International Journal of Hygiene and Environmental Health 219 (2016) 468–474

Contents lists available at ScienceDirect

International Journal of Hygiene and

Environmental Health
journal homepage: www.elsevier.com/locate/ijheh

Potential health consequences of applying mercury-containing

skin-lightening creams during pregnancy and lactation periods
Iman Al-Saleh
Environmental Health Program, Research Centre, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Many studies have highlighted the widespread use of skin-lightening creams containing mercury by
Received 29 January 2016 women during and after pregnancy to remove dark spots. Women, especially pregnant and lactating
Received in revised form 9 March 2016 mothers using these products are at risk of mercury poisoning because sometimes it has no clinical
Accepted 10 March 2016
symptoms, particularly during early exposure. Studies have shown that prenatal and postnatal mercury
exposure can cause permanent neurological damage in children. Furthermore, mercury can cause women
Keywords:
infertility and birth defects. Even though several studies have examined the reproductive and/or devel-
Mercury
opmental consequences of gestational and lactational mercury exposure from fish consumption and/or
Skin-lightening creams
Women
dental amalgam, no studies have assessed the possible effects of the long-term use of mercury-containing
Reproductive toxicity skin-lightening products by women of childbearing age on their pregnancy outcome and children’s health.
Pregnancy This commentary aims to collate information on the popular use of mercury-containing skin-lightening
Lactation creams and sheds the light to the readers about the limitations of the available data on its impact dur-
ing a prenatal and/or postnatal period. There is an urgent need to assess the adverse health effects of
applying these products during pregnancy or lactation on child growth and development through birth
cohort studies. Until data from these studies are available, women should be advised not to use topical
skin-lightening creams during pregnancy and lactation.
© 2016 Elsevier GmbH. All rights reserved.

1. Introduction researchandmarkets.com/reports/1056077/), the market for skin-

Skin-lightening products are sold in different forms, includ-
ing soaps and creams; the soap is usually marketed as “antiseptic
soap” (Glahder et al., 1999; UNEP, 2008). The use of skin-lightening
creams has become a common practice among women for cos-
metics purposes (Olumide et al., 2008; Adawe and Oberg, 2013).
The creams are extensively promoted online, by the media, and
sometimes even by dermatologic clinics. Their use has been pop-
ular for decades among women throughout the world, mainly in
Africa and Asia. Having a light skin or fair complexion has become
an aspiration for many people around the world, and the use of
skin-lightening creams has become an increasingly popular cos-
metic practice in other parts of the world (Blay, 2011; Ladizinski
et al., 2011; Dlova et al., 2015) despite several published studies on
their adverse health effects after extended application. According
to a 2015 report by global industry analysts covering major geo-
graphic regions such as the USA, Japan, Europe, Asia-Pacific (China,
India, and “Rest of Asia-Pacific”), and “Rest of World” (http://www.
E-mail address: iman@kfshrc.edu.sa
lightening creams is projected to reach US$23.0 billion by 2020.
Mercury is added to creams because of its ability to inhibit the
pigment melanin (Engler, 2005). The hypothesis is that mercury
may replace the copper required for tyrosinase activity and thereby
inactivate the enzyme, leading to the whitening action (Denton
et al., 1952). Inorganic mercury is used in these creams because
the skin easily absorbs it (Palmer et al., 2000). Organic forms such
as phenyl mercuric acetate are sometimes used as cosmetic preser-
vatives, and inorganic forms, such as ammoniated mercury, are the
active ingredients in skin-lightening creams (Marzulli and Brown,
1972).
2. Worldwide legislation
The US Food and Drug Administration (US FDA) recently stated
that skin-lightening creams should contain no more than a trace
amount of mercury, less than 1 ppm, as unavoidable impurities
under the conditions of good manufacturing practice (US FDA,
2011). Washam (2011) pointed out that the creams are still cross-
ing the USA border despite FDA recalls prohibiting skin-lightening
creams containing mercury. Health Canada’s draft guidance on
heavy-metal impurities in cosmetics specifies a limit of 3 ppm

http://dx.doi.org/10.1016/j.ijheh.2016.03.002
1438-4639/© 2016 Elsevier GmbH. All rights reserved.
 I. Al-Saleh / International Journal of Hygiene and Environmental Health 219 (2016) 468–474
Table 1
Mercury contents in skin-lightening creams reported from various countries.
Study Location
Murphy et al. (2015) Cambodia
Maneli et al. (2016) South Aftrica
Wang and Zhang (2015) China
Travasso (2014) India
Hamann et al. (2014) USA
Amponsah et al. (2014) Ghana
Adawe and Oberg (2013) Somali
Cristaudo et al. (2013) Italy
Alqadami et al. (2013) Saudi Arabia
Naser and Kirm (2012) Sultanate Oman
Peregrino et al. (2011) Mexico
Al-Saleh et al. (2011a) Saudi Arabia
McKelvey et al. (2011) New York, USA
Al-Ashban et al. (2006) Saudi Arabia
EARTH (2003) Thailand
Al-Saleh and Al-Doush (1997) Saudi Arabia
for mercury as an impurity in cosmetic products (http://www.
hc-sc.gc.ca/cps-spc/pubs/indust/heavy metals-metaux lourds/
index-eng.php). Kenya, Mexico, and Brazil have instituted labeling
systems to inform the public about the limits of mercury in
skin-lightening products, and Russia has banned their sale (Uram
et al., 2010). The Philippines Food and Drug Administration (FDA)
has banned 70 skin-lightening creams containing more than the
allowable limit of 1 ppm mercury since January 2010 (http://www.
cosmeticsdesign-europe.com/Regulation-Safety/Philippines-FDA-
updates-list-of-banned-mercury-laden-cosmetics). A European
Union Directive banned the use of mercury as an ingredient in
cosmetics, including skin-lightening products (EC, 2009).
