The Use of Topical Bleaching Agents Among Women
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Transcript of The Use of Topical Bleaching Agents Among Women
ORIGINAL ARTICLE
The use of topical bleaching agents among women:a cross-sectional study of knowledge, attitude andpractices
KM AlGhamdi*
Dermatology Department, Vitiligo Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia
*Correspondence: KM AlGhamdi. E-mail: [email protected]
AbstractBackground Although the practice of bleaching is common worldwide, there are few studies that discuss
knowledge, attitudes and practices towards bleaching.
Objective The aim of this study was to explore the knowledge, attitudes and practices towards the usage of
topical bleaching agents among women.
Methods A self-administered questionnaire on the use of bleaching creams was distributed randomly to women
attending the outpatient clinics at a university hospital in Saudi Arabia during 2008.
Results Five hundred and nine of 620 women responded (82% response rate). All the participants had dark skin
(skin type 4–5). The mean age was 29.22 ± 9 years. Of the participants, 38.9% (197 ⁄ 506) were current users of
bleaching agents. Only 26.7% (106 ⁄ 397) of the respondents used bleaching agents for medical purposes to treat
localized abnormal skin hyper-pigmentation; 20.8% (101 ⁄ 485) were ready to use any bleaching cream that gives fast
results, even if the components were unknown. Of the respondents, 30% (152 ⁄ 509) used more than 100 g of
bleaching creams monthly. These products were applied to the whole body in 7.3% of the cases. While 10.3%
(28 ⁄ 271) continued applying the bleaching products during pregnancy, 20.8% (54 ⁄ 260) did so during lactation. No
associations could be found between the various sociodemographic variables and differences in the attitude
towards and practice of using bleaching creams.
Conclusion A major proportion of our sample respondents have overused and ⁄ or misused bleaching agents. This
was regardless of age, income, education or marital status. There is a need to educate women about the possible
risks.
Received: 7 November 2009; Accepted: 26 January 2010
Keywordsattitudes, bleaching agents, de-pigmentation, knowledge, misuse, overuse, practices
Conflict of interestNone declared.
IntroductionBleaching agents have been used to lighten skin colour for decades.
It has been a common practice throughout the world, especially in
the sub-Saharan Africa, starting in dark-skinned women, but
recently spreading to fair-skinned women to tone their skin col-
our. The use of bleaching agents is very common in Asia and
Africa, because a having fair skin is linked to beauty and high
social class. In Africa, the use of cosmetic bleaching agents has
been a long-standing practice that chiefly aims to change one’s
skin colour and is a socially acceptable habit.1 It is common
among both men and women.2
Previous studies demonstrated a spectrum of complications
ranging from dermatitis and skin rashes to the development
of diabetes mellitus and renal problems associated with the misuse
of such products. Bleaching products were mainly composed of
mercury, corticosteroids and hydroquinone.2–10 A majority of skin
diseases observed in the users of bleaching products seemed to be
induced, aggravated or modified by these products,3 whereas the
long-term use of these agents was responsible for a high rate of
cutaneous and systemic side-effects.2,5
We feel that the frequency of use of bleaching agents in Saudi
Arabia has been increasing. Bleaching products seem to be highly
ª 2010 The Author
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
DOI: 10.1111/j.1468-3083.2010.03629.x JEADV
overused, although the constitutional skin colour is relatively light
(skin type IV–V). Bleaching products are legal in Saudi Arabia; the
government has not banned any of the bleaching products sus-
pected to be harmful. However, no studies have estimated the
prevalence of use or examined the motives and attitudes behind
using them. The general knowledge of women about the risks of
using skin bleaching agents must be evaluated and the side-effects
of such products should be observed to control this habit. The
aims of this study were to estimate the prevalence of use of bleach-
ing agents among women, to assess the knowledge and practice of
bleaching and to examine attitudes towards this issue.
MethodsA cross-sectional survey was conducted on women who attended
various outpatient clinics at King Khalid University Hospital in
Riyadh, Saudi Arabia, which is a tertiary referral hospital open to
the general public. Data were collected by a trained research assis-
tant between July and September of 2008 from patients as well as
their companions during their wait in the pharmacy area.
The specially designed questionnaire used for data collection in
this study was initially tested three times on 30 subjects each time
to estimate the time taken to complete the questionnaire, deter-
mine the comprehension of questions by the participants and
refine it accordingly. These questionnaires were excluded from the
final analysis. The final self-administrated questionnaire included
27 questions, which required approximately 8 min to answer com-
pletely. It was approved by the ethical committee at King Khalid
University Hospital. It was made clear to the participants that the
research concerned bleaching agents and not regular cosmetics or
make-up. Personal information, including age, marital status, edu-
cational level, occupation and household average monthly income,
was collected. In addition, the questionnaire requested detailed
information regarding the use of bleaching agents such as the
duration and frequency of bleaching product usage, the age at
which the participants started using them, where they obtained
those products from and the reason behind using such products.
