Skin Bleaching: Agents

00:00 So hydroquinone is used for skin bleaching, and we do use hydroquinone for justifiable indications to treat disorders of hyperpigmentation. And it's the benchmark of treating disorders of hyperpigmentation.

00:17 It is safe and effective for disorders of hyperpigmentation when used appropriately by the correct primary care doctor.

00:27 As mentioned, it's the gold standard for treating hyperpigmentation and safe in the correct hands.

00:35 So what are some of the factors that increase the risk of side effects? Protracted administration using hydroquinone for long periods without any supervision.

00:48 Use of high concentrations.

00:50 In fact, a study that was conducted a long time ago by George Findlay in South Africa, who was a dermatologist, who actually coined the term ochronosis.

01:00 It showed that at that time, patients were using concentrations up to 10% of hydroquinone, whereas the recommended is about 4%.

01:11 So sometimes mixing with ingredients that enhance dermal absorption, for example resorcinol can increase the risk of side effects.

01:20 The application to large body surface areas is a problem because it means if you're using all over the body, there's increased absorption of the compound into the systemic area.

01:33 Lack of monitoring by trained dermatologists is a challenge because when you put a patient on hydroquinone, you know what are the side effects, you know how to advise the patient how frequently or less frequently, or whether they should stop the product.

01:49 So if you self-medicate, there's nobody to monitor any of this.

01:55 Again, lack of education on sun protective measures using sunscreens and sun avoidance may increase the risk of side effects.

02:05 Again, in the study that we conducted in South Africa to find out how many of the patients are using skin bleaching, we found that about 95% of them did not know that a use of skin bleaching products can lead to side effects and complications, and of late, we've even described a patient who developed skin cancer from using skin bleaching products. And there's a number of case reports that have also been described by a colleague of mine in Senegal, Professor Fatima Ali.

02:36 So if we look at the short term cutaneous complications, this could be irritant contact dermatitis, irritation from using the irritating products.

02:45 And this typically from concentrations that are higher than 4%, as I have mentioned, and the most common short term adverse events.

02:53 Sometimes when patients use this, we ask them to use the product less frequently every alternate day or twice a week to try and introduce the product slowly into the system and minimize side effects. Allergic contact dermatitis can also be a problem.

03:11 I spoke about exogenous ochronosis, which was first described in South Africa by George Finlay, and this is due to excessive or long term use of hydroquinone.

03:22 And then you get deposition of the pigment in the dermis.

03:27 And this is seen on histology as banana-shaped figures and hence the term ochronosis because you see ochronosis deposition in the dermis.

03:39 This is progressive hyperpigmentation mainly in sun-exposed areas.

03:45 On the picture here you can see the initial stages of exogenous ochronosis.

03:50 You can see the erythema and hyperpigmentation which can be easily misdiagnosed as melasma.

04:00 This condition progresses and you get pigment colloid milium and atrophy of the skin.

04:08 On the neck, you can see the papular and nodular lesions which look like caviar.

04:14 And these are the papules due to chronic or chronic pigmentation in the dermis.

04:21 So how do we treat this regrettable condition called ochronosis.

04:27 It's very challenging to treat ochronosis once it is established.

04:32 But the first things first, try and identify the products the patients are using and stop all suspected creams and try and be compassionate with the patient, not be judgmental because most of them, you know, they don't, didn't know that the products that they were using will cause the problem and there may be psychosocial issues related to it.

04:53 Sun protection is paramount.

04:55 As I mentioned before, broad SPF, broad UVA protection, UVB, and visible light. The skin needs to be to be moisturized because it becomes thin and very sensitive. It is really, really difficult to treat it the most.

05:09 It's a nightmare for dermatologists.

05:12 Cosmetic camouflage at times is our option because there's not much that we can do for a ochronosis.

05:22 The second product we're going to talk about is topical corticosteroids, which have become so common and commonly used in the last ten years or so because they are cheaper and easily available. When topical steroids are used extensively, particularly on larger surface areas, one can have systemic side effects, for example hyperglycemia, hypothalamic pituitary adrenal axis suppression, Cushing's syndrome, and hypertension.

05:53 Of course, one can also get avascular necrosis of the femoral head due to the systemic absorption of the steroids applied over a large surface area.