Despite governmental efforts in many countries to ban the sale
of skin-lightening creams containing mercury, these products are
available for sale over the Internet, providing unlimited access to
potential customers. Hamann et al. (2014) reported that many skin-
lightening creams available to US consumers either online or in
stores contained mercury above the US FDA limit.
3. Mercury contents in skin-lightening creams and their
global use
Many studies worldwide have reported the presence of high
mercury contents in skin-lightening, including countries with strict
legislation as shown in Table 1. For example, Hamann et al.
(2014) found 6.0% of 549 tested products contained mercury above
1000 ppm. In all, 45% of the mercury-containing samples contained
the metal more than 10 000 ppm. High mercury contents well above
the US FDA limits were found in many products sold in Saudi mar-
kets for more than a decade (Al-Saleh and Al-Doush, 1997). The
government later banned some of these products. However, some
are still sold in the Saudi market despite warnings against their
use, as shown by our study in 2011 (Al-Saleh et al., 2011a). A study
by Alghamdi (2010) reported that skin-lightening was a common
practice among Saudi women. The author found that 197 of 506
Saudi women (38.9%) used skin-lightening cream; only 26.7% used
them for medical purposes, and 20.8% were willing to use any
skin-lightening creams that gave the fastest results, even if the com-
ponents were unknown. The authors also found that approximately
10 and 21% of the women applied skin-lightening creams during
pregnancy and lactation, respectively. Naser and Kirm (2012) found
that one-fourth of the skin-lightening creams sold in the Sultanate
of Oman contained mercury above the FDA acceptable limit of
1 ␮g/g, and the highest was 25.7 ␮g/g. A recent study by Wang and
Zhang (2015), however, reported that mercury detected in 91.8% of
various cosmetic products, including skin-lightening creams sold in
China, but levels in all the goods were lower than 1 ␮g/g, the Chi-
469
Found/total Mercury content (ppm)
13/60 (21.7%) 2022, higest 6305
12/29 (41.4%) 30–2300
143/146 (97.9%) Highest 0.045
14/32 (43.8%) 0.1–1.97
33/549 (6%) >1000–45,622
0/50 0.001–0.549
11/27 (40.7%) >1 (1.07 to 33,000)
1/6 (16.7%) 0.039
22/34 (64.7%) >1 (1.289–2745)
25/40 (62.5%) >1
6/16 (37.5%) 878–35,824
2/23 (8.7%) >1 (95.75 & 314,386.67)
8/17 (47.1%) 3.37–41,600
30/88 (34.1%) >1 (2.46–23,222)
10/47 (21.3%) 63.53 to 99,070
17/38 (45%) >1 (1.18–5650)
nese acceptable limit. A recent study by Copan et al. (2015) showed
that users of skin-lightening creams contaminated with mercurous
chloride, or calomel for skin-lightening and acne treatments, led to
a multi-pathway mercury exposure among family members. The
authors found that calomel could change the valence form to ele-
mental mercury and volatilize once exposed to the skin or indoor
surfaces.
Furthermore, a few studies have reported that some mercury
skin-lightening creams contain one or more toxic ingredients that
in most cases were not listed on the packaging, such as met-
als, hydroquinone, titanium dioxide, and corticosteroids (Al-Saleh
et al., 2011a; Cristaudo et al., 2013; Iwegbue et al., 2015). Many of
these ingredients are very harmful and may pose a health risk if the
frequency of application, the duration of treatment and the body
surface area involved are taken into account and if they are used
during pregnancy and lactation.
4. Exposure to mercury from skin-lightening creams and
its health effects
Chan (2011) extensively searched the Medline (1950–2011) and
reported 31 studies of mercury poisoning following the use of skin-
lightening creams containing mercury mostly by women who were
neither pregnant nor breastfeeding and concluded that the use of
mercury in these products should be strictly prohibited. He further
stated that the public should be warned not to use such products,
because their use can result in the systemic absorption and accu-
mulation of mercury, leading to renal, gastrointestinal, and central
nervous system toxicity. Cases of mercury toxicity and dermato-
logic complications due to the use of skin-lightening creams have
been reported since the 1970s (Barr et al., 1973; Summa, 1975;
Luderschmidt and Plewig, 1979; Gras and Mondain, 1981; Dyall-
Smith and Scurry, 1990; Mahé et al., 1993, 2003; Otto et al., 1994;
Sin and Tsang, 2003; Soo et al., 2003; Özkaya et al., 2009). Al-
Saleh and Shinwari (1997) observed an association between the
use of skin-lightening creams and urinary mercury in healthy Saudi
women between the ages of 17 and 58 years, and 23% of the women
had mercury levels above the reference value of 4 ␮g/l proposed by
the World Health Organization in 1991 for non-exposed popula-
tions (WHO, 1991). Mercury levels in urine can increase gradually
with repeated application of skin-lightening creams (Barr et al.,
1973). Interestingly, the Centers for Disease Control and Preven-
tion (CDC, 2012) found high mercury contents in household air and
the urine of both users and non-users of skin-lightening creams.
Some studies have reported the frequent use of skin-lightening
creams and its potential harmful effects (Luderschmidt and Plewig,
1979; Balluz et al., 1997; Garza-Ocanas et al., 1997; Jovanovic et al.,
 470
Table 2
Human exposure to mercury-containing skin-lightening creams and its health effect.

