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The Widespread Use of Skin Lightening Creams in Senegal

The Widespread Use of Skin Lightening Creams in Senegal

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Published by: Marina Bessel on Dec 07, 2012
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© 2002
The International Society of DermatologyInternational Journal of Dermatolog
2002,
41
, 69–72
69
Abstract
Background
The use of skin lightening creams is common in the female population of someAfrican countries. The long-term use of certain products for several months to years may causecutaneous adverse effects.
Methods
From 1992 to 1993, we conducted an epidemiologic and clinical study in Dakar,Senegal. Women were questioned about the use of skin lightening creams and examined forpotential adverse skin reactions. Six hundred and eighty-five Senegalese women participatedin the study.
Results
Twenty-six per cent of women were using skin lightening creams at the time and 36%had used them at some time. The most common products used were hydroquinone andcorticosteroids, but 25% of women had used products of unknown composition. Seventy-fiveper cent of women using such creams showed cutaneous adverse effects. Facial acne was themost common adverse effect.
Conclusions
A major part of the female adult population of Senegal used skin lighteningcreams. The long-term use of these creams is responsible for a high rate of cutaneous adverseeffects. This practice has also been reported in other countries from sub-Saharan Africa andsuggests a widespread use in the African population.
BlackwellScienceLtd
Report
UseofskinlighteningcreamsinSenegal
The widespread use of skin lightening creams in Senegal: apersistent public health problem in West Africa
Pascal del Giudice,
MD
, and Pinier Yves,
MD
From the Unité de Dermatologie et deMaladies Infectieuses et Tropicales, HôpitalBonnet, Fréjus, France
Correspondence
 Pascal del Giudice,
MD
 Unité de Dermatologie et de MaladiesInfectieuses et TropicalesHôpital BonnetAvenue André LéotardBP 11083600 FréjusFranceE-mail
:
 
del-giudice-p@chi-frejus-saint-raphael.fr
Introduction
The use of skin lightening creams is common and widespreadin the sub-Saharan African population.
1–12
The most commonpharmacologic compounds used are hydroquinone, corticos-teroids, and mercurials.
1–4
The long-term use of these prod-ucts for several months to years may cause cutaneous orsystemic side-effects.
1–12
The common use of these creams insub-Saharan Africa contrasts with the few studies and dataavailable. We present the results of a study conducted inDakar (Senegal), where the use of skin lightening creams,locally known as “xessal,” is common. Our purpose is toevaluate the extent of the practice in Senegal and the potentialassociated cutaneous side-effects. We discuss the extent of this phenomenon in the light of the few similar studies fromneighboring countries.
Subjects and methods
The study took place in the outpatients and emergencydepartment of the Hôpital Principal de Dakar (Dakar, Senegal).The choice of this department was based on the facilities availableto question and examine women from the general population in amedical structure. The Hôpital Principal de Dakar is a militaryinstitution and one of the main hospitals of the city. Patients are fromthe general population of Dakar and pay US$8 for a consultation.From May 1992 to May 1993, once a week, women aged 13 yearsand over attending a consultation at the emergency and outpatientsdepartment were asked to participate in the study. Women wereincluded on a random basis. Women with psychiatric and severemedical or surgical diseases were excluded. Participants wereinterviewed by an African nurse using an anonymous question-naire including age, marital status, French speaking ability, and ethnicorigin (the Senegalese people are composed of several popula-tions with different skin pigmentation according to the ethnic origin).“Xessal” is the term used by the Senegalese population to definethe various techniques and preparations used to bleach the skin.Women were questioned as to whether they were currently usingor had used “xessal.” The following data were collected: products,quantity used monthly, frequency of application, duration, and locationof application. The pharmacologic compounds indicated on theinformation notice of each cream were recorded. Given the numberof products, pharmacologic analysis could not be performed. Womenwho were users of “xessal” were examined for skin diseases by adermatologist. Potential systemic adverse effects were not studied.The data were summarized with the use of descriptive statistics.
 
