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ISSN: 2320-5407 Int. J. Adv. Res.

5(1), 2008-2016

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/2972


DOI URL: http://dx.doi.org/10.21474/IJAR01/2972

RESEARCH ARTICLE
AN ONLINE SURVEY OF USING SKIN-LIGHTENING PRODUCTS IN SAUDI FEMALES

Nadia M. Awaji, Nada M. Mahdi, Abrar S. Al Qahtani, Laila A. Alsalman, Fatimah A. Alshehri, Fatimah A.
H. Al-shahrani, Fatimah M. Awaji, Salha O. Alasmari and Fatimah S. Z. Al-shahrani.
Internship, Faculty of Medicine, King Khalid University, Abha, Saudi Arabia.
....
Manuscript Info Abstract
.
Manuscript History Background: Production and marketing of skin lightening products
has become a multi-billion dollar industry, servicing all parts of the
Received: 26 November 2016 world, making it one of the most common forms of potentially harmful
Final Accepted: 27 December 2016 body modification practices worldwide.
Published: January 2017
Objectives: to study the practices of Saudi women regarding topical
Key words:- skin lightening agents.
Skin lightening, Saudi, Women; Subjects and methods: This is a cross sectional study covered
utilization; non-prescription different areas of the Kingdom of Saudi Arabia. It included women
aged between 16 and 60 years, Saudis and live in the kingdom
permanently as well as has online access. Self-administered valid
Arabic questionnaire has been used to collect data from the
participants. It includes personal information, detailed information
regarding the use of skin lightening agents and knowledge of the safety
of these agents. Using all online tools (face book, twitter, whats app,
etc...), the questionnaire was distributed.
Results: Six hundreds and five subjects were included in the study,
their mean age was 35.8 6.6 years, with a range from 2050 years,
slightly more than half of them (50.9%) were singles while 45.6% were
married. Sixty five percent of the participants (393 out of 605) were
current users of topical skin lightening products and 198 (32.7) had
previously used these products. Thus, overall, 438 women out of 605
(72.4%) ever used topical skin lightening products. Almost half of them
(49.9%) obtained these preparations from the pharmacy without
prescription. Among current users, 13.6% had used skin lightening
agents continuously for more than one year. These agents were applied
to the whole body in 11.9% of ever users whereas almost two-thirds of
them (61.8%) used the products on their faces. Only 27.3% of the
participants could recognize that Mercury is the most harmful chemical
to human health, which could be one of the components of skin
lightening agents whereas cortisone was chosen by 41.5% of them.
Fifty-two women (10.1%) reported that they would use skin lightening
creams that gave fast results, even if the components were unknown.
Conclusion: The utilization of skin lightening agents among Saudi
women is a common practice, mostly without prescription.

Copy Right, IJAR, 2016,. All rights reserved.


....
Corresponding Author:- Nadia M. Awaji.
2008
Address:- Internship, Faculty of Medicine, King Khalid University, Abha, Saudi Arabia
.
ISSN: 2320-5407 Int. J. Adv. Res. 5(1), 2008-2016

Introduction:-
Background:-
Skin lightening is the practice of utilizing chemical substances or any other products with a depigmenting potential
in an attempt to lighten skin tone or provide an even skin complexion by lessening the concentration of melanin and
obtain a reduction of the physiological skin pigmentation.(1)

Whiteness of the skin is considered as important element in constructing female beauty worldwide, particularly in
cultures with black colored skin as in Africa, South America and parts in Asia. (2) Skin bleaching preparations
typically used by people with skin phototypes IV to VI on a cosmetic basis, primarily to lighten normally dark skin
in order to fit within the larger societys definition of beauty that is linked to having a fair skin. (3)

Skin lightening is a growing phenomenon around the world and it's becoming a bigger business. The prevalence
rates of using skin bleaching products are variable in different parts of the world. They ranged from 24% among
Japanese women(4) and 30% among women from Ghana(5) to alarming rates in India (65%)(4) and Lagos, Nigeria
(77%).(6)

