Misuse of Topical Corticosteroids for Cosmetic Purpose in Antananarivo, Madagascar

A clinico-epidemiological study of different dermoscopic patterns in hyperpigmented facial lesions in a tertiary care centre

Introduction

Facial pigmentation is a common presentation of patients attending dermatology out patient department (OPD) and is of great concern to patients. Facial pigmentation may be multifactorial and is only rarely diagnosed accurately by a detailed history and clinical examination. Pigmentary disorders cause psychological distress and negatively impact the quality of life of an individual.

Aims and Objectives

(1) To study different dermoscopic patterns in facial melanosis. (2) To estimate the frequency of different dermoscopic patterns.

Materials and Methods

Patients with facial hyperpigmentation attending the dermatology OPD were recruited after taking their written consent. A detailed history was taken to collect demographic data. Clinical examination and dermoscopy were done in all patients. Biopsy was done as and when required. Descriptive statistics has been used to describe the quantitative data. Qualitative data were presented as frequency and percentage for clinical and dermoscopic patterns.

Results

The study included 100 patients with 15 different facial melanoses. The most common age group affected was 21-40 years in 53 (53%) cases. The female-to-male ratio was 1.63:1. Melasma was reported as the most common cause of facial melanosis constituting 49 (49%) of the total cases. Out of the total melasma cases, epidermal melasma constituted 22 (45%) cases, dermal melasma constituted four (4%) cases and mixed melasma constituted 23 (47%) cases. Other cases included were lichen planus pigmentosus (14; 14%), facial acanthosis nigricans (14; 14%), periorbital hyperpigmentation (7; 7%), post-inflammatory hyperpigmentation (4; 4%), exogenous ochronosis (2; 2%), lentigines (2; 2%), frictional melanosis (2;2%), and one case each of Becker's nevus, nevus of Ota, olanzapine-induced hyperpigmentation, Riehl's melanosis, macular amyloidosis, and tanning.

Conclusions

Melasma was reported as the most common cause of facial melanosis. The most common dermoscopic feature was accentuated pseudopigment network. The study is beneficial in understanding the different clinical and dermoscopic patterns of facial melanosis, thus helping the physician to effectively manage the conditions and reduce the need of biopsy.

Limitations

(1) A small sample size. (2) Histopathological correlation was not done in all cases.

Questionnaire-Based Study of 392 Women in Abbottabad, Pakistan, to Evaluate the Types of Cosmetic Products Purchased Between December 2018 and March 2019 and Their Associated Adverse Events

BACKGROUND Cosmetics are applied topically to enhance appearance and are commonly used by women of all ages. Cosmetics contain many chemical agents, but the incidence of adverse reactions is low, possibly due to underreporting. This questionnaire-based study included 392 women to evaluate information on the types of cosmetics purchased between December 2018 and March 2019, their use by the women surveyed, and their associated adverse events. MATERIAL AND METHODS A cross-sectional study was conducted among 392 women in Abbottabad, Pakistan, using a pre-structured and validated questionnaire to evaluate information on the types of cosmetics, their use, and their associated adverse events. Part 1 of the study collected information about demographics. Part 2 contained a total of 11 items, and collected the frequency of use of cosmetic on skin and hair care products. Part 3 consisted of 4 items and collected information about problems encountered due to the use of cosmetics. RESULTS In the winter season, 47.7% (n=187) of women preferred chemical-based cosmetic products, while 30.9% (n=121) preferred Ayurvedic products. Among commonly used cosmetic products, 26.9% (n=106) of women used foundations. The most frequently used skin care product was face wash 39.5% (n=155). The most prevalent adverse events related to cosmetics were pimples (19.9%, n=78), redness (17.6%, n=69), and eye discomfort (15.8%, n=62). Furthermore, 51.3% (n=201) strongly agreed that cosmetics aid in getting a whiter complexion. CONCLUSIONS The survey concluded that most women preferred cosmetics with a chemical base, which are associated with rashes, redness, and acne. It is important to encourage cosmetovigilance and awareness campaigns among cosmetic product sellers and users.

