Western society’s obsession with skin tanning is well recognised but we’re often less aware of the aggressive pursuit of fair skin by those with darker skin. In communities where light skin is associated with success, prestige and envy, women commonly turn to skin lightening products to achieve and maintain their desired complexion.

In India, the appeal of fair skin is deeply rooted in the nation’s culture and the caste system. Higher caste members traditionally had lighter skin and were less likely to be involved in manual work. Many years later, the ruling colonials had fair skin. And in the last century, film, TV and advertisements have been saturated with images of attractive western actresses with fair skin.

Skin lightening creams are reportedly the most popular product on the Indian skin care market, with around 60% of Indian women using the products daily. Local brands make up most of the market share, but in recent years international cosmetic companies have infiltrated the country.

Advertisements for Fair and Lovely, a well-known Indian-made product, imply that regular use will give the user flawless skin. The more important, but not-so-subtle message, however, is that using this product will advance her career or love life.

India is not alone here. Asian and African women also use these products, and they’re increasingly used by men. A 2005 survey published in the International Journal of Dermatology revealed that 92% of Nigerian men and women attending the skin clinic had reported using skin lightening creams over long periods to lighten and even out skin tone, or to improve the appearance of skin prior to an important event.

Ingredients

The skin lightening products available online promise a new and improved image, with names such as Looking Good, Fashion Flair, Crusader, Skin Success and Diva Maxima.

It’s difficult to be sure what is in these products because the manufacturers often don’t fully disclose the ingredients. Some ingredients — such as petroleum jelly, vitamin E and fruit acids — are harmless. They may also contain chemicals that reduce the concentration of melanin (which gives the skin its dark pigmentation).

But some creams contain toxic chemicals that can cause serious side effects. Mercury compounds have been used in skin lightening creams for many years, and excessive use has been linked to brain and kidney problems.

Hydroquinone, another common ingredient, can cause many side effects, including dermatitis (skin irritation), cataracts and blue-black skin discolouration. It may sometimes cause an offensive fish odour in the user.

Many skin lightening creams also contain steroids in doses up to 1,000 times higher than in creams used to treat eczema and other skin conditions. Steroid use can cause all sorts of complications such as thinning of the skin, acne, red stretch marks and discolouration.

Worse still, the steroids in these creams can act like cortisol, a hormone made by the body to deal with stress. Too much cortisol can cause a myriad of problems, including swelling of the face and abdomen, weight gain, thin skin that bruises easily, stretch marks, weak muscles, high blood pressure, diabetes, osteoporosis and depression.

It can also fool the body into ceasing cortisol production. So, if someone suddenly stops using these creams, they could become seriously ill because their stress hormones have been temporarily “turned off”.

The creams must be used continuously to maintain the bleaching effect, otherwise the skin will re-pigment. Sometimes the skin can even become “addicted” to the creams (in the form of a withdrawal rash), making it very difficult to stop using them.

Availability

Lightening creams are mostly manufactured in developing countries where their use is high. But they are also made in western countries, specifically for export to Africa and Asia.

In Australia, these creams are not available in mainstream outlets, but they’re inexpensive and easily accessible online. Most people using skin lightening creams in Australia would have sourced them from their home countries or over the internet. There is often little understanding of the health impacts of these products and from a clinician’s perspective, treatment and follow up is challenging.

Products available in Australia have some similar ingredients. Superfade facecream, which does not contain steroids, is marketed to fade skin blemishes. Creams containing low-dose steroids such as eumovate (used for eczema) are only available from pharmacists after special consultation. Stronger steroid creams can only be obtained with a doctor’s prescription.

My patients

As a doctor in an Australian public hospital, I’ve seen the effects of skin lightening creams first hand. A young African woman recently came to the hospital with dizziness, fatigue, and swelling of her face and abdomen. Her skin colouring was much lighter than the rest of her family and she had areas of bleached skin on her face, hands and neck. She had developed diabetes and her blood cortisol levels were almost undetectable.

We learnt she had been using two different skin lightening creams all over her body. She used the cream to achieve lighter skin and wasn’t particularly concerned about the side effects. She’d sourced the creams from her home country, and many of her African friends had also used them, experiencing similar problems.

It’s unclear how widespread the use of skin lightening creams is in Australia. But the first step to reducing their harm is for health professionals to be aware of their side effects and complications. Consumers also need to be aware of the hazardous effects of these products.

Perhaps with better awareness and the promotion of positive body image through public health campaigns, this practise may become less popular. But let’s not be naive: given the cultural underpinnings of skin lightening, change won’t happen overnight.