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© 2002 The International Society of Dermatology International Journal of Dermatology 2002, 41, 69–72
69
AbstractBackground 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-five 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-five
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.
Blackwell Science LtdReportUse of skin lightening creams in SenegalThe 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 Unité de Dermatologie et de Maladies Infectieuses et Tropicales, Hôpital Bonnet, Fréjus, France
Correspondence Pascal del Giudice, MD Unité de Dermatologie et de Maladies Infectieuses et Tropicales Hôpital Bonnet Avenue André Léotard BP 110 83600 Fréjus France E-mail: [email protected]
Introduction
The use of skin lightening creams is common and widespreadin the sub-Saharan African population.1–12 The most commonpharmacologic compounds used are hydroquinone, corticos-teroids, and mercurials.1–4 The long-term use of these prod-ucts for several months to years may cause cutaneous orsystemic side-effects.1–12 The common use of these creams insub-Saharan Africa contrasts with the few studies and dataavailable. We present the results of a study conducted inDakar (Senegal), where the use of skin lightening creams,locally known as “xessal,” is common. Our purpose is toevaluate the extent of the practice in Senegal and the potentialassociated cutaneous side-effects. We discuss the extent ofthis phenomenon in the light of the few similar studies fromneighboring countries.
Subjects and methods
The study took place in the outpatients and emergency
department of the Hôpital 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
medical structure. The Hôpital 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 question-
naire including age, marital status, French speaking ability, and ethnic
origin (the Senegalese people are composed of several popula-
tions with different skin pigmentation according to the ethnic origin).
“Xessal” is the term used by the Senegalese population to define
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.
International Journal of Dermatology 2002, 41, 69–72 © 2002 The International Society of Dermatology
70 Report Use of skin lightening creams in Senegal del Giudice and Pinier
Results
Among 760 women, 685 (aged 13–78 years; mean,32.6 years) participated in the study. Thirty-six per cent (249)had used “xessal” at least once and 27% (186) were activeusers. Ninety per cent of women using “xessal” were betweenthe ages of 20 and 45 years (extremes, 14–54 years). Womenusing such creams were more often from an ethnic group withhyperpigmentation (odds ratio (OR), 5.1; P = 0.001), highercultural level (French speaking ability) (OR, 1.77; P = 0.001),and more frequently married (OR, 1.61; P = 0.4). The meanduration of use was 50.5 months (extremes, 1–240 months).Forty-three different commercial marks were reported for“xessal.” The most common products were hydroquinoneand corticosteroids, used in 78% and 73% of preparations,respectively. Other products included mercurials and othertopical agents applied directly to the skin, namely detergents,hypochloride sodium, and creams of unknown composition(25% of the products used). None contained identified sun-screen. The different products were used in combinations oftwo to four or even more. Corticosteroid creams and hydro-quinone were associated in the majority of preparations(75%). The main topical corticosteroids were betamethasone(0.05%), difluprednate (0.05%), and less frequently clobeta-sol (0.05%). The concentration of hydroquinone varied from2 to 5%. The number of daily applications varied from one tothree, as did the quantity of creams used. When the desiredpigmentation had been reached, the number of applicationswas modulated to stabilize the “clear” pigmentation. Themajority 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. Therelative proportions of women with no, one, two, three, andmore cutaneous adverse effects were 68 (37%), 50 (27%), 37(20%), 15 (8%), and 15 (8%), respectively. There was a signi-ficantly longer duration of use in women with cutaneousside-effects compared to those without (57.5 months (extremes,1–204 months) vs. 38.7 months (extremes, 1–240 months);P = 0.02). The number of cutaneous adverse effects was corre-lated with the duration of use of “xessal” (r2 = 0.033; ddl = 183;F = 6.18; P = 0.05); however, two women had a duration ofuse of 20 years without significant side-effects. The dermato-logic abnormalities seen are listed in Table 1 (see Figs 1–3).