Study Location Type of studies Age Sample Gender Levels of mercury in Health effect
size

Copan California, Case report of 3 20 months-64 years 4 3 Family 1 -20 months infant exhibited hypertension,
et al. USA families Female:1 refusal to walk, irritability, difficulty sleeping,
(2015) Male and poor appetite
Urine = 6–52 ␮g/g creatinine
Cream = 28,000–38,000 ppm (only used by
mother)
6 months -34 years 11 6 Family 2 -17-year-old male was applying cream twice
Female:5 daily for 6 weeks had weakness in legs to
Male involuntary muscle twitching, severe back
pain, diffuse and visible muscle twitching of

I. Al-Saleh / International Journal of Hygiene and Environmental Health 219 (2016) 468–474
the extremities, tongue, and lips, unsteady gait,
delirium, agitation, sleep disturbances, profuse
sweating, persistent tachycardia, and
hypertension.
Urine = 6–208 ␮g/g creatinine
Cream = 96,000–210,000 ppm
4–39 years 5 3 Family 3 -The 39 years mother exhibited numbness and
Female:2 tingling in her hands and lips, dizziness,
Male forgetfulness, headaches, depression,
irritability, and anxiety. While the 4-year-old
female had no clinical symptoms of mercury
toxicity.
Urine = 21–482 ␮g/g creatinine
Cream = 56,000 ppm
Zhang et al. (2014) Hunan, China Case report 28 years 1 Female Blood: 44,130 ␮g/l Nephrotic syndrome of minimal disease after
11 months of use
Urine: 94,077 ␮g/l
Cream: 6.8 ppm
Drescher et al. (2013) Québec, Canada Case report 39–54 years 4 Female Urine = 7–135 ␮g/l, normal <2 ␮g/l Nonspecific symptoms consistent with chronic
exposure to mercury such as fatigue, dizziness,
and headaches
Two women used cream contained 30,000 ppm
mercury
Tang et al. (2013) Hong Kong, Case report 26–45 years 4 Female Blood: 5–25.9 ␮g/l, Nephrotic syndrome
Cream = 7420–30,000 ppm
McKelvey et al. (2011) New York, USA Cases with elevated ≥20 years 13 Female Urine = ≥ 20 ␮g/l in which 9 of them due to use Not studied
urinary mercury of skin-lightening creams
detected through
population-based
biomonitoring study
Choudhury et al. (2011) England, United Case report Not mentioned 2 Female Blood = 12.6–39.7 ␮g/l Chronic back pain
Kingdom
(normal value < 6 ␮g/l) Nephrotic syndrome
Cream = 30,000 ppm
Chakera et al. (2011) England, United Case report 44 years 2 Female Blood = 30.09 ␮g/l Membranous nephropathy
Kingdom
26 years Cream = 20,000 ppm
Blood = 46.74 ␮g/l
Cream = not reported
Li et al. (2010) Nanjing, China Case report 15–45 years 11 10 Urine = 12–120 ␮g/l after 4–12 months use of Membranous nephropathy started 1 to 6
Female:1 skin-lightening creams months
Male
Tang et al. (2006) Hong Kong Case report 34 years 1 Female Blood = 24.9 ␮g/l Nephrotic syndrome of minimal disease after
once daily for 4 months of use
Urine = 57.6 ␮g/l
 Cream = 30,000 ppm
Kinabo (2005) Dar Es Salaam, Deacriptive study 13–33 years 20 Female Hair = 7.0–880 ␮g/g Not reported
Tanzania
Cream = 0.16–25.30 ppm
Soap = 0.11–8665 ppm
Sin and Tsang (2003) Hong Kong Descriptive study of a 35 years (15–76) 314 313 Urine = 45.2 ␮g/l Asymptonatic with no clinical features
case series Female:1
Male
Blood = 17.1 ␮g/l
Cream = 660–57,000 ppm
Soo et al. (2003) Hong Kong Case report 34 years 1 Female Blood = 32.7 ␮g/l Nephrotic syndrome secondary to
membranous nephropathy after 5 years of
applying
Urine = 754.6 nmol/day
Cream = 1762 ppm

I. Al-Saleh / International Journal of Hygiene and Environmental Health 219 (2016) 468–474
Tlacuilo-Parra et al. (2001) Mexico Case report 30 years 1 Female Blood = 30 ␮g/l clinical suspicion of systemic lupus
erythematosus due to daily use for 5 years
Urine = 150 ␮g/l
Cream = 221,000 ppm
Weldon et al. (2000) Arizona, Texas, New Case series and 14–79 years 203 Female Urine = 146.7 ␮g/l (reference range: 0–20 ␮g/l) Not reported
Mexico & California, cross-sectional survey
USA
126/150 women tested within 120 days of
skin-lightening cream cessation had urinary
mercury >20 ␮g/l
53/203 tested after 120 days of skin-lightening
cream cessation, 26 had urinary mercury
>20 ␮g/l and 7 had mercury >100 ␮g/l
CDC (1996) Texas, New Mexico Case report 3 15 Male Urine = 178 ␮g/l (reference range: 0–20 ␮g/l) Three cases presented symptoms such as
California, USA fatigue, weight loss, weakness, insomnia,
headache, numbness, irritability, short-term
memory, and myalgias of extremities that in
some progressed to paresthesias
35 Female Urine = 355 ␮g/g creatinine (normal: 0–25 ␮g/g
creatinine)
33 Female Urine = 143 ␮g/g creatinine (normal: 0–25 ␮g/g
creatinine)
Crema de Belleza–Manning lists
¨
calomel(mercurous chloride) as an
ingredient = 60,000–80,000 ppm
Otto et al. (1994) Balkan countries Deacriptive Not mentioned 121 Not Urine = 12 ␮g/l (range: 0.15–770 ␮g/l) or Not reported
study-Balkan refugees men- 11.4 ␮g/g creatinine (range: 0.2–446 ␮g/g)
tioned
(56 12 adults and 15 children had values >50 ␮g/l.
