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Table of Contents
Year : 2020  |  Volume : 24  |  Issue : 2  |  Page : 125-129

Self-use of skin-bleaching products among women attending a family medicine clinic: A cross-sectional study

1 Department of Family Medicine, University of Tabuk, Tabuk, Saudi Arabia
2 Internal Medicine, North Armed Forces Hospital, Tabuk, Saudi Arabia

Date of Submission21-Feb-2018
Date of Acceptance09-Jul-2020
Date of Web Publication10-Nov-2020

Correspondence Address:
Dr. Zinab A Alatawi
Tabuk University, Tabuk
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdds.jdds_13_18

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Background: The use of skin-lightening creams is common and widespread in African, Asian, and North American colored no brown to dark. Use of skin-bleaching agents has been reported in Saudi Arabia. The long-term use of these products for several months to years may cause cutaneous or systemic side effects. Purpose: This study aimed to assess the prevalence of self-use of skin-bleaching agents among Saudi women as well as the level of awareness, attitudes, and practice toward the use of these agents. Methods: A cross-sectional study was conducted by the selection of systematic random sampling of female attending the Family Medicine Clinic at Prince Mansour Military Hospital. The data collected by a structured questionnaire included information about background variables and attitudes, awareness, and practice regarding the use of skin-bleaching agents. The data were analyzed using statistical software to yield descriptive and inferential statistics. Results: A total of 358 women aged between 18 and 55 years were included in this study. Nearly 25% of the women were current users of skin-bleaching agents, while 39.6% were only previous users. About a third of women used bleaching creams in the treatment of hypo or hyperpigmented skin and 29.4% used them for cosmetic purposes. Regarding the source of these agents, 38% of women obtained them by medical prescription and 27.8% were from pharmacy without prescription. The reason for using skin-bleaching creams varied: 51.6% of females used creams to increase beauty, 51% for making a new look, 6% for increasing self-confidence, and 4.3% to increase the stability of marriage. Almost 56% of the women reported that cortisone is the most dangerous component in the skin-bleaching agents. Nearly 33% of the women reported being willing to use a quick whitening agent from an unknown source. Higher education and higher income were associated with greater use of skin-lightening creams. Conclusion: The lifetime use of skin-bleaching agents was relatively high, divided evenly on cosmetic and curative purposes. The level of awareness about these agents is low because a considerable proportion of respondents agreed to use agents from unknown sources, in addition to the high use of skin-bleaching agents obtained without medical or pharmacist consultation.

Keywords: Attitudes, knowledge, Saudi, skin bleaching, use, women

How to cite this article:
Alatawi ZA, ALShahrani M. Self-use of skin-bleaching products among women attending a family medicine clinic: A cross-sectional study. J Dermatol Dermatol Surg 2020;24:125-9

How to cite this URL:
Alatawi ZA, ALShahrani M. Self-use of skin-bleaching products among women attending a family medicine clinic: A cross-sectional study. J Dermatol Dermatol Surg [serial online] 2020 [cited 2021 May 11];24:125-9. Available from: https://www.jddsjournal.org/text.asp?2020/24/2/125/300385

  Introduction Top

Skin-bleaching formulas refer to the use of chemical products to lighten skin color, sometimes for therapeutic purposes but more commonly for cosmetic purposes.[1] There is a high prevalence (25%–96%) of skin-bleaching use in African and Asian people for several previous decades.[2],[3] A higher proportion of skin-lightening product users than nonusers believe that lighter skin tone plays a role in self­esteem, the perception of beauty and youth, marriage, and employment chances. The colonial legacy in South Asia may be one of the contributory factors for the belief that white is dominant and beautiful, as normally the White race was the director and the dark natives were the directed.[4] Several fairness cosmetics may include skin-bleaching products such as hydroquinone, high-potent corticosteroids, mercury, hydrogen peroxide, and magnesium peroxide among others. These may cause many side effects including dermatological problems, neurotoxicity, mercury-induced nephropathy, and immunotoxicity.[5]

