Skin diseases associated with the cosmetic use of bleaching products in women from Dakar, Senegal

Skin bleaching: a socioecological perspective

Skin bleaching is a behaviour that is pervasive globally. The chemicals used for skin bleaching are harmful and result in several medical complications, including dermatitis, kidney failure, neuropathy and skin cancer. The socioecological model illustrates skin bleaching risk factors and potential prevention strategies.

Patterns and Motivations of Topical Steroid Use for Skin Whitening in Jazan, Saudi Arabia: A Cross-Sectional Survey

Background The use of topical steroids for skin whitening is prevalent in many regions, including Saudi Arabia. This study aims to analyze the patterns, motivations, and demographic factors associated with the use of topical steroids for cosmetic purposes in Jazan, Saudi Arabia. Methods This cross-sectional survey was conducted online over three weeks. A structured questionnaire was distributed to adults residing in Jazan, collecting data on demographics, topical steroid use, motivations, and product sources. Descriptive statistics were used to analyze the data. Results Among the 340 participants, 173 (50.9%) reported using topical steroids for skin whitening. The majority of users were female (149, 43.8%) and aged between 20 and 30 years (78, 22.9%). Most participants had used topical steroids for less than a year (127, 73.4%), with usage predominantly in the evening (86, 49.7%). Topical steroids were primarily purchased from pharmacies (70, 40.5%), with significant monthly expenditure variability: 55 participants (31.8%) spent between 50 and 110 SAR, and 62 (35.7%) spent more than 150 SAR. Motivations for use included a preference for lighter skin (49, 28.4%) and treatment of melasma (42, 24.3%). Recommendations from friends (71, 41.0%) and TV advertisements (34, 19.8%) influenced product choice. Conclusion Topical steroid use for skin whitening is widespread among adults in Jazan, with a notable emphasis on cosmetic outcomes and substantial financial investment. There is a critical need for increased public education on the risks associated with topical steroids and enhanced professional guidance to promote safer usage practices.

Detection of Steroids in Topical Fairness Preparations Using Histamine Wheal Test

Topical corticosteroid (TC) abuse is a common, worldwide, problem. One of the recent emerging concerns is the adulteration of TC in fairness cream. The presence of TC in skin-whitening cosmetic creams can be detected by high-performance liquid chromatography (HPLC). Since HPLC is expensive, time-taking and not easily available, we suggest the use of histamine wheal test as a simple and inexpensive test to detect the presence of topical steroids in fairness cream.

Suspected inappropriate use of prescription and non-prescription drugs among requesting customers: A Saudi community pharmacists' perspective

Background

Inappropriate use of medications is a global health concern, and this is attributed to the increased accessibility to prescription and non-prescription (over-the-counter) drugs at community pharmacies. We investigated the inappropriate use of prescription and non-prescription drugs in community pharmacies based on the perspectives of the community pharmacists in Saudi Arabia.

Methods

This was a questionnaire-based, cross-sectional survey which employed convenient sampling (snowball technique) to recruit participants. Being a licensed practicing pharmacist in a retail chain or an independent community pharmacy was the inclusion criteria. Participants were asked to report the drugs they suspected of being inappropriately used along with the frequency, age and gender of the suspected customers. Pharmacists were also asked to mention the action taken to limit inappropriate use at their pharmacy.

Results

A total of 397 community pharmacists completed the questionnaire (86.9 % response rate). 86.4% of the pharmacists suspected some level of abuse or misuse to have occurred. After receiving the questionnaire, the pharmacists reported suspected inappropriate use as encountered during the past three months. Cumulative inappropriate use was reported 1069 times (prescription drugs - 530; non-prescription drugs - 539). The top three inappropriately used prescription-drug categories were gabapentinoids (22.5%), antipsychotics (17.5%) and topical corticosteroids (12.1%). Among non-prescription drugs, cough products (33.2%) ranked first, followed by cold and flu products (29.5%) and first-generation antihistamines (10.8%). The cross tabulations revealed that being in the age range of 26-50 years and being a male was significantly associated (p < 0.001) with abuse/misuse of antipsychotics, antidepressants, gabapentinoids, cough products and first-generation antihistamines. Eye products (Bimatoprost) and skin products abuse/misuse had significant association with female gender (p < 0.001).

Conclusion

The results of our study provide crucial information to the healthcare authorities regarding the medications that can be inappropriately used at the community pharmacies in Saudi Arabia which necessitates implementation of stringent dispensing regulations. Educational programs can be implemented to increase the awareness among public regarding the harmful effects of inappropriate use of drugs.

Our evolved understanding of the human health risks of mercury

Mercury (Hg) is a chemical of health concern worldwide that is now being acted upon through the Minamata Convention. Operationalizing the Convention and tracking its effectiveness requires empathy of the diversity and variation of mercury exposure and risk in populations worldwide. As part of the health plenary for the 15th International Conference on Mercury as a Global Pollutant (ICMGP), this review paper details how scientific understandings have evolved over time, from tragic poisoning events in the mid-twentieth century to important epidemiological studies in the late-twentieth century in the Seychelles and Faroe Islands, the Arctic and Amazon. Entering the twenty-first century, studies on diverse source-exposure scenarios (e.g., ASGM, amalgams, contaminated sites, cosmetics, electronic waste) from across global regions have expanded understandings and exemplified the need to consider socio-environmental variables and local contexts when conducting health studies. We conclude with perspectives on next steps for mercury health research in the post-Minamata Convention era.

Reliability assessment and validation of the post-acne hyperpigmentation index (PAHPI) in a population from Sub-Saharan Africa in Senegal

BACKGROUND

A post-acne hyperpigmentation index (PAHPI) has been developed in the United States to better compare therapeutic modalities. Our aim in this study was to validate the PAHPI score in patients with skin type VI from sub-Saharan Africa.

PATIENTS AND METHODS

The study was conducted in Dakar, Senegal. Twenty-one patients with Fitzpatrick skin type VI, aged 17 to 55 years, presenting hyperpigmentation secondary to acne were included. Ongoing use of skin bleaching products or acne treatments was allowed. Four trained dermatologists rated the patients using the PAHPI. A narrow-band reflectance spectrophotometer (Mexameter MX-18, Cologne, Germany) was used to measure the degree of pigmentation of involved and adjacent skin on 6 representative facial lesions.