chil-
dren)
Cream = 708 to 17,200 ppm
Kern et al. (1991) London, United Case report 72 years 1 Male Blood = 128 ␮g/l Sensory-motor peripheral neuropathy
Kingdom
Cream= 50,000–100,000 ppm (used for 40
years)
Oliveira et al. (1987) England, United Case report 46 years 1 Female Urine = 58.41 ␮g/g creatinine Membranous nephropathy
Kingdom
Cream = 10,000 ppm
Kibukamusoke et al. (1974) Uganda Case report 21 years 1 Female No data was reported on mercury levels in Membranous nephropathy after 1–2 years of
biological materials. However, the authors daily use
found that applied cream contained
100,000–150,000 ppm
Barr et al. (1972) Nairobi, Kenya Clinical study 15–56 years 60 Female 32/60 women using cream had urinary Minimal change glomerular lesion in half of

471
mercury 90–250 ␮g/l the women
472 I. Al-Saleh / International Journal of Hygiene and Environmental Health 219 (2016) 468–474
1997; Weldon et al., 2000; McRill et al., 2000; Harada et al., 2001;
Karamagi et al., 2001; del Giudice et al., 2003; Petit et al., 2006;
Mahé et al., 2007). Palmer et al. (2000) showed in an in vitro human
model that mercury could be readily absorbed through the skin,
and the rate of its absorption was relative to the glycerol-containing
formulation. The long-term use of skin-lightening creams has been
responsible for a high rate of adverse cutaneous effects (Sun, 1987;
Pitche et al., 1997; Doe et al., 2001; del Giudice and Yves, 2002;
Morand et al., 2007). Mercury is absorbed through the skin (Barr
et al., 1973; Bourgeois et al., 1986; Palmer et al., 2000) and accu-
mulates in various body tissues but mostly in the kidneys (Al-Saleh
et al., 2004). Nephrotoxic effects have been attributed to the top-
ical application of inorganic mercury salts (Silverberg et al., 1967;
Barr et al., 1972; Kibukamusoke et al., 1974; Lyons et al., 1975;
Brown et al., 1977; Jeddeloh et al., 1985; Oliveira et al., 1987; Soo
et al., 2003; Tang et al., 2006, 2013). A recent case study by Zhang
et al. (2014) described a 28-year-old woman with nephrotic syn-
drome due to the chronic use for 11 months of a skin-lightening
cream with a mercury content of 6.8 ␮g/g. Earlier studies reported
that the kidney was the primary reservoir of mercury, with marked
histological changes after repetitive skin-lightening applications of
either Fair & Lovely or Rose, while fewer extensive changes were
also noted in the liver and brain (Al-Saleh et al., 2003, 2005). Sin and
Tsang, 2003 found that the majority of skin-lightening users had
urinary or blood mercury concentrations >20 or >10 ␮g/l, respec-
tively, but remained asymptomatic. Table 2 lists human exposure
studies related to mercury skin-lightening creams and their health
effects. Most studies were case reports highlighting the involve-
ment of topical use of these creams in membranous nephropathy
and minimal change disease (Barr et al., 1972; Kibukamusoke et al.,
1974; Oliveira et al., 1987; Soo et al., 2003; Li et al., 2010; Chakera
et al., 2011; Choudhury et al., 2011; Tang et al., 2006, 2013; Zhang
et al., 2014). Considering meta-analysis to assess the results of these
studies objectively and quantitatively has not been possible due to
small sample size and no control group was used with which to
compare outcomes. The majority of studies were either descriptive
or case reports, and there is a lack of rigorous scientific studies,
which critically evaluate the adverse health effects associated with
the use mercury-containing skin-lightening creams.
5. Effect of skin-lightening creams on reproduction
The reproductive toxicity of mercury from inhalation, ingestion,
and dental amalgam is well documented (Schuurs, 1999; Shen et al.,
2000; Davis et al., 2001; Khan et al., 2004; Cole et al., 2006), but
studies of toxicity after dermal exposure are still very limited. A
case study by Lauwerys et al. (1987) presented a black mother from
Brussels, Belgium, who had used a soap containing 1% mercury, as
mercuric iodide, for 15 years, including during pregnancy and lac-
tation. The authors reported high levels of mercury in the blood
(91 ␮g/l) and urine (784 ␮g/g creatinine) of the mother four months
after delivery, which confirmed its cutaneous absorption. Similar
results were found for her three-month-old infant (blood: 19 ␮g/l
and urine: 274 ␮g/g creatinine). Our experimental study indicated
that dermal exposure caused significant mercury accumulation in
the ovaries of mice following the application of a skin-lightening
cream (Al-Saleh et al., 2009). A few studies have suggested that
hyperpigmentation during pregnancy or lactation might increase
the use of skin-lightening creams containing mercury (Alghamdi,
2010; Mahé et al., 2007), which in turn would put their developing
fetuses or infants at a high risk (Bose-O’Reilly et al., 2010). Mer-
cury can pass to the fetus through the placenta or to the nursing
infant through breast milk (Al-Saleh et al., 2011b, 2013), which
might cause permanent nephrological and/or neurological deficits.
A search of the Medline database using the PubMed interface with
various subject headings such as mercury, skin-lightening creams,
bleaching creams, pregnancy, lactation, and dermal absorption for
the period from 1972 to 13 December, 2015 was conducted. Though
many experimental and human studies have demonstrated the
adverse effects on offspring of mercury exposure from fish con-
sumption and dental amalgam during pregnancy and/or lactation
(Gandhi et al., 2013; Soussa et al., 2013), no studies have exam-
ined whether exposure to mercury skin-lightening creams during
gestation and lactation might adversely affect birth outcome and
development. Dickenson et al. (2013) reported a case of pregnant
women with high blood mercury levels associated with the use of
skin-lightening creams purchased in a pharmacy in Mexico. This
was an isolated case, but other women may be at risk of using such
products and may introduce harmful health effects to their devel-
oping fetuses. Information from the scientific community for the
long-term health consequences of applying skin-lightening creams
containing mercury, particularly by women of childbearing age on
their children development, however, is lacking. It is hoped that
birth cohort studies addressing these concerns may help to pro-
vide more comprehensive evidence on the adverse health effects of
these products. Applying skin-lightening creams during pregnancy
and lactation should be avoided until data on its safety become
available.