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.

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 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.

Spreading of Dangerous Skin-Lightening Products as a Result of Colourism: A Review

The use of bleaching products can have a medical or cosmetic purpose; in the latter case, skin whitening is most widespread in countries where darker skin tones prevail and can be driven by psychosocial, cultural and economic reasons. Skin-whitening products containing highly toxic active ingredients (in particular mercury derivatives, hydroquinone and corticosteroids) are easily found on the market; the use of these depigmenting agents can be followed by a variety of adverse effects, with very serious and sometimes fatal complications, and is currently an emerging health concern in many countries. This article concisely discusses the reasons for the current prevalence of skin lightening products and provides an overview of the skin lightening agents that pose a threat to human health. The review also reports market surveillance data on the circulation of banned skin lighteners in Europe, obtained through the Safety Gate system.

Topical Steroid Damaged Face: A Cross-Sectional Study from Saudi Arabia

Corticosteroids are one of the anti-inflammatory drugs that are used widely by dermatologists. Significant local adverse effects can happen if topical corticosteroids (TCs) are used incorrectly. This study aimed to assess the prevalence of facial TCs misuse and its adverse effects. This was cross-sectional research: a self-reported questionnaire was distributed among a population of Saudi Arabians aged 16 years and above who were using TCs consecutively. Statistical analysis was performed using SPSS version 26. A total of 611 participants were enrolled in the survey: 401 (65.6%) were university graduates, while 187 (30.6%) were below high school level of education. The number of participants using TCs was 279 (45.7%), while 332 (54.3%) did not use steroids topically. The most used TCs were Mometasone furoate 0.1% cream (18.2%), followed by Fusidic acid/Betamethasone cream (16.7%). A total of 46 reported facial TCs’ side effects. Peeling (52.2%) was the most reported side effect, followed by redness (41.3%). In conclusion, the use of facial TCs among the Saudi population is not uncommon (16.5%). A large population are not aware of the side effects of the unsupervised use of TCs. An effort should be made to increase awareness of the adverse effects of TCs.

Attitude Toward Using the Triple Combination Bleaching Formula and Related Outcomes: A Cross-Sectional Study

Introduction

Kligman’s formula is a topical triple combination consisting of hydroquinone, tretinoin, and topical corticosteroid. It has recently become widely popular among the general population for different purposes. Its improper use can lead to unsatisfactory results and unpleasant side effects.

Aim

This study aimed to assess the attitude, satisfaction, and complications related to topical usage of Kligman’s formula among the general population in Saudi Arabia.

Materials and methods

A cross-sectional study was conducted among the general population of Saudi Arabia. A self-administered questionnaire was distributed among the targeted population using an online survey. The questionnaire includes socio-demographic characteristics, assessment of attitude, and satisfaction in using Kligman’s formula. Data were tabulated and cleaned, and all statistical analyses were performed.

Results

A total of 292 participants met the inclusion criteria (26 males vs. 266 females) with a mean age of 26.9 (SD 7.71) years. Nearly 40% of participants showed a positive attitude in using Kligman’s formula, while 46.9% were satisfied with using it. The most common reason for using Kligman’s formula was to lighten the skin (55.8%), while skin redness was the most commonly reported adverse effect. Factors associated with increased attitude and satisfaction were using Kligman’s formula based on a doctor’s prescription and regular follow-up with a dermatologist.

Conclusion

The general population showed an improper attitude toward using Kligman's formula. However, a better attitude and satisfaction rate can be seen among those using Kligman's formula with prescription and those who regularly visit a dermatologist.

