Two months after first going to hospital, a 65-year-old woman was dead – and her doctors are blaming the cosmetic creams she used on her face and body for decades.
The anonymous patient, from Togo, is one of a string of recent cases reported in medical journals of cancers in black African women linked to skin-lightening creams and lotions, prompting dermatologists to call for better regulation.
The melanin found in darker skin typically offers some protection against the sun damage which can cause cancers.
“Patients with black skin have a natural SPF of about 15, just by having pigmented skin,” says Prof Ncoza Dlova, head of dermatology at the University of KwaZulu-Natal, South Africa,. “If they remove that melanin [with skin lightening creams], they’re actually removing the natural protection.”
Estimates of skin lightening product use in African countries range from 25% to 80% of women. Lighter skin is often seen as more desirable, in a trend with complex drivers including values imported in the colonial era.
Dlova and colleagues are writing up a paper citing more than 55 cancer cases, from countries including Mali and Senegal.
“If we are getting self-induced skin cancer, then that’s a red flag and worrying,” says Dlova. “We have to do something about it.”
The market for skin lightening product is growing, with analysts predicting that the current market size of US$10.7bn (£8bn) will reach US$18.1bn by 2033. There are even reports of the products being used on babies and young children.
For Dlova, they are “a health hazard that needs to be addressed”. Almost every day, she says, her clinic in Durban will see someone with a skin problem linked to lightening products. “Of course, not all of them are coming with skin cancer … They come in with fungal infections that are resistant to the common treatment that we normally use. They present with pimples, referred to as steroid-induced acne, as well as rosacea. Some present with permanent stretch marks; all these complications are extremely common.”
The Togo patient had three large, painful, cancerous tumours on her neck, which she had tried to treat with antibiotics, antiseptics and traditional herbal poultices with no success before going to hospital. One of the tumours was removed, but the others were too close to blood vessels and she could not afford the recommended chemotherapy.
She told her doctors she had used creams that included topical hydroquinone and highly potent corticosteroids for about 30 years.
In another series of eight cancers, reported in Senegal, the women had used similar products for about 20 years on average. Two of those patients died.
Hydroquinone as a skin lightener has been banned in South Africa since 1990, and other African countries including Rwanda, Ivory Coast, Tanzania, Kenya, and Ghana followed suit. Those bans were prompted by serious concerns about an irreversible form of skin damage called ochronosis.
But regulation is often weak, and the products are reportedly still available from street vendors and cosmetic shops.
The use of steroids in skin lighteners is a newer phenomenon. Topical steroids are used in dermatology to treat inflammatory skin conditions such as eczema, but a side-effect is that they make skin lighter, a fact exploited for their use in cosmetics.
If the two problematic ingredients are used together they can have a “synergistic effect”, Dlova says.
The International League of Dermatological Societies (ILDS) has published an alert warning about the dangers of misuse of potent topical steroids, and is calling for governments to better regulate the products. The problem goes beyond Africa, says the ILDS president Prof Henry Lim, with the problem first raised by its members in India.
After South Africa’s hydroquinone ban, there was a lull in how frequently dermatologists encountered complications of skin bleaching, Dlova says “but again, in the last 10 years there was just a sudden eruption of the complications of skin bleaching again. Skin cancer per se had not been described before, it’s only been described recently. So obviously, things have got worse – because from irreversible pigmentation [ochronosis] to skin cancer, those are really red flags implying that we need to do something about it.”
While the desire for lighter skin is not new, Dlova suspects the rise of social media over the past decade has led to increased use, pointing to smartphone filters that make skin look smoother and lighter.
Tackling the issue will require action from many sectors – not only regulatory agencies.
“Marketing, social media and media all have a role to play – fashion, celebrities and all of that. If they use black models who are lighter in skin colour, the message they are conveying is that you are prettier, you can be a model, you are more attractive if you are lighter. So we need to ensure that the advertisements include diverse skin colours when they are choosing their models,” says Dlova.
She also wants to see skin health education in preschools to teach children to be proud of their natural skin, and to get across the message of using sunscreen.
Some black patients will have skin challenges including pigmentation disorders, she says, which may require creams with lightening ingredients. But these should be used under medical supervision.
Part of the ILDS advocacy will be asking pharmaceutical companies to make those prescription products more affordable, so that people do not need to turn to cheaper off-the-shelf products that may be dangerous.