References
Adawe, A., Oberg, C., 2013. Skin-lightening practices and mercury exposure in the
Somali community. Minn. Med. 96, 48–49.
Al-Ashban, R.M., Barratt, D.A., Shah, A.H., 2006. Mercury contents of skin-lightening
creams marketed in Saudi Arabia. J. Saudi Chem. Soc. 10, 383–388.
Al-Saleh, I., Al-Doush, I., 1997. Mercury content in skin-lightening creams and
potential hazards to the health of Saudi women. J. Toxicol. Environ. Health 51,
123–130.
Al-Saleh, I., Shinwari, N., 1997. Urinary mercury levels in females: influence of
skin-lightening creams and dental amalgam fillings. Biometals 10, 315–323.
Al-Saleh, I., Khogali, F., Al-Amodi, M., El-Doush, I., Shinwari, N., Al-Baradei, R., 2003.
Histopathological effects of mercury in skin-lightening cream. J. Environ.
Pathol. Toxicol. Oncol. 22, 287–299.
Al-Saleh, I., Shinwari, N., El-Doush, I., Billedo, G., Al-Amodi, M., Khogali, F., 2004.
Comparison of mercury levels in various tissues of albino and pigmented mice
treated with two different brands of mercury skin-lightening creams.
Biometals 17, 167–175.
Al-Saleh, I., El-Doush, I., Shinwari, N., Al-Baradei, R., Khogali, F., Al-Amodi, M., 2005.
Does low mercury containing skin-lightening cream (fair & lovely) affect the
kidney, liver, and brain of female mice? Cutan. Ocul. Toxicol. 24, 11–29.
Al-Saleh, I., Shinwari, N., Al-Amodi, M., 2009. Accumulation of mercury in ovaries
of mice after the application of skin-lightening creams. Biol. Trace Elem. Res.
131, 43–54.
Al-Saleh, I., Elkhatib, R., Al-Rouqi, R., Al-Enazi, S., Shinwari, N., 2011a. The dangers
of skin-lightening creams. Toxicol. Environ. Chem. 94, 195–219.
Al-Saleh, I., Shinwari, N., Mashhour, A., Mohamed Gel, D., Rabah, A., 2011b. Heavy
metals (lead, cadmium and mercury) in maternal: cord blood and placenta of
healthy women. Int. J. Hyg. Environ. Health 214, 79–101.
Al-Saleh, I., Abduljabbar, M., Al-Rouqi, R., Elkhatib, R., Alshabbaheen, A., Shinwari,
N., 2013. Mercury (Hg) exposure in breast-fed infants and their mothers and
the evidence of oxidative stress. Biol. Trace Elem. Res. 153, 145–154.
Alghamdi, K.M., 2010. The use of topical bleaching agents among women: a
cross-sectional study of knowledge: attitude and practices. J. Eur. Acad.
Dermatol. Venereol. 24, 1214–1219.
Alqadami, A.A., Abdalla, M.A., AlOthman, Z.A., Omer, K., 2013. Application of solid
phase extraction on multiwalled carbon nanotubes of some heavy metal ions
to analysis of skin whitening cosmetics using ICP-AES. Int. J. Environ. Res.
Public Health 10, 361–374.
Amponsah, D.S., Sebiawu, G.E., Voegborlo, R., 2014. Determination of amount of
mercury in some selected skin-lightening creams sold in the Ghanaian market.
Int. J. Eng. Res. Technol. 3, 344–350.
Balluz, L.S., Philen, R.M., Sewell, C.M., Voorhees, R.E., Falter, K.H., Paschal, D., 1997.
Mercury toxicity associated with a beauty lotion. N. M. Int. J. Epidemiol. 26,
1131–1132.
Barr, R.D., Rees, P.H., Cordy, P.E., Kungu, A., Woodger, B.A., Cameron, H.M., 1972.
Nephrotic syndrome in adult Africans in Nairobi. Br. Med. J. 2, 131–134.
Barr, R.D., Woodger, B.A., Rees, P.H., 1973. Levels of mercury in urine correlated
with the use of skin lightening creams. Am. J. Clin. Pathol. 59, 36–40.
Blay, Y.A., 2011. Skin bleaching and global white supremacy: by way of
introduction. J. Pan Afr. Stud. 4, 4–46.
Bose-O’Reilly, S., McCarty, K.M., Steckling, N., Lettmeier, B., 2010. Mercury exposure
and children’s health. Curr. Probl. Pediatr. Adolesc. Health Care 40, 186–215.
 I. Al-Saleh / International Journal of Hygiene and Environmental Health 219 (2016) 468–474
Bourgeois, M., Dooms-Goossens, A., Knockaert, D., Sprengers, D., Van Boven, M.,
Van Tittelboom, T., 1986. Mercury intoxication after topical application of a
metallic mercury ointment. Dermatologica 172, 48–51.
Brown, K.G., Abrahams, C., Meyers, A.M., 1977. The nephrotic syndrome in
Malawian blacks. S. Afr. Med. J. 52, 275–278.
CDC, Centers for Disease Control and Prevention, 1996. Mercury poisoning
associated with beauty cream-Texas, New Mexico, and California, 1995–1996.
MMWR Morb. Mortal. Wkly. Rep. 45, 400–403.