Pharmacists’ Insights and Behaviors in Preventing the Misuse of Topical Corticosteroids in Pakistan: A Mixed-Method Study

Topical corticosteroids (TCs) misuse has become a common issue for healthcare professionals and patients, particularly in Pakistan, as no stringent laws or rules are prohibiting the selling of over-the-counter medicines. The present study was designed to examine pharmacists’ insights and behaviors regarding TCs and their potential role in preventing the misuse of TCs in Pakistan. The study was a cross-sectional mixed-methods research design (phase 1, quantitative; and phase 2, qualitative) conducted from January to June 2021. The pharmacists working in various settings in Karachi were approached through different social media platforms. Data were collected through a web link of an online questionnaire with 30 closed-ended questions. Different statistical methods were employed for tabulating the quantitative data, while inductive thematic analysis was directed to classify themes from the qualitative data and to conclude findings. The mean cumulative knowledge score was 10.59 ± 1.63. The community pharmacists knew more about the available over-the-counter TCs (p = 0.041). The experienced pharmacists were more conversant than fresh pharmacists, regarding the mode of action (p = 0.008), choice of TC potency (p = 0.001), and most common local and systemic adverse effects of TCs (p = 0.001). Overall, respondents had a favorable attitude, with more than 80% agreeing that pharmacists could ensure that important safety issues are communicated with patients, and assist considerably in avoiding TC misuse. Analysis of data has produced 7 themes, 10 sub-themes, and 30 categories. Major themes included: use and misuse of TCs, adverse drug events due to TCs, cosmeto-vigilance, patient education, referral to a physician, and future perspectives for preventing TC misuse. The respondents were well versed with the dilemma of TCs misuse, and they considered patient characteristics, free availability of TCs, and lack of physician-pharmacist coordination as the major reasons. The major barriers for patient education stated by nearly all the respondents were a lack of time and lack of material/information for counseling. They emphasized the need for stringent legal strategies and the enforcement of current drug-control regulations, so that TCs are not supplied without appropriate prescriptions. The present findings indicate that pharmacists had appropriate knowledge and a positive attitude towards their potential role in preventing the misuse of TCs. Further education and sensitization in areas of deprived knowledge will undoubtedly aid in the prevention of TCs misuse by the community.

Impact of Abuse of Topical Corticosteroids and Counterfeit Cosmetic Products for the Face: Prospective Demographic Study in Basrah City, Iraq

BACKGROUND

Topical corticosteroids are highly effective compounds that are now widely used in dermatology for the treatment of various autoimmune and inflammatory disorders. Many corticosteroids are misused for diverse indications such as pigmentation, acne, pruritus, fungal or bacterial infections, rashes, and numerous other conditions. These products contain various constituents, most of which have hazards or toxic elements.

OBJECTIVE

The aim is to raise awareness among individuals in the city of Basrah, Iraq about the uses and abuses of applying fake products to the face to inform the consumers about potential harmful adverse effects.

METHODS

This study was a prospective multi-center clinic questionnaire of a demographic that involved the outpatient dermatology departments at the Al-Basrah teaching hospital and the Abu Al-Khaseeb hospital as well as the private clinics of two dermatology specialists in Basrah. A total of 235 patients with facial dermatoses secondary to the application of topical corticosteroids and counterfeit products or, a mixed formulation, for cosmetic purposes were recruited.

RESULTS

Most enrolled patients were female with 10-20 years aged group. The majority applied these products due to friends or pharmacy encouragement. Motivations for the use of these products included: skin fairness, lightening, and general cosmetic. Interestingly, acne and erythema were common whilst, atrophy, dryness, telangiectasia, and hirsutism appear on long- term use only.

CONCLUSION

The abuse of counterfeit cosmetic products and topical corticosteroids is in progress and they have adverse health events. There are many causes behind the abuse but the lack of education, lack of restriction, profitable for sellers and low prices are the main.

Dermatophyte infection caused by Nannizzia gypsea: A rare case report from Madagascar

We report a rare case of dermatophyte infection of the glabrous skin (Tinea corporis) caused by Nannizzia gypsea (formerly Microsporum gypseum). A 22-year-old Malagasy female who reported close contact reportedly with cats, presented a single round lesion with a peripheral, active, squamous and pruriginous inflammatory bead. Morphologic species identification was confirmed by sequencing the internal transcribed spacer (ITS) region of the genome. Specific treatment with oral loratadine and topical miconazole cream was effective.