MARINA HAROEN

ILMU KESEHATAN KULIT DAN KELAMINFAKULTAS KEDOKTERAN UNIVERSITAS WIJAYA KUSUMASURABAYAComplications of chronic use of skin lightening cosmeticsJOURNAL REVIEW

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Bleaching cosmetics and toiletries are widely used in most African countriesThe active ingredients : hydroquinone, mercury,corticosteroidsSeveral additives enhance the bleaching effectUsed for long duration, on a large body surface area, hot humid conditions percutaneous absorption is enhanced

Abstract

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The complications : - exogenous ochronosis - impaired wound healing - fish odor syndrome - nephropathy - steroid addiction syndrome - predisposition to infections - suppression of hypothalamic-pituitary- adrenal axis

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African patients with these complications physicians anywhere practicing physician to be aware of these complications

A middle-aged Nigerian lady uncontrollable diabetes mellitus and hypothalamicpituitary-adrenal axis suppression chronic use of skin lightening creams

*Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America.

Various chemicals have been used with consequent undesirable side- effects :- phenols ochronosis - mercurials nephropathy - prolonged bleaching squamous cell carcinoma A survey in Mali 25% of 210 women different side-effects from the use of bleaching creams

Literature Review

*Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America.

A survey in Balkan 22.3% of the inhabitants high concentrations of urinary mercuryExogenous ochronosis was first reported in 1906 asymptomatic blue-black macules on the malar areas, temples, inferior cheeks and neck

South Africa limit of 2% hydroquinone content in cosmetic

products

*Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America.

Britain and the USA 2% hydroquinone in cosmetic products, dermatological preparations to 4%An analysis of 41 bleaching creams in the UK in 1986 by Boyle and Kennedy eight contained more than 2% hydroquinone

*This condition resembles endogenous ochronosis in the skinhistologically, but does not exhibit any systemic complicationsor the urinary abnormality

A study of 450 Nigerians who confessed the use of bleaching creams 73.3% were women and 27.6% were men:

- The use of bleaching creams cuts across all sociodemographic characteristics all religious groups, single or married, rich and poor, literate and illiterate, low, middleand upper class use the products The scenario in Nigeria

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Reasons of using to look more attractive, to go with existing fashion trend, to treatskin blemishes, to cleanse or tone the face and body, or to satisfy the taste of ones spouse, because their wives usethem, to advertise their wares, to maintain the light skin color and preventtanning or blotches from sunlightThe scenario in Nigeria

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National Food and Drug Agency of Nigeria (NAFDAC) :

- a maximum of 2% hydroquinone - adverse side-effects prohibited in cosmetics and toiletriesMost products are not registered by NAFDAC, and bear no ingredient labeling nor address of manufacturers the concentrations of chemicals on the labeled products were largely found to be inaccurate

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Using synonyms of hydroquinone to camouflage the productsAll corticosteroid preparations can be purchased the pharmacy shops and drug vendors in the open market place

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The active ingredients hydroquinone,mercury, and a broad spectrum of the very potent corticosteroid preparationsAdditives to enhance lemon juice, potash,tooth paste, liquid milk, pulverized Naphthalene (camphor) balls a mothproofing agent, Vitamin C, peroxides and chlorates Detergents are added to the concoction

Chemicals often used and methods of use

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Some of the creams ~ soaps Additives are not exhaustiveInitiation of the bleaching habit : a total body surface immersion bath is often used for maximum effectThen maintained with daily applications of the creamsContinuous use repigmentation (-)Complications (+) the bleachers often intensify complications would be bleached away

Chemicals often used and methods of use

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Hydroquinone dihydric phenol monobenzyl and monomethyl ether of hydroquinoneHydroquinone competitively inhibit melanin production by inhibiting sulfhydryl groups and acting as a substrate for tyrosinase The melanosomes and ultimatelyThe melanosomes and melanocytes damaged by semiquinone free radicals

Pathogenesis and complications Hydroquinone

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Prolonged application and sun stimulation melanocytes recover from the damaging effect of the hydroquinone which passes down into the papillary dermis of the skin taken up by fibroblasts altered elastic fiber production and excretion of abnormal material into new fiber bundlesBenzoquinone acetic acid bind and cross link collagen fibers degenerative changes due to altered physico-chemical bonds

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Histologic examination of exogenous ochronotic :

- Yellow-brown banana-shaped fibers inthe papillary dermis - Homogenization and swelling of the collagen bundles - Moderate histiocytic infiltrate - Sarcoid-like granulomas withmultinucleated giant cells - Transfollicular elimination ofochronotic fibers - Fibers stain black with Fontana stainand blue-black with methylene bluestain

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Ultrastructural examination :

- homogenous electron-dense - irregular structures embedded in anamorphous granular materialinfiltrating adjacent collagen fibrilbundlesThe source of these ochronotic fibers is not clear