CDC, Centers for Disease Control and Prevention, 2010. Mercury exposure among
household users and nonusers of skin-lightening creams produced in
Mexico–California and Virginia. MMWR Morb. Mortal. Wkly. Rep. 61, 33–36.
Chakera, A., Lasserson, D., Beck, L.H., Roberts, I.S.D., Winearls, C.G., 2011.
Membranous nephropathy after use of UK-manufactured skin creams
containing mercury. QJM 104, 893–896.
Chan, T.Y., 2011. Inorganic mercury poisoning associated with skin-lightening
cosmetic products. Clin. Toxicol. (Phila.) 49, 886–891.
Choudhury, K., Morris, J., Harrison, H., O’Moore, E., 2011. Use of skin lightening
creams. Dangers from mercury. BMJ 342, d1327.
Cole, D.C., Wainman, B., Sanin, L.H., Weber, J.P., Muggah, H., Ibrahim, S., 2006.
Environmental contaminant levels and fecundability among non-smoking
couples. Reprod. Toxicol. 22, 13–19.
Copan, L., Fowles, J., Barreau, T., McGee, N., 2015. Mercury toxicity and
contamination of households from the use of skin creams adulterated with
mercurous chloride (Calomel). Int. J. Environ. Res Public Health 12,
10943–10954.
Cristaudo, A., D’Ilio, S., Gallinella, B., Mosca, A., Majorani, C., Violante, N., Senofonte,
O., Morrone, A., Petrucci, F., 2013. Use of potentially harmful skin-lightening
products among immigrant women in Rome, Italy: a pilot study. Dermatology
226, 200–206.
Davis, B.J., Price, H.C., O’Connor, R.W., Fernando, R., Rowland, A.S., Morgan, D.L.,
2001. Mercury vapor and female reproductive toxicity. Toxicol. Sci. 59,
291–296.
del Giudice, P., Yves, P., 2002. The widespread use of skin lightening creams in
Senegal: a persistent public health Problem in West Africa. Int. J. Dermatol. 41,
69–72.
del Giudice, P., Raynaud, E., Mahé, A., 2003. Cosmetic use of skin depigmentation
products in Africa. Bull. Soc. Pathol. Exot. 96, 389–393.
Denton, C.R., Lerner, A.B., Fitzpatrick, T.B., 1952. Inhibition of melanin formation by
chemical agents. J. Investig. Dermatol. 18, 119–135.
Dickenson, C.A., Woodruff, T.J., Stotland, N.E., Dobraca, D., Das, R., 2013. Elevated
mercury levels in pregnant woman linked to skin cream from Mexico. Am. J.
Obstet. Gynecol. 209, e4–5.
Dlova, N.C., Hamed, S.H., Tsoka-Gwegweni, J., Grobler, A., 2015. Skin lightening
practices: an epidemiological study of South African women of African and
Indian ancestries. Br. J. Dermatol. 173 (Suppl. 2), 2–9.
Doe, P.T., Asiedu, A., Acheampong, J.W., Rowland Payne, C.M., 2001. Skin diseases
in Ghana and the UK. Int. J. Dermatol. 40, 323–326.
Drescher, O., Dewailly, E., Krimholtz, M., Rutchik, J., 2013. ‘Fishy’ make-up on the
hook for mercury exposure: a case series. West Indian Med. J. 62, 770–772.
Dyall-Smith, D.J., Scurry, J.P., 1990. Mercury pigmentation and high mercury levels
from the use of a cosmetic cream. Med. J. Aust. 153 (409–10), 414–415.
EARTH, Ecological Alert and Recovery—Thailand, 2003. Final Report Study of
Mercury Contamination in Face Whitening Products in Thailand. file:///D:/
research%20center9%20November%202003/DOCUMENT/SUMMER/review/
New%20Review%202015/pdfSearches/EARTH%20Hg%20in%20Whitening%20-
%20Report.pdf.
EC, European Commission Regulation No 1223/2009 of the European Parliament
and of the Council of 30 November 2009 on cosmetic products. http://eur-lex.
europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:342:0059:0209:en:PDF.
Engler, D.E., 2005. Mercury bleaching creams. J. Am. Acad. Dermatol. 52,
1113–1114.
Gandhi, D.N., Panchal, G.M., Dhull, D.K., 2013. Influence of gestational exposure on
the effects of prenatal exposure to methyl mercury on postnatal development
in rats. Cent. Eur. J. Public Health 21, 30–35.
Garza-Ocanas, L., Torres-Alanis, O., Pineyro-Lopez, A., 1997. Urinary mercury in
twelve cases of cutaneous mercurous chloride (calomel) exposure: effect of
sodium 2,3-dimercaptopropane-1-sulfonate (DMPS) therapy. J. Toxicol. Clin.
Toxicol. 35, 653–655.
Glahder, C.M., Peter, A., Asmund G., 1999. Mercury in soap in Tanzania. In: Ministry
of Environment and Energy, N.E.R.I. (Ed.), Copenhagen.
Gras, G., Mondain, J., 1981. The Problem of the use of mercurials cosmetics in
Senegal (author’s transl). Toxicol. Eur. Res. 3, 175–178.
Hamann, C.R., Boonchai, W., Wen, L., Sakanashi, E.N., Chu, C.Y., Hamann, K.,
Hamann, C.P., Sinniah, K., Hamann, D., 2014. Spectrometric analysis of mercury
content in 549 skin-lightening products: is mercury toxicity a hidden global
health hazard? J. Am. Acad. Dermatol. 70, 281–287, e3.
Harada, M., Nakachi, S., Tasaka, K., Sakashita, S., Muta, K., Yanagida, K., Doi, R.,
Kizaki, T., Ohno, H., 2001. Wide use of skin-lightening soap may cause mercury
poisoning in Kenya. Sci. Total Environ. 269, 183–187.