RESULTS

The average inter-rater reliability (weighted Kappa) showed substantial agreement for intensity (0.67), moderate agreement for number (0.53) and fair agreement for lesion size (0.28). Inter-rater reliability for the total PAHPI was excellent for both day 1 and day 2 (interclass correlation coefficient of 0.87 and 0.85, respectively; P<0.0001). Intra-rater reliability for total PAHPI ranged from 0.83 to 0.93 (P<0.0001). PAHPI scoring thus demonstrated excellent reliability both between and within raters. The association was moderate to substantial for all raters on both days (range for rho on day 1: 0.531 to 0.815; range for rho on day 2: 0.448 0.762). The correlations between the Mexameter (Courage and Khazaka) measurements and PAHPI scores showed moderate to substantial agreement.

CONCLUSION

Although tested primarily in African American women to date, PAHPI is also valid for patients from sub-Saharan Africa.

Awareness, Perception, and Utilization of Skin Lightening Agents Among Females of Asmara, Eritrea: A Cross-Sectional Study

Background

The use of skin lightening agents (SLAs) is common among African females with black skin color. Although they usually contain harmful ingredients and can cause complications, their use remains to be a common practice. This study was conducted to assess the awareness, perception, and utilization of SLAs among females residing in Asmara, Eritrea.

Methods

A cross-sectional analytical study using a quantitative approach was conducted in representative samples of all beauty salons available in Asmara from May to July, 2021. The study participants were selected using two-stage stratified cluster sampling and data were collected through a face-to-face interview using a structured questionnaire. Descriptive analysis and logistic regression, at bivariate and multivariate level, were performed.

Results

The study enrolled 721 females and 684 completed the study. The majority of the respondents had the perception that SLAs can make someone light colored (84.4%), look beautiful (67.8%), trendy and fashionable (55.0%), and white skin is more attractive than dark skin (58.8%). About two-thirds (64.2%) reported they had previously used SLAs, mainly influenced by friends (60.5%). Approximately 46% were current users, while 53.6% stopped it mainly due to adverse effects, fear of adverse effects and ineffectiveness. A total of 150 products including natural ingredients were mentioned being used to lighten the skin, and Aneeza, Natural face, and Betamethasone containing brands were among the top used products. The occurrence of at least one adverse effect due to the use of SLAs was 43.7%, while 66.5% were satisfied with the use of SLAs. Additionally, employment status and perception of SLAs were found to be determinants of being a current user.

Conclusion

Utilization of SLAs, including products containing harmful or medicinal ingredients, was prevalent among the females of Asmara city. Thus, coordinated regulatory interventions are recommended to tackle unsafe practices and raise public awareness to promote the safe use of cosmetics.

A Cross-Sectional Study of the Knowledge, Practice, and Attitude Towards Skin-Lightening Products Among the General Population in the Western Region of Saudi Arabia

Introduction Skin bleaching is a growing phenomenon worldwide and is becoming an increasing problem. Several skin-lightening products (SLPs) containing mercury, hydroquinone, and corticosteroids have impacted serious dermatological, nephrological, and neurological side effects. There is relatively little regulation, and the products are easily accessible and inexpensive. Justifications and beliefs for the use of these products vary from culture to culture, and there is little previous research on the use and abuse of skin-lightening cosmetics among Saudi women. This study examines the knowledge, attitudes, and practices of the public in the western region of Saudi Arabia regarding SLPs to understand the situation better. Methodology An observational, cross-sectional, questionnaire-based study was conducted over two months between July and August 2022. A 29-question survey was used to collect data from the general population. The study included all women residing in the western region of Saudi Arabia. Non-Arabic speakers were excluded. RStudio (R version 4.1.1) was used to analyze the data. Results A total of 409 participants were included in this study; In general, 146 (35.7%) of the participants said they had ever used an SLP. More than two-thirds (67.1%) had been using them for less than a year. In terms of the most common site of SLPs application, women reported applying the products to the skin of their face (74.7%), elbows (47.3%), and knees (46.6%). Use of SLPs differed significantly across participants' ages, with the proportion of SLP users in the 20-30 age category significantly higher than non-users (50.7% vs. 36.9%, p=0.017), and non-users were more common than users within the age category >50 years. In addition, the proportion of SLP users relative to educational level was significantly higher among participants with a bachelor's degree than the proportion of non-users (69.2% vs. 54.0%, p = 0.009). Conclusions The results of this research show that Saudi women frequently utilize topical lightening products. Therefore, regulation and controlling the use of bleaching products is essential, as is educating women about the risks involved with this practice. The misuse of bleaching products should decline with greater awareness.

A Systematic Review of Mercury Exposures from Skin-Lightening Products

BACKGROUND

The Minamata Convention on Mercury (Article 4) prohibits the manufacture, import, or export of skin-lightening products containing mercury concentrations above 1 ppm. However, there is a lack of knowledge surrounding the global prevalence of mercury-added skin-lightening products.

OBJECTIVE

The objective of this study was to increase our understanding of worldwide human mercury exposure from skin-lightening products.

METHODS

A systematic search of peer-reviewed scientific literature was performed for relevant articles in four databases (PubMed, Web of Science Core Collection, Scopus, and TOXLINE). The search strategy, eligibility criteria, and data-extraction methods were established a priori. The search identified 2,303 unique scientific articles, of which 41 were ultimately deemed eligible for inclusion after iterative screens at the title, abstract, and whole-text levels. To facilitate data extraction and synthesis, all papers were organized according to four data groups a) "Mercury in products," b) "Usage of products," c) "Human biomarkers of exposure," and d) "Health impacts."

RESULTS

This review was based on data contained in 41 peer-reviewed scientific papers from 22 countries worldwide published between 2000 and 2022. In total, we captured mercury concentration values from 787 skin-lightening product samples [overall pooled central median mercury level was 0.49μg/g; interquartile range (IQR): 0.02-5.9] and 1,042 human biomarker measurements from 863 individuals. We also synthesized usage information from 3,898 individuals and self-reported health impacts associated with using mercury-added products from 832 individuals.

DISCUSSION

This review suggests that mercury widely exists as an active ingredient in many skin-lightening products worldwide and that users are at risk of variable and often high exposures. These synthesized findings identify data gaps and help increase our understanding of the health risks associated with the use of these products. https://doi.org/10.1289/EHP10808.