Participants were also asked if they used bleaching creams during
pregnancy and lactation, how much they spent monthly on
bleaching creams and what parts of their bodies was it applied to.
The questionnaire also elicited information about the amount in
grams of bleaching creams used monthly. To help the subjects
express the amount used per month, three empty jars of 30, 60
and 120 g were shown to each subject. For those who did not use
jars, two different tubes of 15 and 30 g were shown. The patients
were also asked about the safety of the bleaching agents, whether
or not they believed that bleaching creams obtained at herbal
stores were safe, whether they thought bleaching creams might
harm their skin or general health, and whether they were willing
to use bleaching creams even if the components of the cream were
unknown. From the given components such as corticosteroids,
hydroquinone and mercury, they were asked to choose the most
dangerous component to human health. They were finally asked
an open-ended question about self-reported side-effects or compli-
cations.
Statistical analysis
The Statistical Package for the Social Sciences Program (SPSS) ver-
sion 16 (SPSS Inc., Chicago, IL, USA) was used for statistical anal-
ysis. Numerical variables were reported as mean ± standard
deviation. A chi-squared test was used for the assessment of associ-
ation between different categorical variables. Results with a P-value
of less than 0.05 were considered statistically significant. Multiple
logistic regression analysis was used to relate the use of bleaching
creams with various sociodemographic variables.
ResultsThe questionnaire was distributed to 620 women. In total, 509
women aged 10–59 years (mean ± SD 29.22 ± 9.07) returned the
questionnaire (82% response rate). The sociodemographic charac-
teristics of the participating females are shown in Table 1.
Knowledge
About 55% (269 ⁄ 492) of the respondents believed that using
bleaching creams could harm their skin, whereas 45.4% (223 ⁄ 492)
did not think so. Approximately 20% (98 ⁄ 498) agreed that using
bleaching agents could harm their general health, whereas 80%
(400 ⁄ 498) did not. When asked to select the most harmful com-
ponent of bleaching agents, 47.3% (238 ⁄ 503) chose corticoster-
oids, while only 38.2% (192 ⁄ 503) selected mercury.
Table 1 Sociodemographic characteristics† of the participantsin the survey
Variables Count Percentage
Age group (years)
Below 20 61 ⁄ 490 12.40
20–29 210 ⁄ 490 42.90
30–39 136 ⁄ 490 27.80
40 and above 83 ⁄ 490 16.90
Marital status
Single 180 ⁄ 502 35.90
Married 305 ⁄ 502 60.80
Divorced 9 ⁄ 502 1.80
Widowed 4 ⁄ 502 0.80
Separated 4 ⁄ 502 0.80
Education
Illiterate 17 ⁄ 486 3.50
High school or lower 246 ⁄ 486 50.60
University or higher 223 ⁄ 486 45.90
Household average monthly income
Less than 2000SR‡ 37 ⁄ 490 7.60
Between 2000 and 5000SR‡ 131 ⁄ 490 26.70
Between 5000 and 10 000 SR‡ 208 ⁄ 490 42.40
More than 10 000SR‡ 83 ⁄ 490 16.90
More than 20 000 SR‡ 31 ⁄ 490 6.30
†Some of the variables are missing. ‡3.74 Saudi Riyals = 1 US Dollar.
ª 2010 The Author
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
2 AlGhamdi
Attitude
In this study, 26.7% (106 ⁄ 397) of the respondents reported that
they used bleaching products for medical purposes to treat local-
ized abnormal skin hyper-pigmentation. While 73.6% (363 ⁄ 493)
of participants desired a lighter skin colour, only 19.9% (98 ⁄ 493)
did not. Of the participants, 56.8% (289 ⁄ 509) believed that lighter
skin colour made them more beautiful, whereas only 15.9%
(81 ⁄ 509) believed that lighter skin colour made them more self-
confident.
Non-medical preparations sold by street vendors and at herbal
shops were considered by 15.3% (77 ⁄ 503) as safe to use, while
69.8% (351 ⁄ 503) disagreed. Of the participants, 14.8% (75 ⁄ 506)
reported that they would recommend the use of those non-medi-
cal preparations to others, whereas 75.1% (380 ⁄ 506) reported that
they would not do so. About 20.8% (95 ⁄ 485) stated that they
would use bleaching creams that gave fast results, even if the com-
ponents were unknown.