06:07 So what are some of the common adverse effects of topical steroid use? This is the most common side effect that we see.

06:15 Steroid induced acne and steroid induced acne is different from acne vulgaris that we spoke about.

06:24 You tend to get what we call monomorphic lesions.

06:27 Monomorphic, it's small lesions that look the same in terms of size.

06:32 And that tells us this is due to steroids.

06:35 And sometimes patients can get either open or closed comedones.

06:40 Skin atrophy and telangiectasia.

06:43 You can see on this picture the skin is thin.

06:46 You can see the blood vessels under the skin.

06:49 And you can get some small vessels that you see particularly on the shoulder there because the steroids, they break down the collagen and then the skin becomes thin.

07:00 And this actually sometimes is irreversible.

07:05 Hypertrichosis. This is due to excessive hair all over the areas that steroids have been used.

07:13 So this is another common side effect of use of topical steroids.

07:19 Perioral dermatitis. This may happen because of use of topical steroids for skin bleaching.

07:28 We also see this condition due to use of topical steroids in patients who have atopic eczema.

07:34 So that's why it's important for these patients to be followed up.

07:38 But once you stop the topical steroids the condition is reversible, fortunately. Another common side effect is tinea.

07:47 You can see on the right foot this is what we call tinea incognito, meaning that, you know, when you look at a patient with tinea corporis, you see the right edge on the area that is active. But in tinea incognito, you don't see the striking edge.

08:04 And it can be easily confused with eczema.

08:07 The patient on the right foot. You can see all the dystrophic nails due to fungal infection of the nails. We call it onychomycosis and the skin thinning on the left foot.

08:16 As you can see that the vessels are quite conspicuous and the skin is so thin.

08:21 And you can also identify the black knuckles that I spoke about.

08:29 What about mercury? So we spoke about hydroquinone.

08:32 We spoke about topical steroids.

08:34 Now we're discussing mercury.

08:36 This can often be found in so-called antiseptic soaps.

08:40 And some of the cutaneous complications include contact dermatitis, erythroderma, flushing, pupura and gingivostomatitis.

08:49 We spoke about the cutaneous complications of mercury.

08:52 Now we're moving on to speak about the systemic complications of mercury.

08:57 And the whole list of them is listed on the slide.

09:05 And mercury salts and pregnancy.

09:07 What's the relationship? You can have significant adverse effects on developing fetus.

09:13 And this can lead to various health issues in children.

09:18 It can also lead to learning disabilities, behavioral problems, and delays in speech acquisition and other side effects.

09:29 As I mentioned, glutathione seems to be the new kid on the block, and a number of our patients have been going for IV drips and taking oral tablets of glutathione for skin bleaching. So what is glutathione? It's an antioxidant that helps with neutralization of free radicals and protects cells from oxidative damage. It's sometimes used during chemotherapy to protect brain cells.

09:58 It's also used in prevention and prophylaxis of nerve disorders such as neuropathies.

10:05 It inhibits melanin via inhibition of Tyrosinase.

10:12 It's often misused as a skin-bleaching agent because of this other ability.

10:19 The side effects of glutathione include lighting of the hair color, hypopigmented patches, and depletion of natural hepatic stores of glutathione.

10:30 It can also cause exacerbation of H.Pylori and increased susceptibility to melanoma.

10:38 We are now going to speak about the last compound that is used for skin bleaching.

10:43 We spoke about four. This is the last one which is phenol.

10:47 It is a strong chemical compound that has been used historically as a skin-bleaching agent.

10:54 It has keratolytic properties as well as inhibitory effects on melanin production.

11:01 It can cause skin irritation and burns.

11:07 Skin bleaching heightens susceptibility to melanoma.

11:13 A number of cases have been reported in Senegal, where squamous cell carcinoma developed after skin bleaching on the face and on the neck.

11:25 It's always recommended that primary care physicians request the patients to bring all of their cosmetics that are used to help them identify the offending products.

11:36 If we don't ask the patients what products they are using, although they will have consulted with you, they will continue using those products because they do not know that they are the ones that are causing the problem.

11:48 Skin bleaching is a problem.

11:50 We have to fight it. We have to challenge it.

11:52 And we have to be advocates against skin bleaching and teach our patients that the best skin color is the one that you are born with.