Quantitative multilayered assessment of skin lightening by photoacoustic microscopy

BACKGROUND

With the emergence of various new skin-lightening products, there is an urgent need to scientifically evaluate the efficacy and toxicology of these products, and provide scientific guidance for their use based on physiological differences between individuals. Visualized imaging methods and quantitative evaluation criteria play key roles in evaluating the efficacy of skin-lightening products. In order to quantify the changes in the multilayered morphology and endogenous components of human skin before and after the use of lightening products, high-resolution three-dimensional (3D) imaging of human skin is required.

METHODS

In this study, photoacoustic microscopy (PAM; SSPM-532, Guangdong Photoacoustic Medical Technology Co., Ltd.) was used to capture the morphological structures of human skin and reveal skin components quantitatively. The efficacy and safety of skin-lightening products were evaluated by measuring skin melanin concentration and observing skin morphology. The melanin concentration in the epidermis was obtained by examining the linear relationship between photoacoustic (PA) signals. Further, the epidermal thickness and the melanin distribution were obtained in the cross-sectional (x-z) and lateral (x-y) images. Finally, the efficacy of skin-lightening products was evaluated according to the concentration and distribution of melanin in the epidermis, and the safety of cosmetics was assessed by observing the vascular morphology in the dermis.

RESULTS

PAM noninvasively could assess the multilayered morphological structures of human skin, which allowed for quantification of epidermal thickness and melanin concentration of different skin sites. Based on this, the efficacy and safety of skin-lightening products in multilayer structures were quantitatively evaluated.

CONCLUSIONS

As a quantitative imaging method, PAM, has the potential to accurately evaluate the use of skin-lightening products. The method can also be extended to assessments within the larger field of aesthetic medicine.

Exogenous ochronosis associated with hydroquinone: a systematic review

Exogenous ochronosis is a potential side effect associated with hydroquinone, and treatment is often unsatisfactory. Our study objectives were to review data on hydroquinone-associated ochronosis to determine risk factors for patients experiencing this adverse event. On September 27, 2020 (MEDLINE/PubMed), and October 30, 2020 (Scopus and Web of Science), databases were searched for "ochronosis + hydroquinone" by both authors to reduce risk basis. PRISMA reporting guidelines were used to select 56 articles with a total of 126 patients with hydroquinone-associated ochronosis. Included articles described hydroquinone-associated ochronosis. Articles were excluded if they had irrelevant content, were non-English language text, and were non-case studies. Full text articles were assessed and recorded. Cross-tabulation analysis was performed on categorical data, and Fisher exact test was performed. Ochronosis was most often reported in middle-aged women (53.2%), of African descent (45.2%), Black races (55.5%), and Fitzpatrick skin types V-VI (52.4%). It was most frequently reported with unknown and hydroquinone concentrations greater than 4% (32.5 and 35.7% cases, respectively). Median duration of use was 5 years, with only four cases reported with courses 3 months or shorter and eight cases reported with use 1 year or less. All patients presented with facial blue-black or gray-blue macules in a reticulate, lace-like fashion. Histopathology consistently showed solar elastosis and brownish-yellow, 'banana-shaped' fibers between degenerated collagen fibers of the papillary dermis. Based on these findings, we conclude that hydroquinone in concentrations above 4% and in treatment courses longer than 3 months may be associated with new-onset ochronosis.

A preliminary study of skin bleaching and factors associated with skin bleaching among women living in Zimbabwe

Background

Skin bleaching was reported to be commonly practiced among women and Africa was reported to be one of the most affected yet the subject is not given much attention in public health research in Zimbabwe despite the adverse effects of skin bleaching on health.

Method

This study was an exploratory cross-sectional survey to explore skin bleaching, skin bleaching patterns and factors associated with skin bleaching among women living in Zimbabwe. An online self-administered questionnaire was sent out to women on social network i.e. WhatsApp, Facebook, LinkedIn and Twitter.

Findings

A total number of 260 respondents, mean age 31.69 (SD, 8.12) years participated in the survey. The prevalence of skin bleaching among the participants was 31.15%. The major reason reported for skin bleaching was to have smooth and healthy skin alongside other factors such as beauty, gaining social favours for example getting married and good jobs. Occupation, complexion and marital status were associated with skin bleaching. The odds of skin bleaching for participants who were employed was 1.45(95% confidence interval [CI],0.32–1.91);p-value 0.02, dark skinned participants 2.56(95% CI, 0.76–2.87);p-value 0.01 and unmarried participants 2.87(95% CI,0.29–3.58);p-value 0.03.

Conclusion

Evidence from the research suggests skin bleaching might be common among women living in Zimbabwe and possibly poses serious health threats to the women. Skin bleaching seems to be deep rooted in colourism. The colourism seems to be taken advantage of by the cosmetic industry which produce the potentially hazardous products which promise the revered light skin to women but which comes with a price. However, the study provides a base for future studies to explore more on skin bleaching practices among women living in Zimbabwe.

Inorganic ions in the skin: Allies or enemies?

Skin constitutes a barrier protecting the organism against physical and chemical factors. Therefore, it is constantly exposed to the xenobiotics, including inorganic ions that are ubiquitous in the environment. Some of them play important roles in homeostasis and regulatory functions of the body, also in the skin, while others can be considered dangerous. Many authors have shown that inorganic ions could penetrate inside the skin and possibly induce local effects. In this review, we give an account of the current knowledge on the effects of skin exposure to inorganic ions. Beneficial effects on skin conditions related to the use of thermal spring waters are discussed together with the application of aluminium in underarm hygiene products and silver salts in treatment of difficult wounds. Finally, the potential consequences of dermal exposure to topical sensitizers and harmful heavy ions including radionuclides are discussed.

Developing a latent class analysis model to identify at-risk populations among people using medicine without prescription

INTRODUCTION

There exist limited strategies to address the issue of topical medication without prescription (MWP) use.

MATERIAL AND METHODS

A survey with pre-coded questionnaires was conducted with 210 patients following up in the dermatology clinic of a tertiary care center. The knowledge and attitude scores were regressed against demographics and exploratory practice questions, and latent class analysis was carried out to check any particular set of characteristics associated with study subpopulations.

RESULTS

Forty-seven (22%) participants were found using topical antimicrobial containing MWP. Participants with good knowledge score had 3.41 (95% C.I. = 1.68-7.33), 2.99 (1.37-6.73), and 2.49 (1.26-5.15) times association with opting of distance as the prime reason for availing topical MWP, habit of always reading the accompanying drug leaflet, and understanding that OTC topical medication may change the effect of the already prescribed drugs. Participants with good attitude score showed 2.76 (1.50-5.13) times association with limiting the use of steroid containing topical MWP. Latent class analysis identified one subset of participants having lesser knowledge and attitude scores and quoted financial reasons for the procurement of MWP; however, it was found to have greater income as compared to remaining participants.

