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Topical skin-lightening agents: Complications associated with misuse

Andrew F Alexis, MD, MPH
Section Editor
Jeffrey S Dover, MD, FRCPC
Deputy Editor
Abena O Ofori, MD


Skin-lightening (or "skin-bleaching") agents are essential tools in the management of disorders of hyperpigmentation, such as melasma and postinflammatory hyperpigmentation. However, misuse of skin-lightening agents, particularly for the purpose of lightening one's natural skin color, can result in multiple short- and long-term complications. Examples include irritant contact dermatitis, exogenous ochronosis, mercury toxicity, cutaneous atrophy, and adrenal insufficiency.

The availability of skin-lightening formulations that are not regulated, that contain ingredients that are illegal to sell without a prescription, or that contain ingredients not intended for cutaneous use contributes to the development of complications. Adverse events may also result from prolonged or excessive use of approved skin-lightening formulations.

Early recognition of signs associated with skin-lightening agent misuse is important in reducing long-term sequelae. The complications associated with misuse of skin-lightening agents will be reviewed here. Appropriate use of skin-lightening agents for the treatment of cutaneous hyperpigmentation is reviewed separately. (See "Melasma", section on 'Management' and "Postinflammatory hyperpigmentation", section on 'Medical treatment'.)


Misuse of skin-lightening agents is a global phenomenon, with the highest rates in Africa, Asia, the Caribbean, and the Middle East, as well as in immigrant populations from these regions in North America and Europe [1,2]. The practice of skin bleaching (deliberate lightening of skin color with the use of various skin-lightening agents) is estimated to range from 25 to 67 percent of various populations in Africa [3,4]. There have been no formal epidemiologic studies in Asia, North America, Europe, and Latin America, although case reports and small series from these countries have demonstrated misuse of skin-lightening agents in populations where the practice of skin bleaching is prevalent [1,5-9].


The skin-lightening industry is a multibillion-dollar industry that is projected to reach 23 billion dollars by the year 2020 [10]. The widespread use of skin-lightening agents stems from cultural and commercial beauty ideals, many of which are propagated by media using local models with fair skin [11,12]. In numerous cultures in Africa, Asia, the Caribbean, and the Middle East, fair skin is frequently equated with higher social status and physical attractiveness due at least in part to complex historical sociopolitical factors. Extensions of these societal and beauty ideals are also seen among the diaspora of these populations residing in the Americas, Europe, and Australia.

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Literature review current through: Nov 2017. | This topic last updated: Mar 27, 2017.
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