Discussion
The use of skin lightening creams in Africans has been knownsince the 1960s.1–12 Concerns about potential adverse effectsprovided the first opportunity to focus on this phenomenon.Indeed, in 1972, Barr et al.5 found that nephrotic syndromesin adult patients in Nairobi were due to the use of topical mer-curials. In South Africa, Dogliotti et al.6 reported an epidemicof leukomelanoderma in relation to the use of the mono-
benzyl ether of hydroquinone. Findlay et al.7 reported the occur-rence of exogenous ochronosis in Africans who used skinlightening creams containing hydroquinone for several years.The first report from West Africa was by Marchand et al.,1 in1975, in a study in Senegal. Subsequently, the same practiceshave been described in Mali and Togo.2,3 A few data have sug-gested that similar practices are common in other Africancountries, such as Zimbabwe, Nigeria, Ivory Coast, Gambia,
Table 1 Main cutaneous diseases in women using “xessal”
Cutaneous disease Frequency (%)
Facial acne 36Facial hypertrichosis 19Cutaneous atrophy 17Stretch marks 17Hyper–hypopigmentation 14Intertrigo 10Pyoderma 9Tinea corporis 6Purpura 3
Figure 1 Facial acne
© 2002 The International Society of Dermatology International Journal of Dermatology 2002, 41, 69–72
71del Giudice and Pinier Use of skin lightening creams in Senegal Report
and Tanzania.13–15 In addition, in some Asian countries, suchas Vietnam and the Malawi, Philippines, similar practiceshave recently been reported.16,17
The expected result of “xessal” in Senegal is to clear theskin to obtain the so-called “teint clair,” which is supposed to“improve appearance” and is considered by women as a
standard of elegance, beauty, and higher social level.18 Thispractice is widespread in Senegal: we found that 27% ofwomen questioned were regular users. In Mali, a neighboringcountry, Mahé et al.2 found similar results, with 25% ofwomen 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 corticosteroidsand hydroquinone, used in combination in most topical prep-arations;1–4 however, in Togo, Pitche et al.3 reported a higherrate of the use of mercurials (31%). Mercurials were popularas depigmentation agents until they were recognized as toxic,and their use was banned in some countries, such as SouthAfrica. These products are used in soaps or creams. They havebeen shown to be nephrotoxic via the absorption of mercurythrough the skin following repeated applications. In our experi-ence, mercurials were rarely used; however, the use of mer-curials has been reported in the past in Senegal, and we cannotexclude the possibility that the women questioned deniedtheir use.19 Hydroquinone was the major skin lighteningagent used in our study population. High concentrations ofhydroquinone-containing bleaching creams have been associ-ated with ochronosis, and may produce contact dermatitisresulting in a secondary postinflammatory hyperpigmentation.20
Corticosteroids were the second most common productsused. As reported in Mali by Mahé et al.,2 topical steroids aresuspected to be responsible for most cutaneous adverse effects.Other products used included detergents, sodium hypochlo-ride, lemon juice, salicylic acid, and others. A high proportionof women (25%) used products of unknown composition.
The mean duration of use was 50.5 months; a few womenhad used “xessal” for longer periods, e.g. 20 years. The pos-sible result of such extensive use is the occurrence of cutane-ous adverse effects. Cutaneous diseases were present in62.5% of women (similar results were found in Togo andMali with 69% and 70%, respectively). Facial acne, presentin 36%, was the main adverse effect (Fig. 1). Facial acne andother frequent cutaneous adverse effects, such as atrophy,hypertrichosis, and stretch marks, are probably a result of theuse of topical steroids as previously reported.2,3 It can beargued that, in the absence of a control group, it is not possi-ble to associate cutaneous diseases with the practice of using“xessal;” however, a rate of facial acne above 30%, whateverthe age group, is not usual. The usual rate of facial acne in thegeneral African adult population is low (< 5%). In addition,facial acne has been reported to be a frequent adverse event insubjects using topical steroids for cosmetic reasons in Viet-nam,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 ofleukomelanoderma were found, as reported with the use ofthe monobenzyl ether of hydroquinone in South Africa, butrather the association of hypopigmentation contrasting withpostinflammatory hyperpigmentation in the same area (Fig. 3).
Figure 2 Stretch marks on the upper part of the body
Figure 3 Pigmentary disorder: hypo–hyperpigmentation
International Journal of Dermatology 2002, 41, 69–72 © 2002 The International Society of Dermatology
72 Report Use of skin lightening creams in Senegal del Giudice and Pinier
Among the female adult population, the use of “xessal”was higher in married women and in those with a higher cul-tural level possibly due to economic reasons. Most productsare easily available on the streets or in market places. They aresold without any medical prescription and control, andimported from neighboring countries.3,4 The cheaper cost ofsuch uncontrolled products is likely to be the main reasonfor their trade. Most topical steroids sold are not allowed inSenegal and other creams have unknown composition.4,19,20
In some West African countries, governments have tried tocontrol this practice, which is considered to be a public healthproblem. In Gambia, for example, the use of bleachingcreams has been forbidden since 1995. This control remainsextremely difficult, however.