Up to 60% of those who practice skin lightening may suffer from at least one complication.[6] Health problems related to skin-lightening products add a burden on health-care services and on the economy of many developing countries. In a Saudi study conducted in Riyadh region, 26.7% of the women used bleaching products to treat abnormal skin hyperpigmentation and 20.8% were ready to use any skin-lightening product that gives quick effects.[7] Nearly 45% of the tested skin-lightening cream in Saudi Arabia contained mercury at levels well above the FDA's acceptable limit of 1 ppm.[8] Our study aimed to investigate the extent of the use of bleaching agents among women in the Taif area as well as the determinants of this use.

  Methods Top

This study was of cross-sectional design carried out in Prince Mansour Military Hospital in Taif City. Prince Mansour Military Hospital provides care in family and community medicine. Taif City is in the Makkah Province of Saudi Arabia at an elevation of 1879 m (6165 ft.) and has a population of almost 1 million (General Census of Population and Housing in 1435 AH). This study recruited the Saudi female attendees of the Family Medicine Clinic at Prince Mansour Hospitals. The sample size was based on an expected frequency of participant's awareness of 50% with 95% confidence interval, yielding a sample size of 359 participants. The number of participants enrolled each day was selected using “systematic random sampling” technique, with spacing unit (K) between sample fractions equal to 3 (40 ÷ 12 ≈ 3). The first patient to select at the beginning of each working day was randomly selected from the first arriving three patients, and then every 3rd patient was invited until the entire 12 patients had been interviewed, by the end of the day. The procedure was repeated daily in each clinic until the entire sample population has all been covered over.

The data collection instrument was a self-administered questionnaire in Arabic with a letter explaining the need for the study. The questionnaire consisted of personal information such as age, education level, marital status, job, and income. Use of skin-lightening products, knowledge of skin-lightening products, reasons for use, application practice, and product's source were assessed. To calibrate the questionnaire, the questionnaire was distributed to three consultants including a family medicine physician, a dermatologist consultant, and a public health consultant.

Data were coded and entered into Statistical Package for Social 40 Sciences (SPSS) software version 20. acquired by IBM in 2009. Descriptive statistics were reported as appropriate. Parametric and nonparametric techniques were used as required. All results of tests with P ≤ 0.05 were considered “statistically significant.”

The regional ethical committee approved the study protocol. Written consent was obtained from the Prince Mansour Hospital administration before starting the study. In addition, consent was obtained from each participant.

  Results Top

The study population consisted of females aged between 18 and 55 years, with a mean age of 34 ± 10.6 years. The amount of monthly used cream ranged between 20 and 180 g with a mean of 41.7 ± 28 g. The mean cost of monthly use was 210 SAR [Table 1].
Table 1: Background characteristics of the respondents

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About a quarter of women were currently using skin-lightening creams, while 39.6% reported previous use [Figure 1]. Approximately 53% of the females were either current or previous users of skin-bleaching creams, while 12% of the females were previous users and were still using creams at the time of the study. The source of bleaching cream was reported as 38.1% by medical prescriptions, 27.8% from pharmacy without prescriptions, 23.2% of them from markets, and 10.8% from beauty shops [Table 2].
Figure 1: The prevalence of use of skin-bleaching agents among Saudi women in Taif area

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Table 2: Practices of women using bleaching creams of the skin

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The skin-lightening creams were ready-made compounds found in the pharmacy in 55.4% of the cream users, a pharmacist's prepared formula in 3.6%, traditional formula in 21.8%, and cosmetic products in 19.2% of the cream users. Nearly 31% of the females used bleaching creams as treatment for hypo or hyperpigmented skin, 29.4% used them only for cosmetic purpose, while 29.4% of them used skin-bleaching creams for both curative and cosmetic purposes. Only 8% of the females used skin-bleaching creams during pregnancy; 31.4% used creams during lactation. The frequency of use varied widely: 30.2% used skin-bleaching creams once a day, 45.5% used them twice a day, and 7.4% used these creams three times a day [Table 2].