International Journal of Dermatology 
2002,
41
, 6972© 2002
The International Society of Dermatology 
70Report
Use of skin lightening creams in Senegal
del Giudice and Pinier 
Results
Among 760 women, 685 (aged 13–78 years; mean,32.6 years) participated in the study. Thirty-six per cent (249)had used “xessal” at least once and 27% (186) were activeusers. Ninety per cent of women using “xessal” were betweenthe ages of 20 and 45 years (extremes, 14–54 years). Womenusing such creams were more often from an ethnic group withhyperpigmentation (odds ratio (OR), 5.1;
P
= 0.001), highercultural level (French speaking ability) (OR, 1.77;
P
= 0.001),and more frequently married (OR, 1.61;
P
= 0.4). The meanduration of use was 50.5 months (extremes, 1–240 months).Forty-three different commercial marks were reported for“xessal.” The most common products were hydroquinoneand corticosteroids, used in 78% and 73% of preparations,respectively. Other products included mercurials and othertopical agents applied directly to the skin, namely detergents,hypochloride sodium, and creams of unknown composition(25% of the products used). None contained identified sun-screen. The different products were used in combinations of two to four or even more. Corticosteroid creams and hydro-quinone were associated in the majority of preparations(75%). The main topical corticosteroids were betamethasone(0.05%), difluprednate (0.05%), and less frequently clobeta-sol (0.05%). The concentration of hydroquinone varied from2 to 5%. The number of daily applications varied from one tothree, as did the quantity of creams used. When the desiredpigmentation had been reached, the number of applicationswas modulated to stabilize the “clear” pigmentation. Themajority of women applied creams to the whole body.One hundred and seventeen women who had used “xessal”(62.5%) had at least one dermatologic adverse effect. Therelative proportions of women with no, one, two, three, andmore cutaneous adverse effects were 68 (37%), 50 (27%), 37(20%), 15 (8%), and 15 (8%), respectively. There was a signi-ficantly longer duration of use in women with cutaneousside-effects compared to those without (57.5 months (extremes,1–204 months) vs. 38.7 months (extremes, 1–240 months);
P
= 0.02). The number of cutaneous adverse effects was corre-lated with the duration of use of “xessal” (
r
2
= 0.033; ddl = 183;
= 6.18;
P
= 0.05); however, two women had a duration of use of 20 years without significant side-effects. The dermato-logic abnormalities seen are listed in Table 1 (see Figs 1–3).
Discussion
The use of skin lightening creams in Africans has been knownsince the 1960s.
1–12
Concerns about potential adverse effectsprovided the first opportunity to focus on this phenomenon.Indeed, in 1972, Barr
et al 
.
5
found that nephrotic syndromesin adult patients in Nairobi were due to the use of topical mer-curials. In South Africa, Dogliotti
et al 
.
6
reported an epidemicof leukomelanoderma in relation to the use of the mono-benzyl ether of hydroquinone. Findlay
et al 
.
7
reported the occur-rence of exogenous ochronosis in Africans who used skinlightening creams containing hydroquinone for several years.The first report from West Africa was by Marchand
et al.
,
1
in1975, in a study in Senegal. Subsequently, the same practiceshave been described in Mali and Togo.
2,3
A few data have sug-gested that similar practices are common in other Africancountries, such as Zimbabwe, Nigeria, Ivory Coast, Gambia,
Table 1
Main cutaneous iseases in women using “xessa
Cutaneous diseaseFrequency (%)
Facial acne36Facial hypertrichosis19Cutaneous atrophy17Stretch marks17Hyperhypopigmentation14Intertrigo10Pyoderma9Tinea corporis6Purpura3
Figure 1
Facial acne
 
© 2002
The International Society of DermatologyInternational Journal of Dermatolog
2002,
41
, 69–72
71
del Giudice and Pinier 
Use of skin lightening creams in Senegal
Report
and Tanzania.
13–15
In addition, in some Asian countries, suchas Vietnam and the Malawi, Philippines, similar practiceshave recently been reported.
16,17
The expected result of “xessal” in Senegal is to clear theskin to obtain the so-called “
teint clair
,” which is supposed to“improve appearance” and is considered by women as astandard of elegance, beauty, and higher social level.
18
Thispractice is widespread in Senegal: we found that 27% of women questioned were regular users. In Mali, a neighboringcountry, Mahé
et al 
.
2
found similar results, with 25% of women from the general population using bleaching creams,and, in Togo, Pitche
et al 
.
3
found an even higher rate of 59%.In Senegal and Mali, the main products are corticosteroidsand hydroquinone, used in combination in most topical prep-arations;
1–4
however, in Togo, Pitche
et al 
.
3
reported a higherrate of the use of mercurials (31%). Mercurials were popularas depigmentation agents until they were recognized as toxic,and their use was banned in some countries, such as SouthAfrica. These products are used in soaps or creams. They havebeen shown to be nephrotoxic via the absorption of mercurythrough the skin following repeated applications. In our experi-ence, mercurials were rarely used; however, the use of mer-curials has been reported in the past in Senegal, and we cannotexclude the possibility that the women questioned deniedtheir use.
19
Hydroquinone was the major skin lighteningagent used in our study population. High concentrations of hydroquinone-containing bleaching creams have been associ-ated with ochronosis, and may produce contact dermatitisresulting in a secondary postinflammatory hyperpigmentation.
20
Corticosteroids were the second most common productsused. As reported in Mali by Mahé
et al.
,
2
topical steroids aresuspected to be responsible for most cutaneous adverse effects.Other products used included detergents, sodium hypochlo-ride, lemon juice, salicylic acid, and others. A high proportionof women (25%) used products of unknown composition.The mean duration of use was 50.5 months; a few womenhad used “xessal” for longer periods, e.g. 20 years. The pos-sible result of such extensive use is the occurrence of cutane-ous adverse effects. Cutaneous diseases were present in62.5% of women (similar results were found in Togo andMali with 69% and 70%, respectively). Facial acne, presentin 36%, was the main adverse effect (Fig. 1). Facial acne andother frequent cutaneous adverse effects, such as atrophy,hypertrichosis, and stretch marks, are probably a result of theuse of topical steroids as previously reported.
2,3
It can beargued that, in the absence of a control group, it is not possi-ble to associate cutaneous diseases with the practice of using“xessal;” however, a rate of facial acne above 30%, whateverthe age group, is not usual. The usual rate of facial acne in thegeneral African adult population is low (< 5%). In addition,facial acne has been reported to be a frequent adverse event insubjects using topical steroids for cosmetic reasons in Viet-nam,
17
Togo, and Mali.
2,3
Stretch marks seen in women using“xessal” were unusual in location, intensity, and number(Fig. 2). No cases of ochronosis were found. No true cases of leukomelanoderma were found, as reported with the use of the monobenzyl ether of hydroquinone in South Africa, butrather the association of hypopigmentation contrasting withpostinflammatory hyperpigmentation in the same area (Fig. 3
)
.
Figure 2
Stretch marks on the upper part of the body
Figure 3
Pigmentary disorder: hypo–hyperpigmentation

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