Production and marketing of skin lightening products has become a multi-billion dollar industry, servicing all parts
of the world, particularly low- and middle-income countries (4) making it one of the most common forms of
potentially harmful body modification practices worldwide as they include potentially harmful over-the-counter
creams, putting them at greater risk for a variety of negative health outcomes. (7)
(8, 9)
The active ingredients used in skin lightening creams are hydroquinone, highly potent corticosteroids and
mercury salts. (10)

The use of skin lightening creams can be potentially dangerous and harmful and carry out several complications
ranging from dermatologic consequences include: epidermal atrophy, ochronosis, eczema, dermatitis, acne to more
serious health risks include diabetes, skin cancer, foetal toxicity , renal and liver impairment and failure. (8-13)

The harms caused by using skin lightening products extend from the acute or chronic long-term exposure to the
often hazardous chemical agents that are present in these products. (14) In addition, the damage from bleaching
products is often exacerbated when users mix skin bleaching products with household chemicals such as toothpaste,
laundry bleach, detergents and even automotive battery acid, a very common practice in some areas, to try to
enhance their effect. (8, 10)

With this global growing phenomenon only few studies were conducted in Saudi Arabia. Therefore more studies
need to be done to assess the magnitude of problem of usage of topical lightening agents among Saudi women.

This study aimed to study the practices of Saudi women regarding topical skin lightening agents.

Subjects and Methods:-


This is a cross sectional study covered different areas of the Kingdom of Saudi Arabia. It included women aged
between 16 and 60 years, Saudis and live in the kingdom permanently as well as has online access.

The minimum sample size for this study has been estimated using Epi-info software and found as 571 women.

Self-administered valid Arabic questionnaire has been used to collect data from the participants. It has been created
and used previously in KSA by Al-Ghamdi.(15) Permission to use the questionnaire was obtained from the author
though an e-mail communication. It includes 27 questions; personal information (age, marital status, educational
level, occupation and household average monthly income), detailed information regarding the use of skin lightening
agents such as the age at which the participants started using them, the duration and frequency of usage, source of
obtaining these agents, reason/s for usage using during pregnancy and lactation, money spent monthly on bleaching
agents, parts of bodies they applied these products to and the amounts (grams) applied. The women 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

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such as corticosteroids, hydroquinone and mercury, they were asked to choose the most dangerous component to
human health.

Using all online tools (face book, twitter, whats app, etc..), the questionnaire was distributed. Only Saudi women
living in KSA and aged between 16 and 60 years were asked to participate in the study by filling the questionnaire.
It was explained that the research concern is skin lightening agents not regular cosmetics.

Approvals from the local training committee and local ethical committee were obtained prior to study conduction.
Participants` permission (completing and sending the questionnaire was considered as consent).

Statistical Package for Social Sciences (SPSS) software version 22.0 will be used for data entry and analysis.
Descriptive statistics (number, percentage) and analytic statistics using Chi Square tests ( 2) to test for the
association and/or the difference between two categorical variables will be applied. P-value equal or less than 0.05
will be considered statistically significant.

Results:-
According to the study design, 605 subjects were included in the study, their mean age was 35.8 6.6 years, with a
range from 2050 years, slightly more than half of them (50.9%) were singles while 45.6% were married. Majority
of them (78.8%) were university and above graduated. More than one-third of them (37.7%) were students and
26.4% were employees. Household average monthly income ranged between 10001 and 20000 SR among 31.1% of
the participants whereas it exceeded 20000 SR among 10.9% of them.

As shown in figure 1, 65% of the participants (393 out of 605) were current users of topical skin lightening products
and 198 (32.7) had previously used these products. Thus, overall, 438 women out of 605 (72.4%) ever used topical
skin lightening products.

Details of using topical skin lightening agents among ever users are described in table 2. Almost half of them
(49.9%) obtained these preparations from the pharmacy without prescription whereas 10% from beauty and
cosmetic shops. The nature of the used agent was most frequently a mixture composed of a readymade drug at the
pharmacy (42.7%) or a beauty non-medical product (29.9%).