CONCLUSION

The strategy to identify the target patient audience so as to deliver patient education intervention programs, regarding safe and effective use of MWP was built.

Study of Clinical Profile of Patients Presenting with Topical Steroid-Induced Facial Dermatosis to a Tertiary Care Hospital

Background:

Topical corticosteroids (TCs) are widely used for various indications in dermatology. However, these can cause a plethora of symptoms if overused or abused. Topical steroid damaged face is a relatively new entity which was described in 2008. TC abuse cause a myriad of side effects viz, erythema, telangiectasia, acne, acneiform eruption, hyper/hypopigmentation, rosacea, and photosensitivity when used inappropriately.

Aim:

The aim of the study was to ascertain the prevalence, demographics, and clinical presentations of TC abuse on faceamong our population.

Materials and Methods:

This was a cross-sectional study performed at dermatology department of a tertiary care teaching hospitallocated in eastern India for 1 year. All patients with facial dermatoses attending the outpatient department were asked about use of TC in recent past and those with positive history were included. A detailed clinical evaluation was undertaken and various demographic and clinical data were recorded.

Results:

A total of 316 patients (53 males, 263 females) presented with topical steroid-induced facial dermatoses during the entire study period. Majority of them used these agents on suggestion of close friends and relatives, pharmacists, television commercials, and doctors. Mometasone in the form “No-Scar” preparation was the most commonly abused topical steroid in our study. The most common side effects encountered were steroid-induced acne (45.2%) or flare of pre-existing acne followed by erythema and telangiectasia (21.2%), hypertrichosis (6.6%), rosacea (2.2%), and atrophy (1.5%). The most common reason for abusing TC was to get a fairer skin tone.

Conclusion:

Our study reports the clinical patterns of TC abused facial dermatoses. The fantasy to get a fairer skin among the people of our country has led to the abuse of topical corticosteroids. We conducted this study to create awareness among these patients about the dreadful effects of steroid misuse.

Is skin bleaching a moral wrong? An African bioethical perspective

Focusing on black communities in Africa, in this paper, I attempt an African bioethico-aesthetic deconstruction of the falsehood in colorist definitions of beauty purveyed by the migration of non-surgical cosmetics to Africa. I provide a novel ethical evaluation of the act of skin bleaching using principles of the African ethic of communion. I argue that skin bleaching is morally wrong to the extent that it promotes disharmonious relations and false identity in the beauty industry in Africa. Drawing on scientific studies that link toxic ingredients in many skin-bleaching products to adverse health effects, I discuss the public health impact of bleaching cosmetics and other problems occasioned by their strategic expansion into African markets. I propose that there is an urgent need for a relational ethic of polycentric governance that would harmoniously regulate the production and distribution of cosmetic products across regions in order to avoid the exploitation of consumers in black African societies, while also protecting consumers' right to make informed choices through education.

Squamous Cell Carcinoma Associated with Cosmetic Use of Bleaching Agents: About a Case in Ivory Coast

Voluntary skin depigmentation is defined as a set of procedures for obtaining skin clarification for cosmetic purposes. Skin cancers are possible complications, but rarely reported. We describe a case observed in Ivory Coast. A 52-year-old Ivorian woman consulted the Dermatology Department of the University Hospital of Treichville, Abidjan for an ulceration of the middle third of the right clavicle evolving for 10 months. A diagnosis of squamous cell carcinoma (SCC) was confirmed by histological examination of the tumour biopsy. Retroviral serology (HIV) was negative. An excision of the tumour was performed. The postoperative consequences were simple. We report a case of SCC following long-term use of depigmenting cosmetic products in a female phototype VI. SCC is the most common skin cancer among black Africans. It is secondary to precancerous lesions or takes place on a damaged skin. Concerning our patient, the onset of this carcinoma could be associated with the carcinogenic effect of hydroquinone and topical corticoids used for a long time. In addition, no precancerous lesion or preexisting condition were found. The chronic evolution without healing was in favour of a neoplastic origin achieved through the analysis of the biopsy sample.

Intersectionality in the Liminal Space: Researching Caribbean Women's Health in the UK Context

African Caribbean women in the UK who are diagnosed with chronic illnesses that are related to overweight and obesity are more likely to experience poorer outcomes than their White British counterparts. It is then important to increase understandings of how women from this ethnic group perceive health with relation to body shape and size so that interventions can be developed to prevent the development of such conditions and to improve outcomes. As such, it is important to develop research methodology that encourages participation in health research from African Caribbean women and enables the capture of in-depth data that gives insight into the nuances of health understandings related to the body and the social realities in which they exist. This paper details the methodological framework of The Big Talk project, an investigation that sought to develop a novel approach to conducting health research with seldom heard communities. The concept of intersectionality, as used in Critical Race Theory, was applied as a theoretical tool for exploring the dynamics of societal power and where this power intersects across the lived realities of race, ethnicity, gender, sexuality, (dis)ability, and class. For this research, these intersections are explored for African Caribbean women and how they relate to concepts of health, body shape, and size. This research study was conducted in spaces identified as liminal spaces for African Caribbean women: talk radio programmes; hairdressing salons and; local community groups. A Black feminist epistemological approach was used to facilitate the collection of data. The data that emerged from these liminal spaces are not necessarily definitive answers on health for African Caribbean women, but rather illuminate alternative ways of understanding the social world from the perspective of those subject to power. This phenomenon makes liminal spaces intersectional in their construction and in taking such an approach to analysis could enable finely grained details of discourses regarding health, wellness and the body to be gathered. The importance of this understanding can help to improve preventive health interventions for African Caribbean women.

Skin-lightening patterns among female students: A cross-sectional study in Saudi Arabia

Background

Skin-lightening products (SLPs) are commonly used worldwide, and their improper use and overuse is becoming a burden on health care workers, including dermatologists.

Objective

This study aimed to determine the characteristics, determinants, preferences, and side effects of the use of SLPs among Saudi female students and their association with mental health.

Methods

A cross-sectional analytic study, using a self-administered prevalidated questionnaire, was conducted among female students in the Aljouf region of Saudi Arabia. We used the consecutive nonprobability sampling technique to recruit participants. The questionnaire contained demographic data, two questions about knowledge of SLPs, eight questions regarding perceptions of fair skin, and three proxy scales for mental health (depression, posttraumatic stress disorder, and Internet addiction).

