UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Topical skin-lightening agents: Complications associated with misuse

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

INTRODUCTION

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'.)

PREVALENCE OF MISUSE

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].

MOTIVATION FOR MISUSE

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.

              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2017. | This topic last updated: Mar 27, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Dadzie OE, Petit A. Skin bleaching: highlighting the misuse of cutaneous depigmenting agents. J Eur Acad Dermatol Venereol 2009; 23:741.
  2. Hamed SH, Tayyem R, Nimer N, Alkhatib HS. Skin-lightening practice among women living in Jordan: prevalence, determinants, and user's awareness. Int J Dermatol 2010; 49:414.
  3. Dlova NC, Hamed SH, Tsoka-Gwegweni J, Grobler A. Skin lightening practices: an epidemiological study of South African women of African and Indian ancestries. Br J Dermatol 2015; 173 Suppl 2:2.
  4. Lartey M, Krampa FD, Abdul-Rahman M, et al. Use of skin-lightening products among selected urban communities in Accra, Ghana. Int J Dermatol 2017; 56:32.
  5. Howard KL, Furner BB. Exogenous ochronosis in a Mexican-American woman. Cutis 1990; 45:180.
  6. Copan L, Fowles J, Barreau T, McGee N. Mercury Toxicity and Contamination of Households from the Use of Skin Creams Adulterated with Mercurous Chloride (Calomel). Int J Environ Res Public Health 2015; 12:10943.
  7. Centers for Disease Control and Prevention (CDC). Mercury poisoning associated with beauty cream--Texas, New Mexico, and California, 1995-1996. MMWR Morb Mortal Wkly Rep 1996; 45:400.
  8. Nagler A, Hale CS, Meehan SA, Leger M. Exogenous ochronosis. Dermatol Online J 2014; 20.
  9. Lawrence N, Bligard CA, Reed R, Perret WJ. Exogenous ochronosis in the United States. J Am Acad Dermatol 1988; 18:1207.
  10. Al-Saleh I. Potential health consequences of applying mercury-containing skin-lightening creams during pregnancy and lactation periods. Int J Hyg Environ Health 2016; 219:468.
  11. Darj E, Infanti JJ, Ahlberg BM, Okumu J. "The fairer the better?" Use of potentially toxic skin bleaching products. Afr Health Sci 2015; 15:1074.
  12. Rusmadi SZ, Syed Ismail SN, Praveena SM. Preliminary study on the skin lightening practice and health symptoms among female students in Malaysia. J Environ Public Health 2015; 2015:591790.
  13. Ahmed AE, Hamid ME. Use of Skin-Whitening Products by Sudanese Undergraduate Females: a Survey. J Racial Ethn Health Disparities 2017; 4:149.
  14. James C, Seixas AA, Harrison A, et al. Childhood Physical and Sexual Abuse in Caribbean Young Adults and Its Association with Depression, Post-Traumatic Stress, and Skin Bleaching. J Depress Anxiety 2016; 5.
  15. Olumide YM, Akinkugbe AO, Altraide D, et al. Complications of chronic use of skin lightening cosmetics. Int J Dermatol 2008; 47:344.
  16. Dlova NC, Hendricks NE, Martincgh BS. Skin-lightening creams used in Durban, South Africa. Int J Dermatol 2012; 51 Suppl 1:51.
  17. www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=700.13&SearchTerm=mercury (Accessed on January 17, 2017).
  18. Hamann CR, Boonchai W, Wen L, et al. Spectrometric analysis of mercury content in 549 skin-lightening products: is mercury toxicity a hidden global health hazard? J Am Acad Dermatol 2014; 70:281.
  19. McKelvey W, Jeffery N, Clark N, et al. Population-based inorganic mercury biomonitoring and the identification of skin care products as a source of exposure in New York City. Environ Health Perspect 2011; 119:203.
  20. Ly F, Soko AS, Dione DA, et al. Aesthetic problems associated with the cosmetic use of bleaching products. Int J Dermatol 2007; 46 Suppl 1:15.
  21. Ladizinski B, Mistry N, Kundu RV. Widespread use of toxic skin lightening compounds: medical and psychosocial aspects. Dermatol Clin 2011; 29:111.
  22. Kramer KE, Lopez A, Stefanato CM, Phillips TJ. Exogenous ochronosis. J Am Acad Dermatol 2000; 42:869.
  23. Dogliotti M, Leibowitz M. Granulomatous ochronosis -- a cosmetic-induced skin disorder in Blacks. S Afr Med J 1979; 56:757.
  24. Findlay GH, Morrison JG, Simson IW. Exogenous ochronosis and pigmented colloid milium from hydroquinone bleaching creams. Br J Dermatol 1975; 93:613.
  25. Charlín R, Barcaui CB, Kac BK, et al. Hydroquinone-induced exogenous ochronosis: a report of four cases and usefulness of dermoscopy. Int J Dermatol 2008; 47:19.
  26. Romero SA, Pereira PM, Mariano AV, et al. Use of dermoscopy for diagnosis of exogenous ochronosis. An Bras Dermatol 2011; 86:S31.
  27. Levin CY, Maibach H. Exogenous ochronosis. An update on clinical features, causative agents and treatment options. Am J Clin Dermatol 2001; 2:213.
  28. Diven DG, Smith EB, Pupo RA, Lee M. Hydroquinone-induced localized exogenous ochronosis treated with dermabrasion and CO2 laser. J Dermatol Surg Oncol 1990; 16:1018.
  29. Bellew SG, Alster TS. Treatment of exogenous ochronosis with a Q-switched alexandrite (755 nm) laser. Dermatol Surg 2004; 30:555.
  30. Tan SK. Exogenous ochronosis - successful outcome after treatment with Q-switched Nd:YAG laser. J Cosmet Laser Ther 2013; 15:274.
  31. Camarasa JG, Serra-Baldrich E. Exogenous ochronosis with allergic contact dermatitis from hydroquinone. Contact Dermatitis 1994; 31:57.
  32. 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; 55:873.
  33. Garcia RL, White JW Jr, Willis WF. Hydroquinone nail pigmentation. Arch Dermatol 1978; 114:1402.
  34. Mann RJ, Harman RR. Nail staining due to hydroquinone skin-lightening creams. Br J Dermatol 1983; 108:363.
  35. Engler DE. Mercury "bleaching" creams. J Am Acad Dermatol 2005; 52:1113.
  36. Chan TY. Inorganic mercury poisoning associated with skin-lightening cosmetic products. Clin Toxicol (Phila) 2011; 49:886.
  37. Weldon MM, Smolinski MS, Maroufi A, et al. Mercury poisoning associated with a Mexican beauty cream. West J Med 2000; 173:15.
  38. Zhang L, Liu F, Peng Y, et al. Nephrotic syndrome of minimal change disease following exposure to mercury-containing skin-lightening cream. Ann Saudi Med 2014; 34:257.
  39. Tang HL, Chu KH, Mak YF, et al. Minimal change disease following exposure to mercury-containing skin lightening cream. Hong Kong Med J 2006; 12:316.
  40. Dickenson CA, Woodruff TJ, Stotland NE, et al. Elevated mercury levels in pregnant woman linked to skin cream from Mexico. Am J Obstet Gynecol 2013; 209:e4.
  41. Tempark T, Phatarakijnirund V, Chatproedprai S, et al. Exogenous Cushing's syndrome due to topical corticosteroid application: case report and review literature. Endocrine 2010; 38:328.
  42. Felten R, Messer L, Moreau P, et al. Osteonecrosis of the femoral head linked to topical steroids for skin bleaching: a case report. Ann Intern Med 2014; 161:763.