Practice
Of the participating women, 38.9% (197 ⁄ 506) were current users
of topical bleaching agents. The age of the participants when they
first started using bleaching creams varied from 10 to 57 years
(mean 23.1 ± 7.3 years). The duration of usage varied from 1 to
150 months (12.5 years) (mean 12.3 ± 23.7 months); of the
respondents, 18.6% (90 ⁄ 486) had used bleaching creams continu-
ously for more than 6 months. Bleaching creams were used by
80.6% (297 ⁄ 368) of participants at least once daily.
About 30% (105 ⁄ 376) of participants reported that they
obtained the bleaching products from herbal shops (Fig. 1) and
22.20% (81 ⁄ 365) stated that they used herbal non-medical bleach-
ing products (Fig. 2). The monthly cost of the bleaching products
varied from 5 to 3000 Saudi Riyals (SR) (mean 223.0 ± 368.9SR,
i.e. about US$60 ± 100). Of women, 16.7% (81 ⁄ 486) reported
that they spent more than 200SR per month on bleaching prod-
ucts (US$53.4).
The amount of the bleaching creams used per month varied
from 2 to 600 g (mean 90.0 ± 80.9). More than 30% of the
respondents (152 ⁄ 486) used more than 100 g of bleaching cream
per month. These products were applied to the whole body in
7.3% of the cases. While 64.6% of the participants (329 ⁄ 509) used
the products on their faces, 26.7% (136 ⁄ 509) used them on their
necks and 17.1% (87 ⁄ 509) used them on their hands. It was self-
reported by 24.4% (124 ⁄ 509) that the colour of their skin returned
to normal once they discontinued the use of bleaching creams
(Fig. 3). In addition, 10.3% (28 ⁄ 271) of women continued apply-
ing the bleaching products throughout pregnancy, while 20.8%
(54 ⁄ 260) did so during lactation.
Non-medicalcosmetic
shops
Herbal shops
35.00
30.00
25.00
20.00
%
15.00
10.00
5.00
0.00Over thecounter
Medicalprescription
24.50%
34.80%
27.90%
12.80%
Figure 1 How the bleaching products were obtained among acohort of 509 Saudi females.
Ready madecosmeticcreams
25.00
17.50%
22.20%19.70%
40.50%
20.00
15.00
%
10.00
5.00
0.00Herbal or
non-medicalpreparations
Medicalpreparations
at pharmacies
Ready made atpharmacies
Figure 2 Types of bleaching products used by a cohort of 509
Saudi females.
Skin dryness
25.00
10.00%
24.40%
11.20%
16.10% 20.00
15.00 %
10.00
5.00
0.00RashSkin returns
to its normalcolor
Skin becomesdarker than
before
Figure 3 Self-reported complications caused by discontinuing
use of bleaching creams among a cohort of 509 females.
ª 2010 The Author
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
The use of topical bleaching agents among women 3
Associations between sociodemographic variables and
the use of bleaching creams
Statistical analysis did not reveal any significant associations
between various sociodemographic variables and details of the use
of bleaching creams or the knowledge of or attitudes towards the
use of them (Table 2).
DiscussionThe results of this survey indicate that the use of bleaching agents
is very common among women visiting outpatient clinics in Saudi
Arabia. In this survey, 38.9% of the participating women are
current users of bleaching agents. The results are of great
importance as the overuse of cosmetic bleaching agents has
various complications.
