Correspondence Address:
Celestine Wong
Skin and Cancer Foundation Inc., 1/80 Drummond Street, Carlton, Melbourne, Victoria
Australia

Full Text

In India, light complexion has been associated with prosperity and beauty for thousands of years and remains a highly desired esthetic ideal. In 2010, skin-lightening products and services valued 250 million USD.[1]

Three classes of medications that are used to treat hyperpigmentation disorders are also used for skin lightening: Hydroquinone, topical corticosteroids, and mercury derivatives. Skin-lightening agents in the form of creams, gels, and ointments have been associated with acne, dyschromia, skin atrophy, irritant or allergic contact dermatitis, hypopigmentation, and bacterial or fungal infections.[2],[3],[4] Despite the widespread use of skin-lightening products, few studies have investigated their potential population health impact in India.

This study aimed to describe the pattern of use of skin-lightening products, factors that influence their use, and associated side effects in a rural North Indian population.

Ethics approval was obtained from the University of Melbourne (HREC 1443397). Recruitment was restricted to consenting adults and excluded patients requiring urgent medical care. Skin-lightening products were defined as topical therapies (creams, lotions, or ointments) applied to achieve lightening.

Participants were recruited from the general outpatient clinics of Champa Christian Hospital in 2014. A cross-sectional survey was conducted and participants were interviewed with the help of a medical interpreter, covering demographics, and outcomes of interest: Perceptions of lighter skin tone, skin lightener use, sunscreen use, and side effects from skin lightener use.

Descriptive statistics of basic demographic and outcome data were collated. Statistical analysis was performed using SPSS. The significance level was set at 0.05, two-tailed. Chi-square tests, Mann–Whitney U-tests, and multiple logistic regression analyses assessed the effect of predictors on outcomes. The reasons given for skin whitener usage were correlated with perceptions of lighter skin tones.

Prevalence of skin-lightening usage is reported to range from 59% to 72%.[4],[5],[6] Therefore, using an assumed prevalence of 60%, a sample size of n = 180 was deemed sufficient to identify known predictors of skin whitener usage with a power of 0.8 (1 − β). Of the 208 individuals approached, 148 consented (response rate 71.2%): 59.9% females, 40.1% males, mean age 31.7 years (range 18–62 years).

[Table 1] displays the results of demographic factors that influence perceptions of lighter skin tones. Lower levels of education were significantly associated with perceptions that class (P = 0.001) and employability (P = 0.018) were negatively affected by lighter skin. Occupation type had a modest effect on perceptions. For example, participants working in housework associated lighter skin with marriageability (P = 0.009) while manual workers did not associate lighter skin with employability (P = 0.015). Males were more likely to perceive that lighter skin increased confidence (P = 0.01). Those of the Brahmin caste, compared to Rajput, were more likely to perceive that lighter skin was associated with higher spiritual standing (P = 0.014). Interestingly, no statistically significant associations were identified for age, marital status, or income.{Table 1}

Overall, 89 of the 148 individuals (60.1%) had used skin lighteners at least once in their lifetime. Bleaching products accounted for 8.6% and corticosteroids for 1.7% of all products used. The majority of individuals using whiteners reported daily use (71.9%). The most common reasons for use were for “even skin tone” (60.7%) and “lightening complexion” (48.3%).

The logistic regression model incorporated predictors that were statistically significant in the univariate analyses. This yielded a model that confirmed age (P = 0.001), gender (P = 0.011), occupation (P = 0.071), education level (P = 0.070), and perception of confidence (P = 0.008) influence skin lightener usage. Students (P = 0.022) and government workers (P = 0.018) were more likely to use skin lighteners than retail workers, and the more highly educated were less likely to use skin lighteners. Those with a positive perception of confidence were more likely to use skin lighteners (P = 0.012).

Of the participants who responded to the question regarding effectiveness of skin lightener use, 59.7% reported perceived improvement in skin color or tone; 20% of participants reported side effects from use – most commonly acne (13.5%), pruritus or irritation (5.6%) and hyperpigmentation (3.4%). Univariate analyses identified that use of bleaching lighteners was associated with more side effects (50%) than other products (17%; P = 0.026).