Results

The mean age of the participants (± standard deviation) was 29 ± 9.6 years. Of the 760 responders, 427 (56.2%) used SLPs; all were women with relatively light skin (types III-V). There was a unanimous positive perception of lighter skin tone among women. The participants used skin-lighteners for cosmetic and medical conditions (67.2% and 17.5%, respectively). The practice was significantly associated with poor mental health status, poor level of knowledge, and lower sociodemographic status (p < .05).

Conclusions

The use of SLPs is highly prevalent among Saudi female students. Users believe that fairer skin is associated with beauty and social advantage. Female students with a lower economic status and poor mental health are more prone to overuse SLPs. A need exists for targeted public health campaigns to raise public awareness about uncontrolled skin lightener usage.

Skin lightening practices, beliefs, and self-reported adverse effects among female health science students in Borama, Somaliland: A cross-sectional survey

Background

Skin-lightening (SL) products are common, especially in Africa. Adverse effects from these products represent a public health concern. Use of these products in Somaliland is unknown.

Objective

This study aimed to determine the prevalence of use of SL products among female health science students, beliefs about these products and practices, and adverse effects experienced.

Methods

This was a cross-sectional survey of a convenience sample of female health science students at Amoud University in Borama, Somaliland.

Results

Of the 400 students who were invited to participate, 265 completed the survey (response rate: 66%). Mean participant age was 21.1 years (standard deviation: 2.0 years). The majority of students were single (91.2%) with a Fitzpatrick skin type of 3 or darker (94.2%). Past or present use of SL products was reported by 25.6% of participants, and 52.2% admitted to current use. Compared with non-users, more SL product users agreed that lighter skin color gives a woman more confidence, helps a woman have better job opportunities, and increases chances of getting married. They also agreed that advertisements on television for SL products influence a women’s preference for a lighter skin tone (p < .05). More than 60% of participants were unsure what active ingredients were in their SL products. Only 9% denied any undesirable adverse effects, and the remainder reported an array of local and systemic adverse effects. The vast majority realize that SL products may cause undesirable local (92%) and systemic (89%) adverse effects.

Limitations

Generalizability is limited because a nonrandomized convenience sample from one university was studied. Response bias also may have skewed results.

Conclusion

Use of SL products among female health science students in Somaliland is common, and causes cutaneous and systemic adverse reactions. Use appears influenced by beliefs about the benefits of lighter skin color. Education is needed on the proper use of these products, how to avoid harmful products, and how to prevent complications.

Skin lightening products' violations in Europe: An analysis of the rapid alert system for dangerous non-food products 2005-2018

BACKGROUND

Skin lightening products containing dangerous levels of chemicals pose a serious health concern for consumers. However, to date, the extent of these products in Europe has not been extensively studied. The aim of this study was to determine whether harmful skin lightening products are available for sale in Europe and what violations exist regarding their composition.

MATERIALS AND METHODS

We queried the Rapex database, which is the Rapid Alert System for dangerous non-food products among 31 European countries, to identify skin lightening cosmetics reported between 2005 and 2018, and presented a detailed summary of these notifications.

RESULTS

In the years 2005-2018, of all violations regarding cosmetics, 26.3% concerned skin lightening products. In the database, 266 reports on skin lightening products were identified. Most of the notifications came from Germany (17.29%), France (17.29%), Portugal (15.41%), and the United Kingdom (11.65%). The majority of the registered products originated from non-European countries, mainly the Côte d'Ivoire (29.70%). The major reason for the violation was the content of hydroquinone, mercury, or clobetasol propionate.

CONCLUSIONS

Hazardous skin lightening products that are not in line with European cosmetics legislation are available on the European market. Most of the products are imported. The main risk associated with these products is the content of hydroquinone, mercury, and clobetasol propionate. It is important to bear in mind that this study focuses on the Rapex system and other sources of information may exist. Based on our findings, a more comprehensive evaluation by international authorities is justified.

Prevalence and patterns of skin toning practices among female students in Ghana: a cross-sectional university-based survey

OBJECTIVE

The use of skin toning products has a deep historical background in low and middle-income countries. Yet, there is no empirical evidence on the prevalence, and patterns of skin toning practices among university students in Ghana. This study sought to examine the prevalence, patterns and socio-demographic factors associated with skin toning practices among female university students in Ghana using a sample of 389 undergraduate female students.

RESULTS

40.9% of respondents had practised skin toning within the last 12 months. Also, 51.3% used skin toning products such as creams (38.9%) and soap or gel (35.5%) to treat a skin disorder. Respondents aged 21 years were more likely to use skin toning products (AOR = 0.400, CI 0.121-1.320), those who had dark skin (AOR = 3.287, CI 1.503-7.187), attended public school (AOR = 1.9, CI 1.1-3.56) and those who attended girls school were more likely to use skin toning products (AOR = 10.764, CI 4.2-27.3). Furthermore, those who were in level 400 (AOR = 49.327, CI 8.48-286.9) and those receiving more than 500 cedis were also more likely to use skin toning products (AOR = 2.118, CI 0.419-10.703). Policy interventions that seek to reduce skin toning practices among university students should consider micro and broader socio-demographic factors.

Skin Bleaching Among African and Afro-Caribbean Women in New York City: Primary Findings from a P30 Pilot Study

INTRODUCTION

The application of skin bleaching products to inhibit melanogenesis is a common practice within the African diaspora. Despite the adverse health effects of skin bleaching, rigorous studies investigating skin bleaching behavior among these populations in the United States are limited. In our P30 pilot study, we explored predictors of skin bleaching practice intensity among African and Afro-Caribbean women.

METHODS

In collaboration with our Community Engagement Core, we conducted a cross-sectional study to investigate the relationship between demographic and psychosocial predictors and skin-bleaching-related practice patterns among African and Afro-Caribbean women in New York City.

RESULTS

Among the 76 participants recruited, the median age at the initiation of skin bleaching was 19.5 (16-25) years, yielding a median duration of 13.5 (6-23) years. Although pregnant women were not actively recruited for the study, 13.2% (n = 10) of the participants used skin bleaching products while pregnant or possibly breastfeeding. Nativeness and education were associated with various components of skin bleaching practice intensity, including duration of skin bleaching, daily use of products, and bleaching of the entire body. Participants' perceived skin-color-related quality of life was not associated with skin bleaching practice intensity.

