Skin Bleaching: Epidemiology and Etiology

00:01 Welcome to our lecture on skin bleaching.

00:06 What is skin bleaching? We use the following synonyms for skin bleaching.

00:12 Some people refer to it as skin lightening, toning, whitening and fading. What does it mean to bleach your skin is actually an act of changing one's normal skin color. Remember, the operating word here is normal skin color to a lighter shade than what you are naturally born with.

00:35 So skin bleaching is a global phenomenon and we look at the history of skin bleaching.

00:42 Ancient civilizations used natural substances like plant extracts and minerals to lighten their skin for cosmetic or cultural reasons.

00:53 During the colonial era, this introduced Western beauty standards to Africa and other countries, which often favored light-skinned tones.

01:06 This influence contributed to the proliferation of skin bleaching products and practices.

01:13 In India, for example, the caste system and skin bleaching has been shown to reflect deep-rooted social hierarchies and notions of beauty.

01:23 More on skin bleaching and its impact.

01:26 The modern media, including television, magazines and social media, have perpetuated the notion that lighter skin is more desirable, leading to increased pressure on individuals to bleach their skin.

01:41 More often I sometimes when I see patients and they look at me and they say, doctor, I want to look like you.

01:47 And I tell them, you've got the most beautiful skin.

01:50 They have dark skin, brown skin, and that is still fine.

01:53 Some of the social implications on skin bleaching can also have a problem because this leads to discrimination and reinforcing colorism within communities, especially where individuals with lighter skin are often favored over those with darker skin.

02:17 What about regulatory efforts in some countries? Well, in some countries they have implemented regulations to control the sale and distribution of skin bleaching products, including banning certain ingredients or requiring warning labels about the risks associated with their use.

02:36 There have been advocacy campaigns promoting self-acceptance and challenging societal beauty standards that prioritize lighter skin, aiming to foster appreciation for diverse skin tones and combat the stigma associated with darker skin.

02:58 If one looks at the historical practices skin bleaching has had its historical roots in the USA, dating back to the early 20th century, when products containing mercury and hydroquinone were commonly used to lighten the skin.

03:14 During the civil rights movement, there was a shift towards embracing African American identity and natural features, leading to a decline in the popularity of skin bleaching among some segments of the population.

03:30 Despite progress in promoting diversity and acceptance of various skin tones, Eurocentric beauty standards continue to influence perceptions of attractiveness in the US, with lighter skin often being associated with success and desirability, and this is a global phenomenon.

03:48 It's not only unique to the United States.

03:53 A number of advocacy and education campaigns have been initiated.

03:59 There are ongoing advocacy efforts aimed at promoting self-acceptance and challenging societal beauty, standards that prioritize lighter skin, advocating for greater representation and appreciation of diverse skin tones in media and popular culture.

04:17 We are also embarking on an advocacy to teach people or to influence people, to realize that the natural skin that we are born with is the best skin that you have.

04:31 We shall talk about this at some later stage.

04:36 So skin bleaching for cosmetic purposes is a global phenomenon, as I have mentioned, with highest rates in Africa, Asia, the Caribbean, the Middle East and South America.

04:48 There's a high prevalence in immigrant populations in North America and Europe, and some individuals have moved to other countries.

04:57 They try and bleach their skin to try and merge with the new countries that they've moved to to try to to camouflage and also try to be more or better accepted.

05:11 So if one looks at the prevalence of skin lightning in African countries, it ranges between 25 and 67%.

05:19 In South Africa, where we looked at a number of patients in a public hospital to see how many patients were actually bleaching their skin.

05:27 Our prevalence was about 33%.

05:33 So why do people bleach their skin? In numerous cultures, less skin pigmentation is frequently equated with higher social status and physical attractiveness. Some people bleach their skin or use bleaching compounds to treat dark skin-specific problems, and this could be due to post-inflammatory Hyperpigmentation or other causes of hyperpigmentation.

06:07 So this is more like justifiable use of products, but it has to be monitored and treated by dermatologists. There are, of course, other social and psychological factors that contribute to skin bleaching.

06:22 If one looks at colourism, it is prejudice and discrimination against individuals with darker skin tone, and this could be another factor that motivates people to bleach their skin.

06:39 So to understand how different skin bleaching agents function, we need to take a closer look at melanin production.

06:47 This is the pathway of melanin production and the products that I have listed.

06:52 They act and the different parts of this flow diagram.

06:58 As we mentioned before in our basic science lecture.

07:01 Melanin is stored in melanosomes and it's transported via the dendrites towards the keratinocytes and then expelled into the extracellular space and then gets inside the cytoplasm of the keratinocyte, forming the protective melanocyte umbrella.

07:18 So how do bleaching agents work? What is their mechanism of action? If we look at hydroquinone, which is the benchmark of the pigmentation agents, it inhibits tyrosinase activity and the conversion of dihydroxyphenylalanine to melanin.

07:37 Topical corticosteroids and mercury salts, they inhibit the effects on melanogenesis.

07:43 And of late, many patients are using corticosteroids more than the other compounds because these are easily available from the markets, from the stores and from the drug pharmacies.

07:55 Some caustic agents have also been used, and they inhibit melanogenesis through toxic effects on melanocytes. This is another new kid on the block, glutathione. It's become quite popular in recent years, and this acts by indirect inhibition of tyrosinase enzyme.

08:14 And of course, phenol inhibits tyrosinase activity.

08:19 So how do we recognize the patients that bleach their skin? You know, from my experience as a clinician, many patients that will present with complications of skin bleaching. And when you ask them what product are you using for skin bleaching, they will deny that they are bleaching their skin.

08:37 And because some of them are embarrassed by the fact that they're trying to change their skin color. So I think as primary healthcare physicians, we need to show compassion and and empathy and try and find out and not be judgmental and find out why patients are bleaching their skin, because the psychosocial nuances to skin bleaching. So the following slides are going to show you how do you recognize those patients who are bleaching their skin, but they are denying the fact that they are bleaching their skin. The first one is looking at the knuckles.

09:13 This can be a sign of skin bleaching in these areas.

09:17 The skin around the joint is thicker and absorbs less of the pigmenting agent.

09:21 This results in a clear contrast to the bleached skin.

09:25 There's no, it's not specific to skin bleaching, but it can be found in other medical conditions, for example, Addison's disease and B12 deficiency or other thyroid dysfunctions.

09:37 There's also another sign that we've picked up, which we call the hand to face contrast, because most people bleach their skin.

09:46 You'll find that there's a huge contrast between the color of the face and the hand.

09:52 So you'll find that the hand is darker compared to the face.

09:56 That on its own, shows that the patient is bleaching their skin.