Iwegbue, C.M., Bassey, F.I., Tesi, G.O., Onyeloni, S.O., Obi, G., Martincigh, B.S., 2015.
Safety evaluation of metal exposure from commonly used moisturizing and
skin-lightening creams in Nigeria. Regul. Toxicol. Pharmacol. 71, 484–490.
Jeddeloh, R.J., Lake, K.D., Brown, D.C., 1985. Ammoniated mercury membranous
nephropathy. Minn. Med. 68, 591–592.
Jovanovic, S., Maisner, V., Horras-Hun, G., Gabrio, T., Schwenk, M., 1997. Poisoning
of a family by a mercury-containing ointment. Gesundheitswesen 59, 405–408.
473
Karamagi, C., Owino, E., Katabira, E.T., 2001. Hydroquinone neuropathy following
use of skin bleaching creams: case report. East Afr. Med. J. 78, 223–224.
Kern, F., Roberts, N., Ostlere, L., Langtry, J., Staughton, R.C., 1991. Ammoniated
mercury ointment as a cause of peripheral neuropathy. Dermatologica 183,
280–282.
Khan, A.T., Atkinson, A., Graham, T.C., Thompson, S.J., Ali, S., Shireen, K.F., 2004.
Effects of inorganic mercury on reproductive performance of mice. Food Chem.
Toxicol. 42, 571–577.
Kibukamusoke, J.W., Davies, D.R., Hutt, M.S., 1974. Membranous nephropathy due
to skin-lightening cream. Br. Med. J. 2, 646–647.
Kinabo, C.P., 2005. Comparative analysis of mercury content in human hair and
cosmetic products used in Dar es Salaam, Tanzania. Tanzania J. Sci. 31, 83–90.
Ladizinski, B., Mistry, N., Kundu, R.V., 2011. Widespread use of toxic skin lightening
compounds: medical and psychosocial aspects. Dermatol. Clin. 29, 111–123.
Lauwerys, R., Bonnier, C., Evrard, P., Gennart, J.P., Bernard, A., 1987. Prenatal and
early postnatal intoxication by inorganic mercury resulting from the maternal
use of mercury containing soap. Hum. Toxicol. 6, 253–256.
Li, S.J., Zhang, S.H., Chen, H.P., Zeng, C.H., Zheng, C.X., Li, L.S., Liu, Z.H., 2010.
Mercury-induced membranous nephropathy: clinical and pathological
features. Clin. Am. Soc. Nephrol. 5, 439–444.
Luderschmidt, C., Plewig, G., 1979. Chronic mercury poisoning following topical
application of skin bleachers (author’s transl). Klin. Wochenschr. 57, 293–298.
Lyons, T.J., Christu, C.N., Larsen, F.S., 1975. Ammoniated mercury ointment and the
nephrotic syndrome. Minn. Med. 58, 383–384.
Mahé, A., Blanc, L., Halna, J.M., Keita, S., Sanogo, T., Bobin, P., 1993. An
epidemiologic survey on the cosmetic use of bleaching agents by the women of
Bamako (Mali). Ann. Dermatol. Venereol. 120, 870–873.
Mahé, A., Ly, F., Aymard, G., Dangou, J.M., 2003. Skin diseases associated with the
cosmetic use of bleaching products in women from Dakar, Senegal. Br. J.
Dermatol. 148, 493–500.
Mahé, A., Perret, J.L., Ly, F., Fall, F., Rault, J.P., Dumont, A., 2007. The cosmetic use of
skin-lightening products during pregnancy in Dakar, Senegal: a common and
potentially hazardous practice. Trans. R. Soc. Trop. Med. Hyg. 101, 183–187.
Maneli, M.H., Wiesner, L., Tinguely, C., Davids, L.M., Spengane, Z., Smith, P., van
Wyk, J.C., Jardine, A., Khumalo, N.P., 2016. Combinations of potent topical
steroids, mercury and hydroquinone are common in internationally
manufactured skin-lightening products: a spectroscopic study. Clin. Exp.
Dermatol. 41 (March (2)), 196–201, http://dx.doi.org/10.1111/ced.12720, Epub
2015 Jul 26. PubMed PMID: 26211494.
Marzulli, F.N., Brown, W.C., 1972. Potential systemic hazards of topically applied
mercurials. J. Soc. Cosmet. Chem. 23, 875–886.
McKelvey, W., Jeffery, N., Clark, N., Kass, D., Parsons, P.J., 2011. Population-based
inorganic mercury biomonitoring and the identification of skin care products
as a source of exposure in New York City. Environ. Health Perspect. 119,
203–209.
McRill, C., Boyer, L.V., Flood, T.J., Ortega, L., 2000. Mercury toxicity due to use of a
cosmetic cream. J. Occup. Environ. Med. 42, 4–7.
Morand, J.J., Ly, F., Lightburn, E., Mahé, A., 2007. Complications of cosmetic skin
bleaching in Africa. Med. Trop. (Mars) 67, 627–634.
Murphy, T., Kim, S., Chanra, P., Lim, S., Wilson, K., Irvine, K.N., Slotton, D.G., Allen, L.,
2015. Mercury contamination of skin-whitening creams in Phnom Penh,
Cambodia. J. Health Pollut. 5, 33–46.
Naser, J., Kirm, I., 2012. Mercury content in low cost skin lightening cream
products. J. Environ. Sci. Eng. 54, 245–248.
Oliveira, D.B., Foster, G., Savill, J., Syme, P.D., Taylor, A., 1987. Membranous
nephropathy caused by mercury-containing skin lightening cream. Postgrad.
Med. J. 63, 303–304.
Olumide, Y.M., Akinkugbe, A.O., Altraide, D., Mohammed, T., Ahamefule, N.,
Ayanlowo, S., Onyekonwu, C., Essen, N., 2008. Complications of chronic use of
skin-lightening cosmetics. Int. J. Dermatol. 47, 344–353.