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Topical hydroquinones inhibit homogentisic acid oxidase in the skin local accumulation of homogentisic acid polymerizes to form ochronotic pigmentPigmented particles may be elastic or collagen fibersMelanocytes may be involvedmost cases involve sun-exposed sites one case is reported of ochronosis that avoided areas of vitiligocollagen bundles may be responsible for the loss of elasticity and poor wound healing

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Complications of hydroquinone use :

- dermatitis - exogenous ochronosis - cataract - pigmented colloid milia - scleral and nail pigmentation - patchy depigmentationExogenous ochronotic : -(1) Erythema and mild pigmentati

-(2) hyperpigmentation, black colloid milia and scanty atrophy -(3) papulonodules with or without surrounding inflammation

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Pruritic papular eruption (PPE) with background of ochronotic pigmentation on bleached skin HIV/AIDS patientsSquamous cell carcinoma on the site of chronic exogenous ochronosis

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Coalescence of multiple colloid milia big nodular lesions Colored pigmentation of all 20 nails yellow nail syndrome phenomenon pseudo yellownail syndromeAbnormal repigmentation on discontinuing therapy Meirowsky effect of long wavelengths of ultraviolet light darkening melanin already present in the skin and leading to a skin color darker than that prior to bleachingLoss of elasticity of the skin and impaired wound healing

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Like the fish odor syndrome trimethylaminuria body odor of rotten fish excretion of chemical, rimethylamine in the breath, urine, sweat, saliva, and vaginal secretionsTrimethylamine (TMA) is produced in the gut by bacterial degradation of choline and lecithin-rich foods

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Hydroquinone is an antioxidant reducing the ability to oxidize trimethylamine in chronic bleachershydroquinone as an inducing, precipitating factor in redisposed subjectsTreatment of exogenous ochronosis :

- has been disappointing - Tretinoin gel, cryotherapy, and trichloroacetic acid - dermabrasion - CO2 laser , Q-switched ruby laser

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Three forms: organic, inorganic and elementalProtoplasmic poison absorbed by the respiratory tract, through the skin, gastrointestinal tract excreted through the kidneys and colonUsed for treating syphilis, psoriasis, ringworm, ophthalmic solutions, teething powders, and diuretic no longer commonly used in medications

Mercury

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Mercury toxicity an acute or chronicAcute toxicity pneumonitis and gastric discomfortChronic toxicity neurological manifestations and nephrotoxicityMembranous glomerulonephritis andProliferative glomerulonephritis used mercury containing skin lightening creams

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Mercury bleaches the skin inactivating the sulfhydryl enzymesSulfhydryl enzymes mercaptans capture mercurial ions replace copper by competitive inhibition inactivation of the tyrosinase interrupting melanin productionChronic use of mercury increased pigmentation accumulation of mercury granules in the dermisDeposition of mercury in keratin also leads to discolorationAnd brittleness of the nails

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Corticosteroids bleach the skin inhibition of endogenous steroid production decrease in precursor hormone levels This precursor hormone, propiocortin is also the precursor for melanocyte stimulating hormone negative feedback decreased amounts of the hormoneTopical steroids cytostatic to the epidermis decrease the rate of epidermal turnover fewer, abnormal, and less pigmented melanocytes

Corticosteroids

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The skin lightening properties vasoconstrictor (blanching) effect.Fluocinonide (Topsyn gel), Betamethasone dipropionate(Diprosone), and Clobetasol propionate (Temovate) strongest topical corticoids commonly used bleaching agents in NigeriaApplied over a large surface area for prolonged periods and the occlusive effect of environmental heat and humidity percutaneous absorption, and hence, complicationsComplications of chronic corticosteroid use are shown in Table 3

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Result of chronic daily application for greater than a 1-month period of a potent or moderately potent glucocorticosteroid preparation to the

facial skin, neck, scrotum or vulvaWithdrawing the topical steroid severe burning relieved by further steroid applications rebound vasodilatation

Steroid addiction syndrome

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Permanent redness of the facial skin thinning and fine wrinkling of the skinRedness is so striking phenomenon Lhomme rouge.Permanent redness >> male bleachersThe thinning and wrinkling of the skin on the neck pseudo pseudoxanthoma elasticum

Steroid addiction syndrome

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Dermatophyte infectionTinea faciei >> mimic cutaneous lupus erythematosus or rosaceaVery bizarre and extensive Tinea corposis and cruris transmitted to the spouse and baby Tinea incognitoTinea versicolor very extensive and usually pigmented with dirty brown scales

Predisposition to infections

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Viral warts eruptive manner rather reminiscent of eruptive seborrheic keratosis (Leser-Trlat sign) pseudo-Leser-Trelat sign

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allergic contact dermatitis :

-patient with an eczematous dermatitis worse or is refractory to topical steroid treatment

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**Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America.*Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America.*Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America.*This condition resembles endogenous ochronosis in the skinhistologically, but does not exhibit any systemic complicationsor the urinary abnormality

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