CONCLUSION

Skin bleaching is a habitual practice that likely requires culturally sensitive interventions to promote behavioral change. The existence of prenatal and postnatal exposure to mercury, hydroquinone, and other potentially harmful chemicals in skin bleaching products highlights an urgent need to explore the adverse effects of skin bleaching practices on birth outcomes and the growth and neurodevelopment of young babies.

Adverse cutaneous reactions to skin care products on the face vary with age, but not with sex

BACKGROUND

Adverse skin reactions to skin care products have been increasing in recent years. However, to date, these reactions have not been well characterized.

OBJECTIVE

To describe the symptoms, clinical signs and frequency of adverse cutaneous reactions to skin care products on the face in males vs females of various ages.

PATIENTS AND METHODS

All outpatients diagnosed with adverse cutaneous reactions to skin care products on the face examined by dermatologists at the Dermatology Hospital of South Medical University between November 1, 2016 and October 31, 2017, employing a questionnaire and an interview, were eligible. The associations of adverse cutaneous reactions with age and sex were analysed.

RESULTS

A total of 433 outpatients, accounting for 0.12% of all outpatients, were assessed. Of these, 223 patients, including 204 females and 19 males, aged 4 to 75 years, were eventually diagnosed with adverse reactions to skin care products on the face. Eighty-two per cent of patients experienced pruritus, 80% showed erythema, and 48% showed visible swelling. The incidence rates of both xerosis and oedema correlated positively with age, whereas acne-like lesions were negatively associated with age, but not with sex.

CONCLUSIONS

Our results indicate that pruritus, xerosis and erythema are common adverse cutaneous reactions to facial skin care products. These reactions vary with age, but not with sex. Vigorous safety testing should precede the marketing of skin care products.

The global prevalence and correlates of skin bleaching: a meta-analysis and meta-regression analysis

PURPOSE

To estimate and investigate the global lifetime prevalence and correlates of skin bleaching.

METHODS

A meta-analysis and meta-regression analysis was performed based on a systematic and comprehensive literature search conducted in Google Scholar, ISI Web of Science, ProQuest, PsycNET, PubMed, and other relevant websites and reference lists. A total of 68 studies (67,665 participants) providing original data on the lifetime prevalence of skin bleaching were included. Publication bias was corrected using the trim and fill procedure.

RESULTS

The pooled (imputed) lifetime prevalence of skin bleaching was 27.7% (95% CI: 19.6-37.5, I²  = 99.6, P < 0.01). The highest significant prevalences were associated with: males (28.0%), topical corticosteroid use (51.8%), Africa (27.1%), persons aged ≤30 years (55.9%), individuals with only primary school education (31.6%), urban or semiurban residents (74.9%), patients (21.3%), data from 2010-2017 (26.8%), dermatological evaluation and testing-based assessment (24.9%), random sampling methods (29.2%), and moderate quality studies (32.3%). The proportion of females in study samples was significantly related to skin bleaching prevalence.

CONCLUSION

Despite some limitations, our results indicate that the practice of skin bleaching is a serious global public health issue that should be addressed through appropriate public health interventions.

Topical Steroid Damaged/Dependent Face (TSDF): A Study from a Tertiary Care Hospital in Eastern India

Background:

Awareness against abuse of topical corticosteroids (TC), especially over the face, has been going on for last 5 years in India. In spite of that we are getting lots of cases in our hospitals.

Aims:

The aims of this study were to ascertain the demographics, magnitude and clinical features of TC misuse on the face among the dermatology outpatient department (OPD) attendees and to analyze its causes.

Methods:

This study was conducted in a tertiary care medical center of eastern India. Patients with relevant facial dermatoses were asked about their current use of topical formulations and confirmed to be TSDF were included in the study.

Results:

A total of 748 patients with facial dermatoses were screened, of which 271 (36.22%) were using TC. Of them mostly young adults between 20 and 29 years (37.10%) were using TC. Average duration between starting of use of medication and the onset of symptoms was 5 months. Ninety-eight (36.16%) patients were using topical corticosteroid for the treatment of acne and 74 (27.30%) were using as depigmenting cream. About 108 (39.85%) patients bought medicine over the counter being recommended by pharmacist/shop owner. Rosacea like features with photosensitivity was the most common adverse effect found in 79 (29.15%) patients whereas comedonal acne/acne exacerbation were found in 68 (25.09%) patients. Most of them (227, 83.76%) were unaware about the side effects of steroids.

Conclusions:

TC misuse in patients with facial dermatoses is still quite common even after efforts to grow the awareness among population.

Misuse of Topical Corticosteroids for Cosmetic Purpose in Antananarivo, Madagascar

This cross-sectional study was conducted in Antananarivo, Madagascar, from June to September 2012. We aim to evaluate the misuse of TC on the face for cosmetic purpose and the adverse effects due to its application. A questionnaire-based analysis was done among females who use topical corticosteroids on the face for cosmetic purpose. Of the 770 women questioned, 384 (49,8%) used topical corticosteroids for cosmetic purpose whose mean age was 38 years (range 16-73 years). Two hundred and sixty-one females (68%) used TC combined with handcrafted cosmetics, and 123 (32%) used TC alone. "Pandalao," which contains salicylic acid, peppermint oil, lanolin, powder of Juanes de Vigo (mercury powder), and Vaseline, is the most handcrafted cosmetic combined with TC in our study (used by 29,4% respondents). Only one (0,26%) had obtained the TC by physician's prescription, 234 (61%) from cosmetic retailers, 92 (23%) directly from local pharmacies, 49 (12%) from beauticians, and 15 (4%) from unspecified sources. Lightening of skin color was the main reason for using TC in 44,8% of respondents in the absence of any primary dermatosis. Pigmentation disorders (63,2%) and cutaneous atrophy (52,1%) were the most adverse effects noted.

Use of skin-lightening products among selected urban communities in Accra, Ghana

BACKGROUND

The practice of skin lightening has been reported from North America, Europe, Asia, and Africa. In literature, some prevalence rates exceed 50%, and both sexes are involved. Common agents used include hydroquinone, mercury, corticosteroids, and caustic agents. The agents are easily accessible and affordable with very little regulation. Cutaneous and systemic side effects occur but do not appear to be a deterrent, as the notion of light skin as a surrogate for beauty is strong. In Ghana, anecdotal reports of high bleaching rates among certain urban communities resulted in a study supported by the Food and Drugs Authority to determine various facets of this practice.

