosis, in relation to the use of hydroquinone, wasone of the concerns expressed by the FDA in relation to this agent. However, a review of the English-language scientificliterature reveals that most of the reported cases of hydroquinone-induced exogenous ochronosis occurs in Africa, wherethe cultural practice of skin bleaching is highly prevalent. Skin bleaching is the practice of applying hydroquinone and/orother depigmenting agents to specific or widespread areas of the body, the primary function being to lighten normallydark skin. This practice typically occurs in men and women with Fitzpatrick skin phototypes IV to VI. It is a dangerouspractice associated with a diverse range of side-effects, including mercury poisoning. Thus, this current discussion withinthe dermatological community on the safety of hydroquinone provides a unique opportunity to raise awareness aboutskin bleaching.
Received: 20 September 2008; Accepted: 16 December 2008
 corticosteroids, depigmentating agents, hydroquinone, skin bleaching
 The US Food and Drug Administration (FDA) Over-the-CounterMiscellaneous Panel had designated 2% as a safe concentrationfor hydroquinone products until 29 August 2006, when the FDApublished a monograph in the US Federal Register proposing toban all hydroquinone products that have not been approved viaa New Drug Application process.
 This proposal arose followingthe failure of manufacturers to comply to a request by the FDAfor safety studies on hydroquinone. In addition, the FDA hascited many safety concerns about this product, including theoccurrence of hydroquinone-induced ochronosis. Nonetheless,hydroquinone remains a popular agent for the treatment of pigmentory disorders in people with skin phototypes IV to VI.
 Thus, the proposal to ban this agent has prompted many withinthe dermatological community to publish articles that address theconcerns of the FDA. One important point highlighted in some of these published articles is that hydroquinone-induced ochronosisoccurs typically in Africa, where the cultural practice of skinbleaching is prevalent.
 Thus, this current discussion within thedermatological community about the safety and regulation of hydroquinone is a perfect opportunity to present an overview of the practice of skin bleaching, and to raise more awareness on theoccurrence and dangers of this practice.Skin bleaching is the practice by which depigmenting agents areused typically by people with skin phototypes IV to VI on a cosmeticbasis, primarily to lighten normally dark skin. The practice of skinbleaching dates back over many years in different communitiesaround the world. In fact, in the early 1900s some US physiciansadvocated the use of radiation therapy as a skin bleaching agent.
 Despite the initial early enthusiasm for this treatment, the many undesirable side-effects of this therapy became apparent, leadingto an end to this dangerous practice. Currently, skin bleachingremains a common part of life within some African communities,reflected even by the local vernacular. For example, in Mali andSenegal, the term
 are, respectively, used to describethis practice,
 while in Ghana, the term
 is used to describethe ochronosis that develops as a side-effect of this practice.Interviews conducted on skin bleachers in sub-Saharan Africancountries highlights many factors driving this practice. A desire tolighten skin colour is cited as a primary motivating factor for skinbleaching.
 This is because in some countries, white skin is stillperceived to be associated with social privileges, including better
 Dadzie and Petit
 © 2009 The Authors
 , 741750Journal compilation © 2009 European Academy of Dermatology and Venereology
  job and marital prospects. However, some skin bleachers may notdesire white skin, but instead desire radiant skin.
 Up until recentyears there was limited choice with regard to the types of cosmeticproducts available in Africa and Europe, especially for individualswith Fitzpatrick skin phototype VI.
 In absence of such products,bleaching the skin may be perceived as an alternative method of enhancing one’s beauty, especially prior to important social events.
 Other reasons cited by individuals partaking in skin bleachinginclude imitation of others and dependency on the products.
 Finally, the higher prevalence of dyschromias in people withskin phototypes IV to VI may be another factor that initiates,promotes, and/or excuses this practice.
 As a result of a lack of understanding about the appropriate use of depigmenting agents,coupled with negative cultural perceptions about dark skin, thesecutaneous depigmenting agents may be subsequently intentionally or inadvertently misused.
Prevalence of skin bleaching
 A review of the scientific literature demonstrates that individualsfrom diverse communities around the world, including Africa,North America, Europe, Asia and the Middle East practice skinbleaching. Evidence from the non-medical press further highlightsthe global burden of this practice. Thus, scientific studies conductedon the practice of skin bleaching, as summarized in Tables 1 and2 and discussed in detail below, may only represent the clinicaliceberg of a more widespread problem.
 The worldwide awareness of the cultural practice of skinbleaching originates from the work of Findlay 
et al 
 who in 1975first reported on the occurrence of exogenous ochronosis inSouth African women. These women had used high concentrations(3.5–7%) of hydroquinone-containing agents over the course of many years for bleaching their skin. Skin bleaching remained aproblem in South Africa and by 1986 the total sales volume of skinlighteners was an estimated 30 million pounds.
 Currently, skinbleaching continues to have an impact on dermatological practicein many sub-Saharan African communities, with prevalence ratesof this practice in community and clinic settings documented tobe between 26% and 67%.
 This estimate is based on descriptive
 An overview of studies conducted worldwide on the cosmetic use of depigmenting agents (prevalence and types of agents used)
Reference (country oforigin and type of study)Prevalence of skinbleachingType of depigmenting agentsSite and frequency ofuse of depigmentingagentsDuration of use
(Nigeria,community study)77.3% (females, 72.4%;males, 27.6%)Hydroquinone; mercury;corticosteroids; locally concoctedsoaps/creamsNot specified in study1–3 years (46.3%) Ajose
(Nigeria, hospitalstudy)Females, 40%; males, 2%Hydroquinone; class I and IIsteroids; mercurials; phenolicscaustics; unknown chemicals andplant derivatives; combinationsNot specified in study6 monthsover20 yearsFaye
et al 
(Mali, hospitalstudy)Not specified in studyHydroquinone; steroids;mercurials; unknown compositionNot specified in studyNot specified in studyDel Giudice
et al 
 (Senegal, hospital study)27% active skin bleachersHydroquinone; corticosteroids;mercurials; detergents;hypochloride sodium; unknowncompositionOnce to thrice per day50.5 months (mean),range 1–240 monthsLy
et al 
(Senegal,hospital study)Not specified in studyCorticosteroids; hydroquinone;vegetable extracts; causticproducts; unknown compositionNot specified in study6.7 ± 5 years (mean),range 1–30 yearsMahé
et al 
(Senegal,hospital study)52.7% (± 5)48.7% hydroquinone; steroids;caustic agents; unknowncomposition; mercury iodideWhole body; once ortwice per day4 years (median)Mahé
et al 
(Senegal,maternity centre)68.7%Hydroquinone; corticosteroids;mercurialsWhole body (85.2%); atleast once per day5 year (mean), range3 month–24 yearsNnoruk
et al 
(Nigeria,hospital study)58.7%Steroids; hydroquinone;mercurials; kojic acid; alphahydroxyl acids; unknowncompositionWhole body; face; twiceper day5 years ± 1.3 yearsPetit
et al 
(France,hospital study)80%Steroids; hydroquinoneEntire body and face; atleast once per day14 years (mean),range 1–38 yearsPitché
et al 
. (Togo,community study)58.9%Mercurials; hydroquinone;steroids; unknown compositionNot specified in studyNot specified in studyTraore
et al 
(BurkinaFaso, community study)44.3%Phenolics; steroids; combinationof agents; mercurials; unknowncompositionNot specied in study13 years

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