The commonest reported reasons for using these preparations were just to lighten the color of the skin (34.5%), to
heal pigmented areas like freckles (25.6%) or both (28.3%).

The age of the women when they first started using bleaching agents varied from 1 to 57 years (mean 21.3 6.8
years) and in 66.9% of them, it ranged between 16 and 25 years. Skin lightening products were used by 35.8%
participants at least once daily. The monthly cost of the skin lightening agents ranged between 4 to 3000 Saudi
Riyals (SR) (mean 173.9 310.1 SR). Seventy-seven women (18.9%) reported that they spent more than 200 SR per
month on skin lightening preparations. The amount of the skin lightening agent consumed per month ranged
between 1 to 1000 gm (mean 29.0 103.9 gm). Thirty-one women (11.3%) consumed more than 50 gm of skin
lightening agent per month. Additionally, 6.8% of women continued applying the skin lightening agents throughout
pregnancy whereas 15.9% did so during lactation.

Among current users, 13.6% had used skin lightening agents continuously for more than one year whereas 61.4% of
them had used them continuously between 2 and 12 months. Overall the duration of continuing use ranged between
one and 200 months (6.716.8). Table 3

Figure 2 shows that these agents were applied to the whole body in 11.9% of ever users whereas almost two-thirds
of them (61.8%) used the products on their faces, 46.7% used them on their necks and 24.9% used them on their
hands.

Almost one-third of the respondents (38.7%) reported that the colour of their skin returned to normal once they
discontinued the use of skin lightening products whereas 10.1% of then reported that their skin became even darker
than before use. Skin dryness was reported by 8.2% of users.

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Only 27.3% of the participants could recognize that Mercury is the most harmful chemical to human health, which
could be one of the components of skin lightening agents whereas cortisone was chosen by 41.5% of them.

About one-fifth (20.6%) of the participants believed that misusing skin lightening products could harm their skin
whereas 48.2% agreed that using slin lightening agents could harm their general health.

About one-third of the participants (32.4%) considered the use of skin lightening agents sold at herbal stores safe
whereas 24.6% of them would recommend the use of skin lightening sold at herbal shops to others. Almost two
thirds of the respondents (67.3%) wanted the color of their skin to be lighter than its normal color.

From figure 3, it is shown that 46.6% of the participants believed that lighter skin colour made them more beautiful,
whereas 42.5% believed that lighter skin colour made them more self-confident. More than one-third of them
(40.4%) used skin lightening agents to renew look. Only 12.3% of singles believed that lighter skin colour increase
chances of finding a spouse and 14.9% of married participants believed that it stabilizes marriage.

Fifty-two women (10.1%) reported that they would use skin lightening creams that gave fast results, even if the
components were unknown.

Table 3 showed that all studied socio-demographic factors were not significantly associated with current usage of
skin lightening agents.

Table 1:- Socio-demographic characteristics of the participants.


Variables Frequency Percentage
N=605
Age (years)
16-25 334 55.2
26-35 161 26.6
36-45 86 14.2
>45 24 4.0
Marital status
Single 308 50.9
Married 276 45.6
Divorced/separated 11 1.8
Widowed 10 1.7
Educational Level
High school or lower 128 21.2
University or higher 477 78.8
Occupation
Student 228 37.7
Unemployed 78 12.6
House wife 121 20.0
Employee 160 26.4
Others 20 3.3
Household average monthly income in Saudi Riyals
<2000
2000-5000 68 11.2
5001-10000 103 17.0
10001-20000 180 29.8
>20000 188 31.1
66 10.9

