Report

Blackwell Science Ltd Use of skin lightening creams in Senegal

The widespread use of skin lightening creams in Senegal: a persistent public health problem in West Africa

Pascal del Giudice, MD, and Pinier Yves, MD

From the Unit de Dermatologie et de Maladies Infectieuses et Tropicales, Hpital Bonnet, Frjus, France Correspondence Pascal del Giudice, MD Unit de Dermatologie et de Maladies Infectieuses et Tropicales Hpital Bonnet Avenue Andr Lotard BP 110 83600 Frjus France E-mail: del-giudice-p@chi-frejus-saintraphael.fr

Abstract
Background The use of skin lightening creams is common in the female population of some African countries. The long-term use of certain products for several months to years may cause cutaneous 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 for potential adverse skin reactions. Six hundred and eighty-ve Senegalese women participated in 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 and corticosteroids, but 25% of women had used products of unknown composition. Seventy-ve per cent of women using such creams showed cutaneous adverse effects. Facial acne was the most common adverse effect. Conclusions A major part of the female adult population of Senegal used skin lightening creams. The long-term use of these creams is responsible for a high rate of cutaneous adverse effects. This practice has also been reported in other countries from sub-Saharan Africa and suggests a widespread use in the African population.

Introduction The use of skin lightening creams is common and widespread in the sub-Saharan African population.112 The most common pharmacologic compounds used are hydroquinone, corticosteroids, and mercurials.14 The long-term use of these products for several months to years may cause cutaneous or systemic side-effects.112 The common use of these creams in sub-Saharan Africa contrasts with the few studies and data available. We present the results of a study conducted in Dakar (Senegal), where the use of skin lightening creams, locally known as xessal, is common. Our purpose is to evaluate the extent of the practice in Senegal and the potential associated cutaneous side-effects. We discuss the extent of this phenomenon in the light of the few similar studies from neighboring countries. Subjects and methods
The study took place in the outpatients and emergency department of the Hpital Principal de Dakar (Dakar, Senegal). The choice of this department was based on the facilities available to question and examine women from the general population in a
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medical structure. The Hpital Principal de Dakar is a military institution and one of the main hospitals of the city. Patients are from the general population of Dakar and pay US$8 for a consultation. From May 1992 to May 1993, once a week, women aged 13 years and over attending a consultation at the emergency and outpatients department were asked to participate in the study. Women were included on a random basis. Women with psychiatric and severe medical or surgical diseases were excluded. Participants were interviewed by an African nurse using an anonymous questionnaire including age, marital status, French speaking ability, and ethnic origin (the Senegalese people are composed of several populations with different skin pigmentation according to the ethnic origin). Xessal is the term used by the Senegalese population to dene the various techniques and preparations used to bleach the skin. Women were questioned as to whether they were currently using or had used xessal. The following data were collected: products, quantity used monthly, frequency of application, duration, and location of application. The pharmacologic compounds indicated on the information notice of each cream were recorded. Given the number of products, pharmacologic analysis could not be performed. Women who were users of xessal were examined for skin diseases by a dermatologist. Potential systemic adverse effects were not studied. The data were summarized with the use of descriptive statistics.
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Results Among 760 women, 685 (aged 1378 years; mean, 32.6 years) participated in the study. Thirty-six per cent (249) had used xessal at least once and 27% (186) were active users. Ninety per cent of women using xessal were between the ages of 20 and 45 years (extremes, 1454 years). Women using such creams were more often from an ethnic group with hyperpigmentation (odds ratio (OR), 5.1; P = 0.001), higher cultural level (French speaking ability) (OR, 1.77; P = 0.001), and more frequently married (OR, 1.61; P = 0.4). The mean duration of use was 50.5 months (extremes, 1 240 months). Forty-three different commercial marks were reported for xessal. The most common products were hydroquinone and corticosteroids, used in 78% and 73% of preparations, respectively. Other products included mercurials and other topical agents applied directly to the skin, namely detergents, hypochloride sodium, and creams of unknown composition (25% of the products used). None contained identified sunscreen. The different products were used in combinations of two to four or even more. Corticosteroid creams and hydroquinone were associated in the majority of preparations (75%). The main topical corticosteroids were betamethasone (0.05%), difluprednate (0.05%), and less frequently clobetasol (0.05%). The concentration of hydroquinone varied from 2 to 5%. The number of daily applications varied from one to three, as did the quantity of creams used. When the desired pigmentation had been reached, the number of applications was modulated to stabilize the clear pigmentation. The majority 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. The relative proportions of women with no, one, two, three, and more cutaneous adverse effects were 68 (37%), 50 (27%), 37 (20%), 15 (8%), and 15 (8%), respectively. There was a significantly longer duration of use in women with cutaneous side-effects compared to those without (57.5 months (extremes, 1204 months) vs. 38.7 months (extremes, 1240 months); P = 0.02). The number of cutaneous adverse effects was correlated with the duration of use of xessal (r2 = 0.033; ddl = 183; F = 6.18; P = 0.05); however, two women had a duration of use of 20 years without significant side-effects. The dermatologic abnormalities seen are listed in Table 1 (see Figs 13). Discussion The use of skin lightening creams in Africans has been known since the 1960s.112 Concerns about potential adverse effects provided the first opportunity to focus on this phenomenon. Indeed, in 1972, Barr et al.5 found that nephrotic syndromes in adult patients in Nairobi were due to the use of topical mercurials. In South Africa, Dogliotti et al.6 reported an epidemic of leukomelanoderma in relation to the use of the monoInternational Journal of Dermatology 2002, 41, 69 72

