Skin lightening cream: an emerging medical challenge

In contrast to this profile, she appeared cushingoid (moon facies, central obesity, skin fragility and striae) with skin depigmentation on her face, back and hands (Box, A). Her blood pressure was 130/80 mmHg, fasting glucose level was 7.3 mmol/L (RI, 4–6 mmol/L) and glycated haemoglobin level was 7.0% (RI, < 6.0%). Adrenocorticotropic hormone (ACTH) was < 2 pmol/L (RI, 0–10 pmol/L), with inadequate cortisol response to ACTH (169 nmol/L at 60 minutes). She did not comply with a 24-hour urine collection. Screening for exogenous glucocorticoid exposure showed prolonged use of three skin-lightening creams containing hydroquinone, 0.05% clobetasol propionate and 0.05% betamethasone, respectively. The patient was advised to stop using the steroid creams, and weaning treatment with short-term glucocorticoid replacement and hypoglycaemic therapy was initiated. The patient’s hand 4 weeks after she stopped using the cream is shown in the Box (B).

The use of skin-lightening products in African women is common (up to 25%1). These products may contain potent corticosteroids such as clobetasol propionate and betamethasone dipropionate (super potent; class 1), and fluticasone propionate (potent; class 3).2 Glucocorticoids decrease propiocortin, the precursor for melanocyte stimulating hormone, and cause epidermal cytostasis; prolonged use may reduce epidermal turnover, with fewer and less pigmented melanocytes.3

The severity of complications from these products depends on the potency, quantity, duration and extent of application. Cutaneous complications include atrophy, telangiectasia, dermatitis, acne, striae, purpura, hypopigmentation and steroid addiction syndrome.2 Endocrine complications include those associated with an exogenous Cushing syndrome — diabetes mellitus, hypertension, oedema, menstrual irregularities and osteoporosis. Prolonged inhibition of the hypothalamic–pituitary–adrenal axis may result in hypoadrenal crisis if the product is withdrawn abruptly. Application of 50 g/week of clobetasol propionate (3.5 g applied twice daily; typical use) may cause secondary adrenal failure:4 this equates to 500 g/week of 1% hydrocortisone.5

Lightening creams are exported to, and also manufactured locally in, African countries (eg, Nigeria) where there are high rates of use.3 In Australia, prescription of highly potent topical steroids is limited to specialist prescribers. However, internet availability bypasses these regulations; ingredients may not be disclosed and counterfeit versions are available.

Our aim in this letter is to educate practitioners about the inclusion of potent corticosteroids in skin-bleaching products, and their potential adverse effects. The Therapeutic Goods Administration has been notified.

Comparison of the patient’s hand at presentation (A) and 4 weeks after she stopped using the skin lightening creams (B), showing the return of skin pigmentation on the knuckles and in the nail beds