Acceptance of traditional methods of preparation was common as 34.8% agreed with the use of skin-bleaching creams prepared by traditional methods, while 28.9% disagreed. In addition, 33% of the women agreed to recommend the use of these creams prepared by traditional methods (Itara), whereas 30.8% did not agree to recommend this type of preparation [Table 3].
Table 3: Knowledge and attitudes toward using bleaching creams

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The reasons behind the use of skin-bleaching creams differed among cream users. Nearly 31.3% of the women use skin-bleaching creams to increase beauty, 20.1% use them for a new look, 8% use them to increase self-confidence, 1.9% use them to increase the stability of marriage, and 52% because the use of such creams has perceived as a trend. Almost 33% of these women used creams that achieve quick whitening effect, whereas 67.3% did not use this kind of cream. Approximately 24% of cream users strongly agreed that they have a desire of white skin, 51% just agreed, while 15.2% disagreed and 4.2% strongly disagreed. Nearly 33.3% of the females thought that skin-bleaching creams cause skin problems, 41.1% thought they did not, whereas 25.6% did not know whether these creams cause skin problem [Table 3].

With regard to the associations between demographics and current or previous use of skin-bleaching creams, the association between marital status and the current or previous use was not statistically significant (P = 0.438). However, educational level and current or previous use was statistically significantly related (P = 0.00). Nearly 62% of the women with university or postgraduate degree were either current or previous users of skin-bleaching creams As to 41% of women with secondary school or less, and only 13% of illiterate women used bleaching cream.

In addition, the association between occupation and current or previous use was statistically significant (P = 0.024). Women who were employed had the highest current or previous prevalence of skin cream use. Higher income was also associated with current or previous use (P = 0.002). Women with income more than 1000 SAR had the highest percentage of bleaching cream use currently or previously. Age group was not statistically significantly associated with current or previous use (P = 0.245) [Table 4].
Table 4: Associations between demographics and current or previous use of bleaching creams

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  Discussion Top

The cosmetic use of skin-bleaching products is a common practice in dark-skinned women.[9] The use of skin-lightening creams is common and widespread in the sub-Saharan African population[10] and in many other parts of the world, including Saudi Arabia.[11] The long-term use of these products for months to years may cause cutaneous or systemic side effects.[12]

The prevalence of the current use of topical bleaching agents in our study (12%) is comparable with other prevalence studies carried out in Nigeria and Senegal. The studies conducted in Nigeria and Senegal showed that the use of cosmetic bleaching products ranged from 53% to 59% of the people surveyed.[6],[13] Nearly 31.3% of the females use bleaching creams to increase their beauty because even skin color is considered a universal sign of youth and beauty.[14]

The mean monthly cost of bleaching agents was 210 SAR. The lower cost of uncontrolled products is likely to be the main reason for their trade.[15] The mean duration of use was 2.4 months; this was not in agreement with previous work[15] in which the mean duration of use was 50.5 months and in which a few women had used bleaching creams for longer periods, for example, 20 years. The possible result of such extensive use is the occurrence of cutaneous adverse effects. The amount of bleaching products used each month in our study ranged between 20 and 180 g (mean 41.7 g/month), which was compared with another study conducted in Saudi Arabia in which the amount of bleaching products used each month ranged between 2 and 600 g (mean 90.09 g/month).[7] In Nigeria, the quantity varied from 60 to 150 g/month, whereas in Senegal, the quantity ranged between 15 and 350 g/month.[6],[13] The resultant mean of 41.7 g in our study seems quite enough, as 45 g of cream is required on an average to cover the whole body.[7]

The use of bleaching creams was higher in single females unlike what was found in a previous study;[10] this could be related to a desire to increase beauty to increase their chance of getting marriage. Use of bleaching creams was also higher (50%) in females with higher income, although this does not appear to be a consistent finding.[7],[10] Nearly 35% of the women in this study agreed with the use of cream from Itara (traditional formula), which may be attributed to the easy accessibility and availability of traditional products on the streets or in market places. These products are sold without any medical prescription or control, and are imported from neighboring countries.[10]