Table 1 Main cutaneous diseases in women using xessal

Cutaneous disease Facial acne Facial hypertrichosis Cutaneous atrophy Stretch marks Hyperhypopigmentation Intertrigo Pyoderma Tinea corporis Purpura Frequency (%) 36 19 17 17 14 10 9 6 3

Figure 1 Facial acne

benzyl ether of hydroquinone. Findlay et al.7 reported the occurrence of exogenous ochronosis in Africans who used skin lightening creams containing hydroquinone for several years. The first report from West Africa was by Marchand et al.,1 in 1975, in a study in Senegal. Subsequently, the same practices have been described in Mali and Togo.2,3 A few data have suggested that similar practices are common in other African countries, such as Zimbabwe, Nigeria, Ivory Coast, Gambia,
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Figure 2 Stretch marks on the upper part of the body

Figure 3 Pigmentary disorder: hypo hyperpigmentation

and Tanzania.1315 In addition, in some Asian countries, such as Vietnam and the Malawi, Philippines, similar practices have recently been reported.16,17 The expected result of xessal in Senegal is to clear the skin to obtain the so-called teint clair, which is supposed to improve appearance and is considered by women as a
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standard of elegance, beauty, and higher social level.18 This practice is widespread in Senegal: we found that 27% of women questioned were regular users. In Mali, a neighboring country, Mah 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 corticosteroids and hydroquinone, used in combination in most topical preparations;14 however, in Togo, Pitche et al.3 reported a higher rate of the use of mercurials (31%). Mercurials were popular as depigmentation agents until they were recognized as toxic, and their use was banned in some countries, such as South Africa. These products are used in soaps or creams. They have been shown to be nephrotoxic via the absorption of mercury through the skin following repeated applications. In our experience, mercurials were rarely used; however, the use of mercurials has been reported in the past in Senegal, and we cannot exclude the possibility that the women questioned denied their use.19 Hydroquinone was the major skin lightening agent used in our study population. High concentrations of hydroquinone-containing bleaching creams have been associated with ochronosis, and may produce contact dermatitis resulting in a secondary postinflammatory hyperpigmentation.20 Corticosteroids were the second most common products used. As reported in Mali by Mah et al.,2 topical steroids are suspected to be responsible for most cutaneous adverse effects. Other products used included detergents, sodium hypochloride, lemon juice, salicylic acid, and others. A high proportion of women (25%) used products of unknown composition. The mean duration of use was 50.5 months; a few women had used xessal for longer periods, e.g. 20 years. The possible result of such extensive use is the occurrence of cutaneous adverse effects. Cutaneous diseases were present in 62.5% of women (similar results were found in Togo and Mali with 69% and 70%, respectively). Facial acne, present in 36%, was the main adverse effect (Fig. 1). Facial acne and other frequent cutaneous adverse effects, such as atrophy, hypertrichosis, and stretch marks, are probably a result of the use of topical steroids as previously reported.2,3 It can be argued that, in the absence of a control group, it is not possible to associate cutaneous diseases with the practice of using xessal; however, a rate of facial acne above 30%, whatever the age group, is not usual. The usual rate of facial acne in the general African adult population is low (< 5%). In addition, facial acne has been reported to be a frequent adverse event in subjects using topical steroids for cosmetic reasons in Vietnam,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, but rather the association of hypopigmentation contrasting with postinflammatory hyperpigmentation in the same area (Fig. 3).
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Among the female adult population, the use of xessal was higher in married women and in those with a higher cultural level possibly due to economic reasons. Most products are easily available on the streets or in market places. They are sold without any medical prescription and control, and imported from neighboring countries.3,4 The cheaper cost of such uncontrolled products is likely to be the main reason for their trade. Most topical steroids sold are not allowed in Senegal and other creams have unknown composition.4,19,20 In some West African countries, governments have tried to control this practice, which is considered to be a public health problem. In Gambia, for example, the use of bleaching creams has been forbidden since 1995. This control remains extremely difficult, however. A large proportion of women (93%) agreed to answer the questionnaire, but many of them may not have given real and complete responses. Indeed, a proportion of women may have denied the use of xessal because this practice is usually hidden. Despite these limitations, our study provides data confirming the extensive and uncontrolled use of bleaching agents in the female African population. A few previous studies involving a limited sample population from neighboring countries, published in the French literature, have shown similar results. Recent observations suggest that similar practices exist in the African population in Europe, West Indies, and Asia. Markey et al.21 have noted that large quantities of skin lightening creams are sold in Britain to Afro-Caribbeans and Asians. In France, most products can be found without any control in specialized African shops and sold as innocent cosmetic creams. The use of skin lightening creams in African countries, such as Senegal, is ongoing despite information campaigns. The standard of beauty, teint clair (clear skin), promoted by African magazines will continue; therefore, we must be aware of such cosmetic practices in African women and provide safe products. Acknowledgments Dr Lamine Ciss, my colleagues, and nurses from the Hpital Principal de Dakar provided help, Dr Counillon and Dr Antoine Mah provided helpful discussions, and Dr Jean Philippe Lacour critically reviewed the manuscript. References
1 Marchand JP, NDiaye B, Arnold J, Sarrat H. Les accidents des pratiques de dpigmentation cutane cosmtique chez la femme africaine. Bull Soc Med Afr Noire Lgue Frse 1976; 21: 190 199. 2 Mah A, Keita S, Bobin T. Complications dermatologiques