METHODS

A cross-sectional study among adults in selected urban fishing communities of Accra was undertaken. Consecutive cases were enrolled after written informed consent. A questionnaire was administered, followed by physical examination and clinical photographs. Descriptive statistics were used to analyze the data.

RESULTS

Of the 555 participants from the three communities, prevalence was 279 (50.3%). Duration of use ranged from 2 months to 17 years. Approximately 212 (76%) used more than one product, and 231 (82%) used agents on their face and body. Dermatological features were hypopigmentation 270 (96.8%), other color changes including ochronosis 241 (86.4%), changes in consistency 141 (50.3%), striae 157 (56.3%), and infections 42 (15.1%).

CONCLUSIONS

The prevalence of skin bleaching was 50.3% in these communities, which is high considering the adverse effects from the practice. We recommend regulation of products by enforcing the law, more education, and a population prevalence study.

[Pityriasis versicolor in infants: unusual clinical presentation and role of corticosteroids used as depigmenting agent for cosmetic purposes in the mother]

We report two cases of Pityriasis versicolor (PV) in infants aged 12 and 18 months. The latter were brought to medical attention because of hypochromic and achromic, round macules involving the limbs and the face. Physical examination of their mothers showed voluntary depigmentation for cosmetic purposes due to the use of corticosteroids and hydroquinone, on average, over a 5-year period. The scotch tape test performed in one of the infants and his mother showed short filaments and clusters of spores. Treatment was based on ketoconazole. After 8 weeks, all patients reported favorable outcomes despite the persistence of some hypochomic macules. The peculiarities of this study are, on the one hand the topography of the lower limbs and on the other hand a positive family history of PV whose occurrence is favored by the use of depigmenting agents based on corticosteroids. Corticosteroids favor the atrophic and achromic feature of the lesions. Indeed, achromic lesions on the lower limbs were described in adults undergoing artificial depigmentation.

Topical Corticosteroid Misuse: The Scenario in Patients Attending a Tertiary Care Hospital in New Delhi

INTRODUCTION

Irrational use of Topical Corticosteroid (TC) is quite common in India due to unrestricted availability and use of TC not only by general public but also by physicians and chemists due to quick relief of symptoms in different dermatological conditions.

AIM

The present study was conducted to evaluate and analyse the prevalence of misuse of TC and the causes behind misuse of TC among patients in a dermatology outpatient department in New Delhi.

MATERIALS AND METHODS

This was a cross-sectional observational questionnaire based study conducted over a period of 5 months (1^st June 2015 to 30^th November 2015). Patients were questioned and assessed for misuse of TCs in terms of indication, dose, frequency, duration and source of recommendation of TC.

RESULTS

During the study period, 256 (11.77%) patients presented with inappropriate use of TC out of 2174 patients attending OPD of dermatology unit of a government hospital. A total of 250 patients presented with adverse effects of TC resulting from the misuse of these drugs. There were 60%female patients and 20-29 years (38%) was the most common age group affected. We found fungal infection (38%) was the most common reason of abuse followed by facial acne (29%) and lightening of skin colour (8.4%). Friends and family (33.2%) were found to be the most influencing factors for misuse of TC. Betamethasone (72.8%) was the most commonly used TC preparation and tinea incognito (26.4%) followed by facial acne (25.6%) were the most common side effect experienced.

CONCLUSION

Outcome of the misuse of TC could be dreadful and the cause for same lies at all levels- patients, family, physicians and the regulatory authorities.

Knowledge about, attitude toward, and practice of skin lightening products use and its social correlates among university students in five Association of Southeast Asian Nations (ASEAN) countries

BACKGROUND

The aim of this study was to investigate the knowledge about, attitude toward, and use of skin lightening products (SLP) and its social and psychological correlates among university students from five Association of Southeast Asian Nations (ASEAN) countries.

METHODS

In a cross sectional survey, 3259 undergraduate university students (Mean age = 20.5 years, SD = 1.6) from five ASEAN countries responded to an anonymous questionnaire. Multivariate logistic regression analysis was used to identify associations between sociodemographic characteristics, knowledge, attitude, poor mental health, and SLP use.

RESULTS

Overall, 79.1% of the students were aware that the use of SLP can harm the skin, and 30.1% knew the active ingredients of SLP. Most students had a positive perception of having a lighter skin tone and SLP. Overall, the prevalence of SLP use over the past 12 months was 30.7%, 16.7% of male, and 30.0% of female students, ranging from 13.4% in Myanmar to 69.4% in Thailand. In multivariate logistic regression analysis, among women, older age, coming from a poorer family, residing in an upper middle income country, awareness of active skin lightening ingredients, and poor mental health were associated with SLP, while among men, not aware of the negative effects of SLP and awareness of active skin lightening ingredients and poor mental health were associated with SLP use.

CONCLUSION

A high prevalence of SLP use was found in a large sample of ASEAN university students, and several social and mental health-related risk factors were found that may help in guiding interventions.

Skin Bleaching and Dermatologic Health of African and Afro-Caribbean Populations in the US: New Directions for Methodologically Rigorous, Multidisciplinary, and Culturally Sensitive Research

Skin-bleaching practices, such as using skin creams and soaps to achieve a lighter skin tone, are common throughout the world and are triggered by cosmetic reasons that oftentimes have deep historical, economic, sociocultural, and psychosocial roots. Exposure to chemicals in the bleaching products, notably, mercury (Hg), hydroquinone, and steroids, has been associated with a variety of adverse health effects, such as Hg poisoning and exogenous ochronosis. In New York City (NYC), skin care product use has been identified as an important route of Hg exposure, especially among Caribbean-born blacks and Dominicans. However, surprisingly sparse information is available on the epidemiology of the health impacts of skin-bleaching practices among these populations. We highlight the dearth of large-scale, comprehensive, community-based, clinical, and translational research in this area, especially the limited skin-bleaching-related research among non-White populations in the US. We offer five new research directions, including investigating the known and under-studied health consequences among populations for which the skin bleach practice is newly emerging at an alarming rate using innovative laboratory and statistical methods. We call for conducting methodologically rigorous, multidisciplinary, and culturally sensitive research in order to provide insights into the root and the epidemiological status of the practice and provide evidence of exposure-outcome associations, with an ultimate goal of developing potential intervention strategies to reduce the health burdens of skin-bleaching practice.

