Skin‐lightening creams used in Durban, South Africa

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 facial products, which are readily found in supermarkets, cosmetic shops, as well as sold by hawkers on city streets, in Durban, South Africa, were randomly selected for analysis. Selection criteria were based on: Word of mouth recommendations for skin-lightening creams. Facial cosmetic creams claiming skin-lightening properties (fades dark spots, marks or blemishes, complexion enhancer, exfoliative properties, etc.). Prescribed products. The 10 study products are listed in Table 1. The average cost is between R10 and R35 per unit, with content ranging from 20 g to 50 g per unit. The creams were extracted with methanol and the resulting extracts were analyzed by means of high-performance liquid chromatography with both ultraviolet and fluorescence detection. An isocratic elution method was used to separate the components of the extracts. Mercury in the creams was determined by cold vapour atomic absorption spectrometry. Before analysis for mercury the creams were digested in a (5:1 vol/vol) mixture of nitric and hydrochloric acids. In all cases, the samples were analyzed in triplicate. Of the 10 top-selling skin-lightening creams nine (90%) were found to contain banned or illegal compounds. Six (60%) of them were manufactured in South Africa and the rest were illegally imported from Taiwan (1–10%), Italy (1–10%), and the UK (1–10%). Four products (40%) contained mercury as an active ingredient, two (20%) contained corticosteroids, two (20%) resorcinol, and one (10%) a derivative of HQ. The majority of products contained banned substances. Only three (30%) products contained the active ingredients labeled on the packaging. Two (20%) were incorrectly labeled, as they were found to contain mercury instead of the natural albumen and placenta, or phenol and 8-hydroxyquinoline, that was declared on the packaging (Table 1). None of the products had a warning on the packaging alerting the consumer to stop using the cream if side effects were experienced or advice to use the product with a sunscreen, as is stipulated by law on the sale of cosmetics and toiletries in South Africa.9 HQ was not found in the top 10 skin-bleaching products sold on the market in Durban. Only one product contained a HQ derivative. On the other hand, nearly half of the products contained mercury as an active ingredient, although there was no indication of this compound on the packaging label. The export of mercury-containing cosmetics was banned11 in the EU in 2003, yet sample 6 (Rico complexion cream), which contains mercury, was manufactured in the UK and imported to South Africa. Clobetasol propionate and betamethasone dipropionate are potent topical steroids. They are prescription drugs whose supply by unauthorized people is illegal in South Africa, and yet they are easily purchased from street vendors at a very low cost of R10 compared with the retail cost at pharmacies, which ranges between R100 and R150/unit. Of major concern also is the fact that prescription drugs such as corticosteroid creams are easily dispensed by some unscrupulous pharmacies without an official prescription, and are sold at some general practitioner rooms by receptionists without the patient consulting the doctor. The risk of side-effects with such potent steroids is increased by their inappropriate and uncontrolled use, and moreover their application to thin skin areas such as the face and neck may result in skin atrophy and telangectasia. We have no knowledge of the original source of the preparations or whether they all originate from the same supplier. Topical corticosteroids as well as mercury, resorcinol, and HQ-containing creams are widely available in South Africa, but there is no governing body that regulates or controls their sale and availability. Concern about the side-effects and easy availability of these products, has already been voiced by dermatologists.1,2,7 Although our sample number was small and represented only some central Durban city outlets, data analysis is ongoing and we are presently looking at the top 40 selling skin-lightening creams in the whole of South Africa for the presence of banned skin-lightening compounds and corticosteroids. Since the last study by Findlay and De Beer, 31 years ago,10 old brand names have come and gone and new appealing and provocative names continue to intrude and flood the South African market. Stronger regulations and restrictions need to be imposed on cosmetic shops and supermarkets. In addition, continuous education of consumers about side-effects of these creams is mandatory. The South African Medicines Control Council and the South African National Consumer body need to be informed to investigate the unscrupulous distribution of these products. Advertisements for skin-lightening creams should be controlled and the use of fair-skinned models for advertising skin products aimed at the black consumer should be banned. On completion of the second larger battery of tests, we wish to commit to a massive, aggressive public education campaign based on the above findings and give better protection to consumers in an area fraught with consumer exploitation and selling of illegal skin lighteners.