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des produits dpigmentants Bamako (Mali). Ann Dermatol Venereol 1994; 121: 142146. Pitche P, Afanou A, Amanga Y, Tchanga-Walla K. Prvalence des accidents cutans lis lutilisation de cosmtiques dpigmentants chez les femmes Lom. Cahiers Sant 1997; 7: 161164. Sylla R, Diouf A, Ndiaye B, et al. Pratique de la dpigmentation artificielle de la peau chez les femmes Dakar et tude analytique des produits dits cosmtiques utiliss. Dakar Md 1994; 39: 223226. Barr RD, Rees PH, Cordy PE, et al. Nephrotic syndrome in adult Africans in Nairobi. Br Med J 1972; 2: 131134. Dogliotti M, Caro I, Hartdegen RG, Whiting DA. Leucomelanoderma in blacks. A recent epidemic. S Afr Med J 1974; 48: 15551558. Findlay GH, Morrison GH, Simson IW. Exogenous ochronosis and pigmented colloid milium from hydroquinone bleaching creams. Br J Dermatol 1975; 93: 613 622. Findlay GH. Ochronosis following skin bleaching with hydroquinone. J Am Acad Dermatol 1982; 6: 10921093. Bentley-Phillips B, Bayles MAH. Acquired hypomelanosis: hyperpigmentation following reactions to hydroquinones. Br J Dermatol 1974; 90: 232 233. Dogliotti M, Leibowitz M. Granulomatosis ochronosis a cosmetic-induced skin disorder in blacks. S Afr Med J 1979; 56: 757760. Bentley-Phillips B, Bayles MA. Butylated hydrotoluene as a skin lightener. Arch Dermatol 1974; 109: 216 217. Bentley-Phillips B, Bayles MAH. Cutaneous reactions to topical application of hydroquinone. Results of a 6-year investigation. S Afr Med J 1975; 49: 13911395. Olumide YM, Odunowo BD, Odiase AO. Regional dermatosis in the African. Part I. Facial hypermelanosis. Int J Dermatol 1991; 30: 186189. Brown KGE, Abrahams C, Meyers AM. The nephrotic syndrome in Malawian blacks. S Afr Med J 1977; 52: 275277. Muchadeyi E, Thompson S, Baker N. A survey of the constituents, availability and the use of skin lightening creams in Zimbabwe. Central Afr J Med 1983; 29: 225227. Easton A. Women have deadly desire for paler skin in the Philippines. Lancet 1998; 352: 555. Legoux A, Hanh TT, Binh TT, Hoa LL. Acns induites par les cosmtiques et les dermocorticodes Cantho (Vietnam). Poster no. 5. Journes Dermatologiques de Paris, Paris, France, 1998. Fitoussi C. La cosmetologie des sujets peau noire. Dermatol Prat 1997; 197: 34. Gras G, Mondain J. Problmes poss par lutilisation des cosmtiques mercuriels au Sngal. Tox Eur Res 1981; 3: 175178. Burke PA, Maibach HI. Exogenous ochronosis: an overview. J Dermatol Treat 1997; 8: 2126. Markey AC, Kobza Black A, Rycroft RJG. Confetti-like depigmentation from hydroquinone. Contact Derm 1989; 20: 148149.

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