Mercury, hydroquinone and clobetasol propionate in skin lightening products in West Africa and Canada

Skin lightening products are types of cosmetics (creams, gels, lotions and soaps) applied voluntarily on skin. Several of these products contain a variety of active ingredients that are highly toxic. Among those toxic agents, the present study focuses on mercury, hydroquinone, and clobetasol propionate. Out of the 93 lightening soaps and 98 creams purchased in large city markets in sub-Saharan West Africa and in small ethnic shops in Canada, 68-84% of all creams and 7.5-65% of all soaps exceeded regulatory guidelines for at least one active ingredient when considering different regulations. Mercury was found in high concentrations mainly in soaps, while hydroquinone and clobetasol propionate concentrations exceeded US FDA standards in some creams for all countries included in our study. Concentrations of the three compounds declared on labels of soaps and creams usually did not correspond to concentrations actually measured, particularly for mercury and hydroquinone. Overall, our results indicate that most studied skin-lightening products are potentially toxic and that product labels are frequently inaccurate with respect to the presence of toxic agents.

Burden of fungal infections in Senegal

Senegal has a high rate of tuberculosis and a low HIV seropositivity rate and aspergilloma, life-threatening fungal infections, dermatophytosis and mycetoma have been reported in this study. All published epidemiology papers reporting fungal infection rates from Senegal were identified. Where no data existed, we used specific populations at risk and fungal infection frequencies in each to estimate national incidence or prevalence. The results show that tinea capitis is common being found in 25% of children, ~1.5 million. About 191,000 Senegalese women get recurrent vaginal thrush, ≥4 times annually. We estimate 685 incident cases of chronic pulmonary aspergillosis (CPA) following TB and prevalence of 2160 cases. Asthma prevalence in adults varies from 3.2% to 8.2% (mean 5%); 9976 adults have allergic bronchopulmonary aspergillosis (ABPA) and 13,168 have severe asthma with fungal sensitisation (SAFS). Of the 59,000 estimated HIV-positive patients, 366 develop cryptococcal meningitis; 1149 develop Pneumocystis pneumonia and 1946 develop oesophageal candidiasis, in which oral candidiasis (53%) and dermatophytosis (16%) are common. Since 2008-2010, 113 cases of mycetoma were diagnosed. In conclusion, we estimate that 1,743,507 (12.5%) people in Senegal suffer from a fungal infection, excluding oral candidiasis, fungal keratitis, invasive candidiasis or aspergillosis. Diagnostic and treatment deficiencies should be rectified to allow epidemiological studies.

[Cutaneous depigmentation in black female population for cosmetic purposes: results of a KAP survey conducted in Abidjan (Ivory Coast)]

INTRODUCTION

Cutaneous depigmentation for cosmeticis purposes is a widespread practice among black African women. It has many complications that have been well documented for decades. However, the reasons of practitioners are not well known. The aim of our study was to understand the motivating reasons of these women in order to conduct a communication campaign for behavior change.

METHODS

We performed a cross-sectional KAP survey (Knowledge/Attitudes/Practices) at the Dermatology Department of the University Hospital of Treichville (Abidjan) Data were analyzed using Epi Info 3.5.1. and 6.04 software.

RESULTS

Practitioners were mostly young urban single, literate and professionally active women (20-40 years). Cutaneous depigmentation and its consequences were known to women, however, they thought that women with the lightest complexion were more attractive. They were influenced by media and friends. The most frequently observed complications were exogenous ochronosis and stretch marks. The local means of communication remained what essentially sustained the information needs of these women, because they help them to change their behavior.

CONCLUSION

The development of local communication strategies for behavior change seems necessary to stop the phenomenon of cutaneous depigmentation for cosmetic purposes in black female population in Abidjan.

Skin lightening practices: an epidemiological study of South African women of African and Indian ancestries

BACKGROUND

Cutaneous adverse sequelae of skin lightening creams present with myriad skin complications and affect dermatology practice, particularly in sub-Saharan Africa where such products are widely used, with a prevalence of 25-67%.

OBJECTIVES

To examine the skin lightening practices of both African and Indian women living in South Africa.

METHODS

A cross-sectional survey was undertaken in the general outpatient departments of two regional university hospitals in Durban, South Africa. All consenting African and Indian women aged 18-70 years were recruited and asked to complete a questionnaire.

RESULTS

Six hundred women completed the questionnaire, of whom 32·7% reported using skin lightening products. The main reasons cited were treatment of skin problems (66·7%) and skin lightening (33·3%). Products were purchased from a variety of sources. Twenty-five percent reported using sunscreen.

CONCLUSIONS

The use of skin lightening cosmetics is common among darkly pigmented South African women, including those of both African and Indian ancestries. Despite more than 20 years of governmental regulations aimed at prohibiting both the sale of cosmetics containing mercury, hydroquinone and corticosteroids, and the advertising of any kind of skin lightener, they are far from having disappeared. The main motivations for using these products are the desire to treat skin disorders and to achieve a lighter skin colour. Television and magazine advertisements seem to influence women's choice of these products and, thus, would be efficient channels for raising public awareness about the dangers of using uncontrolled skin lighteners.

Prevalence of Topical Steroid Misuse Among Rural Masses

Background:

A lot of cosmetic and Ayurvedic products containing unlabeled depigmenting agent and steroids are available readily over the counter sale. The side effects of these products are not documented and can lead to adverse effects of continuous usage.

Objective:

By this study, we aimed to find out the true nature of the above problem and it's implication in the Indian rural scenario.

Methodology:

All patients attending dermatology department during the period of 3 months from May to June 2013 for skin diseases were enquired about unsupervised use of any cosmetic product on their facial skin, duration of use, any side effect experienced through the prescribed questionnaire.

Results:

Total 50 patients were recruited for the study. Out of which, 48% were males and 52% were females. Seventy-four percent of people had applied topical products/steroids in an attempt of attainment of fair complexion, 14% for melasma, 8% for acne induced hyperpigmentation, and 4% for dark circles. About 80% people had obtained one or the other products over the counter sale, 8% had followed the attractive advertisements, 8% had started the application on the recommendation of friends/family while only 4% people had correctly gone through the proper channel to consult a dermatologist.

Conclusion:

The problem of topical products or steroids abuse is rampant and significant, and unless and until immediate steps are taken to root out this problem from our setup, the condition will become worse all the more.