A large proportion of women (93%) agreed to answer thequestionnaire, but many of them may not have given real andcomplete responses. Indeed, a proportion of women mayhave denied the use of “xessal” because this practice is usuallyhidden. Despite these limitations, our study provides dataconfirming the extensive and uncontrolled use of bleachingagents in the female African population. A few previous stud-ies involving a limited sample population from neighboringcountries, published in the French literature, have shownsimilar results. Recent observations suggest that similar prac-tices exist in the African population in Europe, West Indies,and Asia. Markey et al.21 have noted that “large quantities ofskin lightening creams are sold in Britain to Afro-Caribbeansand Asians.” In France, most products can be found withoutany control in specialized African shops and sold as “innocent”cosmetic creams.
The use of skin lightening creams in African countries, suchas Senegal, is ongoing despite information campaigns. Thestandard of beauty, “teint clair” (clear skin), promoted byAfrican magazines will continue; therefore, we must be awareof such cosmetic practices in African women and providesafe products.
Acknowledgments
Dr Lamine Cissé, my colleagues, and nurses from theHôpital Principal de Dakar provided help, Dr Counillon andDr Antoine Mahé provided helpful discussions, and Dr JeanPhilippe Lacour critically reviewed the manuscript.
References
1 Marchand JP, N’Diaye B, Arnold J, Sarrat H. Les accidents des pratiques de dépigmentation cutanée cosmétique chez la femme africaine. Bull Soc Med Afr Noire Lgue Frse 1976; 21: 190–199.
2 Mahé A, Keita S, Bobin T. Complications dermatologiques
des produits dépigmentants à Bamako (Mali). Ann Dermatol Venereol 1994; 121: 142–146.
3 Pitche P, Afanou A, Amanga Y, Tchangaï-Walla K. Prévalence des accidents cutanés liés à l’utilisation de cosmétiques dépigmentants chez les femmes à Lomé. Cahiers Santé 1997; 7: 161–164.
4 Sylla R, Diouf A, Ndiaye B, et al. Pratique de la dépigmentation artificielle de la peau chez les femmes à Dakar et étude analytique des produits dits cosmétiques utilisés. Dakar Méd 1994; 39: 223–226.
5 Barr RD, Rees PH, Cordy PE, et al. Nephrotic syndrome in adult Africans in Nairobi. Br Med J 1972; 2: 131–134.
6 Dogliotti M, Caro I, Hartdegen RG, Whiting DA. Leucomelanoderma in blacks. A recent epidemic. S Afr Med J 1974; 48: 1555–1558.
7 Findlay GH, Morrison GH, Simson IW. Exogenous ochronosis and pigmented colloid milium from hydroquinone bleaching creams. Br J Dermatol 1975; 93: 613–622.
8 Findlay GH. Ochronosis following skin bleaching with hydroquinone. J Am Acad Dermatol 1982; 6: 1092–1093.
9 Bentley-Phillips B, Bayles MAH. Acquired hypomelanosis: hyperpigmentation following reactions to hydroquinones. Br J Dermatol 1974; 90: 232–233.
10 Dogliotti M, Leibowitz M. Granulomatosis ochronosis – a cosmetic-induced skin disorder in blacks. S Afr Med J 1979; 56: 757–760.
11 Bentley-Phillips B, Bayles MA. Butylated hydrotoluene as a skin lightener. Arch Dermatol 1974; 109: 216–217.
12 Bentley-Phillips B, Bayles MAH. Cutaneous reactions to topical application of hydroquinone. Results of a 6-year investigation. S Afr Med J 1975; 49: 1391–1395.
13 Olumide YM, Odunowo BD, Odiase AO. Regional dermatosis in the African. Part I. Facial hypermelanosis. Int J Dermatol 1991; 30: 186–189.
14 Brown KGE, Abrahams C, Meyers AM. The nephrotic syndrome in Malawian blacks. S Afr Med J 1977; 52: 275–277.
15 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: 225–227.
16 Easton A. Women have deadly desire for paler skin in the Philippines. Lancet 1998; 352: 555.
17 Legoux A, Hanh TT, Binh TT, Hoa LL. Acnés induites par les cosmétiques et les dermocorticoïdes à Cantho (Vietnam). Poster no. 5. Journées Dermatologiques de Paris, Paris, France, 1998.
18 Fitoussi C. La cosmetologie des sujets à peau noire. Dermatol Prat 1997; 197: 3–4.
19 Gras G, Mondain J. Problèmes posés par l’utilisation des cosmétiques mercuriels au Sénégal. Tox Eur Res 1981; 3: 175–178.
20 Burke PA, Maibach HI. Exogenous ochronosis: an overview. J Dermatol Treat 1997; 8: 21–26.
21 Markey AC, Kobza Black A, Rycroft RJG. Confetti-like depigmentation from hydroquinone. Contact Derm 1989; 20: 148–149.