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Table 2:- Details of using topical skin lightening agents among women who ever used them (n=438)
Statements Responses Frequency Percentage
Method of obtaining the skin -Prescription 126 28.8
lightening agent -From the pharmacy without 214 49.9
prescription
-From herbal shops and open 44 10.0
markets
-Beauty and cosmetic shops. 54 12.3
The nature of the agent used -Is composed of a readymade drug 187 42.7
at the pharmacy
-Mixture composed at the 85 19.4
pharmacy
-Mixture composed at herbal shops 35 8.0
-Beauty product, non-medical
131 29.9
The reason behind the use -To heal pigmented areas like 112 25.6
freckles
-Just to lighten the color of the skin 151 34.5
-Both of the above reasons
-Others 124 28.3
51 11.6
Frequency of applying skin lightening Once daily 157 35.8
agent Twice daily 84 19.2
Three times daily 10 2.3
Not daily 158 36.1
Before a year 29 6.6
Using the agent during pregnancy -Yes 21 6.8
(n=311) -No 290 93.2
Using the agent during lactation -Yes 47 15.9
(n=295) -No 248 84.1
Monthly cost of the agent in Saudi <100 197 48.3
Riyals (n=408) 100-200 134 32.8
>200 77 18.9
Amount of cream you use monthly 10 211 76.7
(gms) (n=275) 11-50 33 12.0
>50 31 11.3
Age (years) at starting using skin 15 61 14.6
lightening agent (n=417) 16-25 279 66.9
>25 77 18.5
Duration of using skin lightening agents 1 66 25.0
continuously (Months) (n=264) 2-12 162 61.4
>12 36 13.6

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Table 3:- Socio-demographic factors associated with current usage of skin lightening products
Ever use of skin lightening 2 p-value
products
No Yes
N=167 N=438
Age (years)
16-25 (n=334) 86 (25.7) 248 (74.3)
26-35 (n=161) 46 (28.6) 115 (71.4)
36-45 (n=86) 30 (34.9) 56 (65.1)
>45 (n=24) 5 (20.8) 19 (79.2 3.48 0.323
Marital status
Single (n=308) 80 (26.0) 228 (74.0)
Married (n=276) 78 (28.3) 198 (71.7)
Divorced/separated (n=11) 5 (45.5) 6 (54.5)
Widowed (n=10) 4 (40.0) 6 (60.0) 2.99 0.393
Educational Level
High school or lower (n=128) 34 (26.6) 94 (73.4)
University or higher (n=477) 133 (17.9) 344 (72.1) 0.09 0.767
Occupation
Student (n=228) 60 (26.3) 168 (73.7)
Unemployed (n=76) 22 (28.9) 54 (71.1)
House wife (n=121) 31 (25.6) 90 (74.4)
Employee (n=160) 45 (28.1) 115 (71.9)
Others (n=20) 9 (45.0) 11 (55.0) 3.55 0.471
Household average monthly income in Saudi
Riyals
<2000 (n=68) 23 (33.8) 45 (66.2)
2000-5000 (n=103) 33 (32.0) 70 (68.0)
5001-10000 (n=180) 48 (26.7 132 (73.3)
10001-20000 (n=188) 45 (23.9) 143 (76.1)
>20000 (n=66) 18 (27.3) 48 (72.7) 3.68 0.451

212, 35.0%

Yes
393, 65.0%
No

Figure 1:- Prevalence of using skin lightening products among of Saudi females.

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61.8
70
60 46.7
50
40
24.9
30 18.3
11.9
20 7.2
5.9 3.8
10
0

Figure 2:- Areas for application of skin bleaching agents among the participants

50
45
40
35
30
25 46.6 42.5
20 40.4
15
10
5 12.3 14.9 11.5
6.6 2.5 5 4.1
0

Figure 3:- Reasons for ever using skin lightening agents among the participants (n=438)

Discussion:-
This study was carried out to fill a gap of knowledge regarding the magnitude of utilizing skin lightening agents
despite their dexterous health risk among Saudi women.