Otto, M., Ahlemeyer, C., Tasche, H., von Muhlendahl, K.E., 1994. Endemic mercury
burden caused by a bleaching ointment in Balken refugees. Gesundheits 56,
686–689.
Özkaya, E., Mirzoyeva, L., Ötkür, B., 2009. Mercury-induced systemic allergic
dermatitis caused by ‘white precipitate’ in a skin lightening cream. Contact
Dermat. 60, 61–63.
Palmer, R.B., Godwin, D.A., McKinney, P.E., 2000. Transdermal kinetics of a
mercurous chloride beauty cream: an in vitro human skin analysis. J. Toxicol.
Clin. Toxicol. 38, 701–707.
Peregrino, C.P., Moreno, M.V., Miranda, S.V., Rubio, A.D., Leal, L.O., 2011. Mercury
levels in locally manufactured Mexican skin-lightening creams. Int. J. Environ.
Res. Public Health 8, 2516–2523.
Petit, A., Cohen-Ludmann, C., Clevenbergh, P., Bergmann, J.F., Dubertret, L., 2006.
Skin lightening and its complications among African people living in Paris. J.
Am. Acad. Dermatol. 55, 873–878.
Pitche, P., Afanou, A., Amanga, Y., Tchangai-Walla, K., 1997. Prevalence of skin
disorders associated with the use of bleaching cosmetics by Lome women.
Sante 7, 161–164.
Schuurs, A.H., 1999. Reproductive toxicity of occupational mercury. A review of the
literature. J. Dent. 27, 249–256.
Shen, W., Chen, Y., Li, C., Ji, Q., 2000. Effect of mercury chloride on the reproductive
function and visceral organ of female mouse. Wei Sheng Yan Jiu 29, 75–77.
Silverberg, D.S., McCall, J.T., Hunt, J.C., 1967. Nephrotic syndrome with use of
ammoniated mercury. Arch. Intern. Med. 120, 581–586.
Sin, K.W., Tsang, H.F., 2003. Large-scale mercury exposure due to a cream
cosmetic: community-wide case series. Hong Kong Med. J. 9, 329–334.
474 I. Al-Saleh / International Journal of Hygiene and Environmental Health 219 (2016) 468–474
Soo, Y.O., Chow, K.M., Lam, C.W., Lai, F.M., Szeto, C.C., Chan, M.H., Li, P.K., 2003. A
whitened face woman with nephrotic syndrome. Am. J. Kidney Dis. 41,
250–253.
Soussa, E., Shalaby, Y., Maria, A.M., Maria, O.M., 2013. Evaluation of oral tissue
response and blood levels of mercury released from dental amalgam in rats.
Arch. Oral Biol. 58, 981–988.
Summa, J.D., 1975. Chronic mercury poisoning from cosmetic creams (author’s
transl). MMW. Munch. Med. Wochenschr. 117, 1121–1124.
Sun, C.C., 1987. Allergic contact dermatitis of the face from contact with nickel and
ammoniated mercury in spectacle frames and skin-lightening creams. Contact
Dermat. 17, 306–309.
Tang, H.L., Chu, K.H., Mak, Y.F., Lee, W., Cheuk, A., Yim, K.F., Fung, K.S., Chan, H.W.,
Tong, K.L., 2006. Minimal change disease following exposure to
mercury-containing skin lightening cream. Hong Kong Med. J. 12, 316–318.
Tang, H.L., Mak, Y.F., Chu, K.H., Lee, W., Fung, S.K., Chan, T.Y., Tong, K.L., 2013.
Minimal change disease caused by exposure to mercury-containing skin
lightening cream: a report of 4 cases. Clin. Nephrol. 79, 326–329.
Tlacuilo-Parra, A., Guevara-Gutiérrez, E., Luna-Encinas, J.A., 2001. Percutaneous
mercury poisoning with a beauty cream in Mexico. J. Am. Acad. Dermatol. 45,
966–967.
Travasso, C., 2014. Skin whitening cream may contain mercury, and lipstick may
contain chromium and nickel, Indian study shows. BMJ 348, g1330.
UNEP, United Nations Environment Programme, 2008. Mercury in products and
wastes. In: Division of Technology, I. A. E., Chemicals Branch (Ed.), Geneva,
Switzerland.
Uram, E., Bischofer, B., Hagemann S., 2010. Market analysis of some
mercury-containing products and their mercury-free alternatives in selected
regions. Gesellschaft für Anlagenund Reaktorsicherheit (GRS) mbH.
US FDA, United States Food and Drug Administration Department of Health and
Human Services 2011. Use of mercury compounds in cosmetics including use
as skin bleaching agents in cosmetic preparations also regarded as drugs.
Wang, L., Zhang, H., 2015. Mercury content in marketed cosmetics: analytical
survey in Shijiazhuang, China. Cutan. Ocul. Toxicol., 1–5.
Washam, C., 2011. Beastly beauty products: exposure to inorganic mercury in
skin-lightening creams. Environ. Health Perspect. 119, A80.
Weldon, M.M., Smolinski, M.S., Maroufi, A., Hasty, B.W., Gilliss, D.L., Boulanger, L.L.,
Balluz, L.S., Dutton, R.J., 2000. Mercury poisoning associated with a Mexican
beauty cream. West J. Med. 173, 15–18, discussion 19.
WHO, World Health Organization, 1991. Environmental Health Criteria 118:
Inorganic Mercury. WHO, Geneva.
Zhang, L., Liu, F., Peng, Y., Sun, L., Chen, C., 2014. Nephrotic syndrome of minimal
change disease following exposure to mercury-containing skin-lightening
cream. Ann. Saudi Med. 34, 257–261.