Bleaching agents are composed of various products, many of
which are still unidentified.1 The most common pharmacological
compounds used are hydroquinone, corticosteroids and mercuri-
als.5 Hydroquinone is the most prescribed skin-lightening agent
worldwide despite its inconsistent effects and safety concerns.11
Hydroquinone, a metabolite of benzene, which is leukaemogenic,
is a bleaching agent that can burn skin, especially when it is
exposed to ultraviolet light. One of its side-effects is ochronosis;
while the full degree of its side-effects is still unknown, studies
have associated it with liver damage and thyroid disorders.11
Treatment of rats with hydroquinone caused mutations in devel-
oping fetuses and decreased female fertility11,12 and leukaemia was
observed in female rats. Although leukaemia in rat and human
leukaemia have different origins, with human leukaemia originat-
ing in the bone marrow and leukaemia of rat originating in the
spleen, the FDA could still not rule out the leukaemogenic risks of
hydroquinone.11,12
Topical corticosteroids clearly lighten the skin, but the mecha-
nism of melanogenesis inhibition is still imprecise.9 Corticoster-
oids lighten the skin either by initial blanching as a result of
vasoconstriction which slows down skin cell turnover, decreasing
the number and activity of melanocytes, or by reducing produc-
tion of precursor steroid hormones.13
The damage produced by steroid-containing bleaching products
included skin atrophy, thinning and breaking of the skin giving
rise to acneform eruptions, hypertrichosis, telangiectasias, and fun-
gal ⁄ bacterial infections. Less common damage included unusual
presentation of scabies, pediculosis and warts.1–15 Medical condi-
tions associated with the use of steroid-containing bleaching
products were diabetes mellitus, hypertension and obesity. The
side-effects depended on the period of the use and the nature of
the products used.1–15
Mercury was used as mercurious chloride, mercurious oxide
and ammoniated mercury in many cosmetic products at the start
of the 20th century, before the serious toxicity of mercury was dis-
covered. Mercury toxicity can cause psychiatric and neurological
problems as well as renal impairment and a paradoxical increase
in skin pigmentation.16–20 As the daily uptake from skin absorp-
tion is up to 20 times more than that taken from food, toxicity is
a major concern and legislation prohibits the use mercury in many
countries. However, it is still used in some skin whitening prod-
ucts, as mercury deactivates the enzyme that causes the production
of melanin.15 Long-term usage of mercurial products makes the
skin and nails darker, because mercury accumulates in the epider-
mis, hair follicles and dermis.12
The prevalence of the current use of topical bleaching agents in
our study (38.9%) is comparable with other prevalence studies
carried out in Nigeria and Senegal. The studies conducted in Nige-
ria and Senegal showed that the use of cosmetic bleaching prod-
ucts ranged from 53% to 59% of people surveyed.2,3 In our study,
only 7.3% of the cases applied the bleaching products to their
whole body, while this percentage was as high as 81.3% and 92%
in Nigeria and Senegal respectively.2,3 In Saudi Arabia, 10.3% of
the participating women continued applying bleaching products
throughout pregnancy, while 20.8% did during lactation. The
results were more drastic in Senegal where 81% of the women
carried on with their use during pregnancy and 87% did so during
lactation. In our study, the duration of the bleaching practice
varied from 1 to 150 months (12.5 years), while in Senegal, the
duration varied from 1 to 420 months (35 years). The amount of
bleaching products used each month in Saudi Arabia ranged
between 2 and 600 g (mean 90.09 g ⁄ month). In Nigeria, the
Table 2 Current use of bleaching products associated with
demographic characteristics
Demographicvariables
Current use Chi-square P-value
Yes No
N (%) N (%)
Age (years)
£ 30 131 (40.2) 195 (59.8) 0.36 0.39
> 30 66 (36.1) 117 (63.9)
Educational level
Illiterate 8 (47.1) 9 (52.9)
High school or lower 100 (40.7) 146 (59.3) 2.46 0.29
University or higher 77 (34.5) 146 (65.5)
Marital status
Single 80 (44.4) 100 (55.6)
Married 109 (35.7) 196 (64.3) 4.3 0.12
Divorced ⁄ widowed ⁄separated
5 (29.4) 12 (70.6)
Occupation
Student 53 (42.7) 71 (57.3)
Unemployed 22 (48.9) 23 (51.1)
Home maker 71 (37.0) 121 (63.0) 3.84 0.43
Employed 42 (35.3) 77 (64.7)
Others 6 (33.3) 12 (66.7)
Household average monthly income (SR)
£ 10 000 150 (39.9) 226 (60.1) 0.06 0.80
> 10 000 44 (38.6) 70 (61.4)
ª 2010 The Author
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
4 AlGhamdi
quantity varied from 60 to 150 g ⁄ month, while in Senegal, the
quantity ranged between 15 and 350 g ⁄ month.2,3 The 600 g maxi-
mum used in our study seems quite outrageous, as 45 g of cream
is required on average to cover the whole body. Although it
appears that the results of our study are less dramatic than those
from the African studies, considering differences in skin colour,
they are still extreme. In Africa, skin colour is dark black or skin
type VI, while in Saudi Arabia, it is lighter (skin type IV–V).
Moreover, our study sample was from all outpatient clinics, while
the African studies drew their participants from dermatology
clinics where patients presenting with cutaneous complications of
this practice were probably found.
It was expected that more educated women, knowing the risks
of bleaching products, would avoid their use. It was also expected
that the use of bleaching products would be most prevalent among
participants in their teens to late 20s. The results of our study con-
tradict our expectations; women in Saudi Arabia use bleaching
products extensively regardless of age, educational level, income or
marital status. Multiple logistic regression analysis did not detect
any correlations between sociodemographic variables and the use
of bleaching products, indicating that bleaching products are
widely used by women in general, even older and educated ones.