The prevalence of current utilization of skin lightening agents in the current study was 65% whereas that of ever
usage was72.4%. This figure agrees which those reported in different places of the world. Prevalence rates of 67.2%
has been observed in Singal, (16) Jordan (60.7%),(17) and Nigeria (72.4%). (18) In Malaysia, a rate of 60.6% has been
reported. (19) In Lahore,(20) a rate of 59% of skin lightening agents usage was reported while in Sudan, a rate of
55.4% was observed among university students. (21) However, it is lower than that reported in another Saudi study (
38.9%). (15) These figures are of great importance as the overuse of such preparations has various health outcomes.

In the current study, 13.6% had utilized skin lightening agents continuously for more than one year with an overall
duration ranged between one and 200 months. Al Ghamdi reported that the duration of the skin lightening ranged
between 1 to 150 months, (15) while in Senegal, the duration ranged between 1 to 420 months. (9)

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Skin lightening agents are harmful to general health at a level that is comparable or even exceeds the level of other
risk behaviours. (14) Despite of this fact, knowledge of the dangerousness of skin lightening agents is lacking in the
present study as Mercury which is the most dangerous constituent of skin lightening agents, was identified by only
27.3% of the participants as the most toxic product of these agents whereas 41.5% selected cortisone. Similar results
have been observed in another Saudi study. (16)

Regarding the amount of skin lightening cream used each month, it ranged between 1 to 1000 gm (mean 29.0
103.9 gm). In another Saudi study, it ranged between 2 and 600 g (mean 90.09 g month). In African countries like
Senegal,(9) the amount ranged between 15 and 350 month while in Nigeria, the amount ranged between 60 to 150
gram month.(22) The maximum amount used in the present study (1000 gm) is considered very high if we know that
45 gm of skin lightening cream is quite enough to cover the whole body. (15) The difference between our figures and
those reported in African countries is attributed to the fact that skin colour in African countries is dark black while in
Saudi Arabia, it is lighter.(15)

In the present study, 6.8% of women continued applying the skin lightening agents throughout pregnancy whereas
15.9% did so during lactation. Comparable results were observed in another study carried by Al Ghamdi in Saudi
Arabia where10.3% of women continued applying skin lightening agents during pregnancy and 20.8% during
lactation.(15) These figures are very low compared to those reported in Senegal where rate of application of skin
lightening products throughout pregnancy or lactation were 81% and 87%, respectively. (9)
In accordance with Hamed et al. (2010), (17) beauty and self-confidence were commonly identified as reasons for
using these agents in the present study as they reported that women who use skin lightening agents were more likely
to consider having a lighter skin colour plays a positive role in self confidence, perception of beauty, employment
and marriage opportunities compared with non-users.

In the current study, 11.9% of women applied skin lightening agents to their whole body. This figure is higher than
that reported in another Saudi study conducted among women visiting outpatient clinics (7.3%). (15) However, it is
much lower than figures reported from African countries (Nigeria 81.3% (22) and Senegal 92%).(9)

In accordance with others, (15, 17, 21) the chief area for application of skin lightening agents in the present study was
the face. This is could be due to the fact that the face is the beauty and attraction sign among females, also it has a
relatively small surface area, but the women might think that the white face is more beautiful than the black one
regardless the homogeneity of the face colour with other body areas.

Complications of continuous application of skin lightening agents reported in the present study were return of skin
colour to its normal skin colour or even to darker on, skin dryness and skin rash. These adverse effects prevent the
consumers to continue the application. Therefore, there is a need to aware the general population of women to seek
medical advice instead of continuing using these preparations without advice.

Among important limitations of the present study its cross-sectional design that doesnt prove causality. Also, it
includes women who had an internet access which limits the generalizability of results. However, it includes a
relatively considerable sample size as well as it faces an important health issue rarely investigated in Saudi Arabia

Conclusively, the utilization of skin lightening agents among Saudi women is a common practice, mostly without
prescription. Therefore we recommended supervising sale and marketing of these products, particularly the herbal
preparations that have unknown or harmful components and enhancing public awareness about the dangerous effects
of uncontrolled using of such agents.

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