The use of skin-lightening products is common in North India. In this study, 60% of participants reported using such products. This is similar to the prevalence in African populations that also have high levels of use: Nigeria (58.7%–77.3%),[6] Senegal (68.7%),[5] and Togo (58.9%).[4]

This study outlines favorable views of lighter skin; a likely social impetus for lightener use. Most participants agreed that lighter skin tone improved confidence and granted a more youthful appearance, but fewer felt it influenced employment prospects, marriageability, and social class. The perceptions around marriageability and employment differ from existing qualitative research undertaken elsewhere in India.[7] A similar study from Jordan outlined different patterns of responses, whereby Jordanians perceived lighter skin as associated with beauty and marriage prospects, but not with self-confidence, youthfulness, or social status.[8] Clearly, perceptions of fair skin differ between various ethnicities and communities. Given India's diversity, further research among urban communities or other geographical regions could clarify variations in perceptions across India. Perhaps, as expected, Brahmins were more likely to associate lighter skin tone with higher spiritual status.[7] However, this finding did not translate to actual differences in rate of skin lightener use, which remained relatively constant across all castes.

Similar to other cultures, this study identified that being young and female were significant predictors for skin lightener use.[5] This might be expected given prevailing views on light skin bestowing femininity and youthfulness. Market research in India suggests that the age of skin lightener users is decreasing, with 12–14 years old making up 13% of all users.[9] This is concerning as such users are vulnerable to advertising and are typically unaware of potential side effects.

Prevalence of skin lightener usage among males was higher (46%) than rates observed in Nigerian studies (2% and 27.6%).[6] Even more so than females, males tended to agree that lighter skin was confidence boosting. This is consistent with Narayan's observation of a concerted marketing drive targeting rural Indian males who now make up 10% of fairness cream sales.[10]

Education has a significant “blunting” effect on perceptions of lighter skin and subsequently on skin lightener use. Higher educated participants did not view lighter skin tone as beneficial for social status or job prospects. This finding was consistent with the Jordanian study, where higher education levels were associated with diminished belief that lighter skin improves employability.[8]

Regarding the outcomes of skin lightener use, 60% of users in the study reported perceived improved skin color or tone. Similar levels of satisfaction have been reported elsewhere.[7] Only 20% of participants reported side effects in contrast to 50%–70% reported in other studies.[2],[6] A possible explanation is a difference in type of skin-lightening agents used. While other papers report frequent use of corticosteroids and hydroquinone,[2],[6] participants in this study tended to use inexpensive, less potent skin lighteners. Of the 18 cases where side effects were observed, five cases involved bleaching products. Despite a lower-than-expected complication rate, this widespread usage raises a significant concern for population health.

Some possible strategies to raise public awareness about the risks of skin-lightening product misuse include (1) conduct school-based lessons about healthy skin care, featuring use of nonperfumed moisturizer and sunscreens rather than possibly ineffective and skin-irritating over-the-counter lightening creams; (2) social media campaigns; and (3) tighter government regulations around the availability of high-potency skin lightening agents (e.g., strong topical corticosteroids have serious, adverse dermatological effects).

For convenience, this study was conducted in a hospital outpatient clinic setting, which could make it difficult to generalize the findings to the local community. However, the fact that the participants were attending outpatients for general medical/surgical conditions is unlikely to have affected participants' perception or prevalence of skin lightener use, which is largely cosmetic. Therefore, there is little reason to think that patterns of skin whitener usage vary dramatically between those visiting outpatients and those in the general community. However, without studies undertaken elsewhere, generalizing beyond these local communities in North India is difficult given the socioeconomic and cultural diversity in India.

This study demonstrates a high prevalence of skin lighteners in this population group, especially among young females. Believing that lighter skin is beneficial for self-esteem is a predictor for skin lightener use. Conversely, higher education is associated with lower perceived benefits of fairer skin and therefore reduced lightener use. Further education and regulation are required to address potentially dangerous usage of skin-lightening products.

Acknowledgments

We wish to acknowledge Dr. C Grills for her expert advice and support in conducting this research. We wish to acknowledge Dr. N Tan and Ms. Nicole Hughes for their support in preparing and drafting the manuscript. We wish to acknowledge Dr. N Sharma for technical support in this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References