A previous study performed in Mali showed that bleaching agent-
related complications were particularly frequent in unmarried
women (39%), literate women (34%) and female students
(45%).21
Participants self-reported the complications caused after discon-
tinuation of bleaching practice. The reported complications
included skin dryness, skin rash and the return to the normal skin
colour or to a darker than normal colour (Fig. 3). Such side-effects
prevent the users from discontinuing this practice, as it is difficult
for them to cope with these symptoms. This dilemma stresses the
need to alert the public to seek medical help instead of continuing
the bleaching practice.
Mercury is the most dangerous constituent of bleaching prod-
ucts, as it is highly toxic. It was predicted that most of the partici-
pants would know about the toxicity of mercury and accordingly
would select it when responding to the most toxic component
question. However, only 38.2% of the respondents (192 ⁄ 503)
selected mercury, while more than 47% (238 ⁄ 503) selected corti-
costeroids. This was true regardless of education or age, indicating
the prevalent lack of knowledge in this regard.
It was expected that women with higher incomes would be the
ones capable of paying for such cosmetic products. This was also
contradicted by our results as there was no association between
income and the use of bleaching products. Three participants
claimed to spend 3000SR monthly on bleaching products (about
US$800), which is a surprising cost as the average monthly income
per capita in Saudi Arabia according to the 2008 CIA world fact
book is US$1708.22 On average, women spend US$59.47 monthly
on bleaching products, which is more than the average person
would earn for a whole day of work.
About 75% of the bleaching products used were not obtained
by a medical prescription. This surprisingly high percentage reveals
the inadequate ways of obtaining such products and further high-
lights the importance of managing the problem. The sources from
which the bleaching creams were obtained varied from pharmacies
to cosmetic shops and herbal markets (Fig. 1). Many bleaching
creams claimed to be composed of ‘natural herbs’. A Saudi study
conducted by Bogusz et al.23 examined some of the creams claim-
ing to be natural herbal preparations sold at the markets in Saudi
Arabia. Eleven preparations that claimed to treat skin pigmenta-
tion problems were studied. In most of the cases, the products
contained high concentrations of heavy metals; the mercury con-
centration was 0.57–12.6%, while the concentration of lead was
over 1.5%.22 Such results seem to agree with ours, as both studies
indicate the importance of educating the public about the dangers
associated with using herbal preparations, especially when the
components are unknown. Strikingly, more than 20% of partici-
pants were willing to use bleaching products even if the compo-
nents were unknown. Unfortunately, the marketing of such
products is legal in Saudi Arabia.
Several studies reported complications caused by the overuse
and misuse of topical bleaching agents.1–14 However, our survey is
the first to describe the level of knowledge that Saudi women par-
ticipants visiting outpatient clinics had of bleaching products as
well as their attitudes towards such products and their use of
them. Limitations of our work include the use of a convenience
sample, which might not be representative of the whole commu-
nity; however, a strength of the work is the use of a large sample
size (509).
Future research should investigate the prevalence and type of
cutaneous and systemic complications of bleaching agents in our
society. Furthermore, detailed pharmacological examination of the
components of these bleaching agents needs to be conducted.
Education of the public on the risks of bleaching product use is
clearly imperative and would mitigate the side-effects of their use.
Health education programmes should target women through vari-
ous media options including leaflets, television and radio. Within
hospitals, we suggest that education programmes about the dan-
gers of misuse and overuse of topical bleaching agents be inte-
grated into existing health education programmes. Health
regulators must focus on limiting the herbal preparations that
have unknown or harmful components. The sales and marketing
of bleaching products must be controlled, which could be done by
imposing fines and penalties on the marketers of such products.
There is a need for a nationwide health-education campaign to
tackle this issue.
ConclusionsThe results of this survey reveal that the use of topical bleaching
agents is very common among Saudi women. Numerous women
of different age, class and marital status are seeking lighter
complexions and are consequently using bleaching products
ª 2010 The Author
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
The use of topical bleaching agents among women 5
excessively, which could cause several health problems. It is impor-
tant to control the use of bleaching products and to educate
women about the dangers associated with this practice. Increased
awareness should reduce the abuse of bleaching agents.
AcknowledgementsThe author thanks Dr Davinder Parsad and Prof. Ahmed
Mandil, Professor of Epidemiology, Family and Community
Medicine Department, College of Medicine, King Saud Univer-
sity for kindly critically reviewing the paper.
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ª 2010 The Author
JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology
6 AlGhamdi