Skin‐lightening creams used in Durban, South Africa

Abstract

Skin creams that have bleaching properties and that are reputed to improve the complexion are much sought after by black South African women. The legacy of apartheid in South Africa has left more than what is overtly obvious for black South Africans and indoctrinated misconceptions that will take many years to change. “Black” for the purposes of this paper refers to the African, coloured, and Indian women in South Africa. Pigmentary conformists are viewed as unattractive. A lighter complexion is preferred by many. According to Findlay,1 the skin that black people most wish to avoid is a dull, drab, dusty, or scaly surface. Brightness is what they are looking for. In addition, some of the patients use skin-lightening creams as self-medication in an effort to get rid of common dermatological conditions such as acne, melasma, and postinflammatory hyperpigmentation. The use of creams to lighten the skin remains a widespread and common practice in many African countries2. The most common agents used include mercury-containing compounds,3 hydroquinone (p-dihydroxybenzene) (HQ) and its derivatives, resorcinol, and topical steroids of various potency. Most frequently, more than one agent is used at a time. Numerous studies on different populations of African men and women have demonstrated the occurrence of harmful long-term side effects from the use of skin-lightening cosmetics.2,4,5 Mercury compounds have been banned in cosmetics in several countries owing to nephrotoxicity and neurotoxicity. Reactions to phenolic detergent germicides6 and monobenzylether of HQ3 have been reported. In 1975, Findlay7 reported ochronosis after prolonged use of skin-lightening creams containing HQ, which inhibits tyrosinase and prevents the conversion of tyrosine to dihydroxyphenylalanine, a precursor of melanin. The pigmentation, which is blue–black clinically, appears ochre-colored microscopically, hence the term ochronosis. In these patients, the facial skin overcomes this lightening effect and becomes darker with continued use of cream, particularly in sun-exposed areas. The darker areas, which have a reticulated and ripple-like sooty appearance, corresponds to those areas in which the cream is well rubbed in. The clinical findings can be graded into mild (coarsening and darkening of the skin), moderate (large black papules with normal skin in between), and severe (black, caviar-like papules) ochronosis8. Recommendations were made in 1983 by the South African Department of Health and Welfare to limit the concentration of HQ in over-the-counter (OTC) skin lighteners to no more than 2%, and this is now enforced. We have noticed several African women presenting to us with steroid-induced acne and steroid addiction syndrome. An alarming number present with permanently damaged skin due to the use of OTC preparations and products sold by street vendors. We have also observed a change in the pattern in the last 10–15 years, as we are seeing more steroid-induced cutaneous side effects than exogenous ochronosis. Topical steroids cause an array of cutaneous side effects such as telangiectasia, atrophy, hirsutism, steroid-induced acne, striae, and opportunistic infections2,4. The initial clearing of the skin noticed after application of topical steroids might give a false sense of security and confidence, as it is later followed by a rebound worsening of acne. Of particular concern is the challenge in the treatment of steroid acne, which is a common sequelae of steroid abuse. The response to treatment is slow and patients may agonize for several months. During this period, they need proper advice and support during the withdrawal phase. The last paper on skin-lightening products on the market in South Africa was published by Findlay and De Beer 31 years ago.10 Here in we report the findings from an investigation of the contents of the top 10 best-selling skin-lightening creams available on the market in Durban, South Africa. Ten commercial skin-lightening fac