Only 8% used skin-bleaching creams during pregnancy; use was greater in Senegal where 81% of the women carried on with their use during pregnancy and 87% did so during lactation.[6],[13]

  Conclusion Top

While about one-third of the females were aware that bleaching creams cause skin problems, the nature and methods of the use of skin-lightening products, which are often applied to the whole body over a number of years, expose users to risks connected with systemic exposure to ingredients which may be toxic. The cosmetic use of such products for the purpose of skin bleaching carries potential risks that may require public health action.[16]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dadzie OE, Petit A. Skin bleaching: Highlighting the misuse of cutaneous depigmenting agents. J Eur Acad Dermatol Venereol 2009;23:741-50.  Back to cited text no. 1
Wone I, Tal-Dia A, Diallo OF, Badiane M, Touré K, Diallo I.[Prevalence of the use of skin bleaching cosmetics in two areas in Dakar (Sénégal)]. Dakar Med 2000;45:154-7.  Back to cited text no. 2
Charles, Christopher and Blay, Yaba, Editorial: Skin Bleaching and Global White Supremacy (2011). Journal of Pan African Studies, Vol. 4, No. 4, June 2011.  Back to cited text no. 3
Hamed SH, Tayyem R, Nimer N, AlKhatib HS. Skin-lightening practice among women living in Jordan: Prevalence, determinants, and user's awareness. Int J Dermatol 2010;49:414-20.  Back to cited text no. 4
Shankar PR, Subish P. Fair skin in South Asia: An obsession? J Pak Assoc Dermatol 2016;17:100-4.  Back to cited text no. 5
Mahé A, Ly F, Aymard G, Dangou JM. Skin diseases associated with the cosmetic use of bleaching products in women from Dakar, Senegal. Br J Dermatol 2003;148:493-500.  Back to cited text no. 6
Alghamdi K. The use of topical bleaching agents among women: A cross-sectional study of knowledge, attitude and practices. J Europ Acad Dermatol Venereol 2010;24:1214-9.  Back to cited text no. 7
al-Saleh I, al-Doush I. Mercury content in skin-lightening creams and potential hazards to the health of Saudi Women. J Toxicol Environ Health 1997;51:123-30.  Back to cited text no. 8
Godlee F. Skin lighteners cause permanent damage. Br Med J 1992;305:333.  Back to cited text no. 9
Palokinam Pitche, Akouété Afanou, Yao Amanga, Kissem Tchangaï-Walla. Prevalence of skin accidents linked to the use of depigmenting cosmetics among women in Lomé. Francophone study and research notebooks / Health. 1997;7: 161-164.  Back to cited text no. 10
Oliveira DB, Foster G, Savill J, Syme PD, Taylor A. Membranous nephropathy caused by mercury-containing skin lightening cream. Postgrad Med J 1987;63:303-4.  Back to cited text no. 11
Mahé A, Keita S, Bobin P, editors. Dermatological complications of the cosmetic use of depigmenting products in Bamako (Mali). Masson: Annals of dermatology and venereology; 1994.  Back to cited text no. 12
Nnoruka E, Okoye O. Topical steroid abuse: Its use as a depigmenting agent. J Natl Med Assoc 2006;98:934-9.  Back to cited text no. 13
Draelos ZD. Skin lightening preparations and the hydroquinone controversy. Dermatol Ther 2007;20:308-13.  Back to cited text no. 14
del Giudice P, Yves P. The widespread use of skin lightening creams in Senegal: A persistent public health problem in West Africa. Int J Dermatol 2002;41:69-72.  Back to cited text no. 15
Mahé A, Ly F, Perret JL. Systemic complications of the cosmetic use of skin-bleaching products. Int J Dermatol 2005;44 Suppl 1:37-8.  Back to cited text no. 16


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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