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Ep 36: Skin Whitening is Neither Safe nor Trendy – A Dermatologist’s Take on Skin Color
Dr.TWL: Hi guys and welcome to today’s episode of Dermatologist Talks: Science of beauty. I’m Dr. Teo Wan Lin of TWL Specialist Skin & Laser Centre and Dr.TWL Dermaceuticals. Today we’re going talk about the phenomenon of skin whitening or lightening, and the dangers involved. We will also talk about the social and cultural contexts of skin colour and skin tone all around the world. Hopefully, I’ll also answer your most pressing questions about skin tone and skin color along the way.
Chelsea: Well this is a topic I’ve always wanted to explore more of and is a topic very relevant to this part of the world. For those of you who are unfamiliar, skin bleaching or lightening is a process in which substances are used in procedures where the goal is to reduce melanin concentration in the skin for a lighter/fairer complexion. This phenomenon is closely tied to Asian beauty ideals of wanting fairer skin. This shows clearly as skin whitening is a booming business in Asia. Estimates project that by 2027, the skin whitening industry will be worth over $24 billion dollars.
Why melanin is important
Dr.TWL: In Asia, the idea of having fair skin unfortunately ties to the concept that beautiful, healthy skin has to be fair, smooth and soft without wrinkles. As opposed to the false stereotype that aged skin is one that is dark. Not taking into consideration that dark skin can also be free of wrinkles, have a smooth, soft texture. Without the accompanying signs of photoageing as well. Well, there is some correlation of skin darkening and hyperpigmentation with the physical signs of photoageing. This is due to exposure to ultraviolet light radiation. However, the message here isn’t science-based. It it does not take into consideration our natural skin tone, which is a result of our ethnicity. Skin of colour deems to have more inherent melanin as a result of genetic factors. Melanin is photoprotective and prevents us from getting sunburns.
The cultural context of skin whitening
Chelsea: Skin bleaching or lightening is a well-documented and ancient practice dating back to the 1500s continues to be a thriving business. This is in the form of soaps, creams, pills, and even injectables in many cultures.
Dr.TWL: A little bit about the context of skin whitening or skin bleaching. It is a very popular cosmetic practice in skin of color on various continents from Africa, East Asia, South Asia and Southeast Asia. For example, a study by Rusmadi and his colleagues reported that 60% of Malaysians use skin lightening products. 61% perceive that lighter skin gives them a healthier and younger look.
The methods of skin lightening and skin bleaching range from using topical corticosteroids to prescription medications like hydroquinone. Both of which are prescription medications, illegal for over-the-counter cosmetics. They also do not indicate for skin bleaching. All these results in the removal of pigment from the skin. However, it is important to note that such way of usage is inappropriate and dangerous. Mercury, which is neurotoxic, has been found in over-the-counter products sold in South Asia and in products promoting skin lightening.
Embracing your natural skin tone
The key message here is that one should embrace your natural skin tone and skin colour because that’s what you’re born with. Societal messaging via advertisements and brand marketing, especially with regards to products that target hyperpigmentation must gear to the right perspective especially in this age. It is not about having fairer or whiter skin. But in terms of encouraging healthy skin and embracing your natural skin tone, I feel that it is a huge factor driving the dangerous practices of skin lightening all over the world. It is not just an unrealistic beauty ideal. It’s also a very unhealthy one that can significantly damage one’s self-esteem. Hence, I think we need to tread very carefully here. Hopefully as a society, especially beauty influencers and key leaders, we take a stand encouraging correct perspectives of skin colour.
Common misconceptions relating to skin color
Chelsea: Yeah, growing up I actually think it was a little bit of the opposite for me. Due to the influence of Western media, my friends and I always wanted to look more bronzed and tan. Much to the dismay of my grandma or other older relatives, So I was a little bit on the other side of the spectrum. I would l always want to go out in the sun and suntan or sunbathe. I do recognise now that it isn’t healthy as well. But I do remember growing up with relatives always telling me I looked too dark. That I should stay out of the sun and keep the skin fair. Luckily, it was never to the extent of using skin lightening creams or ‘supplements’. But I do know that this is not the case with everyone.
In many Asian societies, many do still see skin tone as a sign of social class, with western colonial influences of the 18th and 19th centuries making it so that the light-skinned European colonizers became a mark of higher status, whereas the darker skin of Asians a marker of lower class and status.
Changing beauty standards
Dr. TWL: Yes, while history does play a part in the obsession with lighter skin in Asia, I do want to remind people that healthy, beautiful skin is one that is resilient to environmental damage and retains its normal, healthy, natural color, as opposed to a skin that is artificially bleached or sunburnt.
One way to drive home this message is through government campaigns and raising awareness. Interestingly, a lot of media influencers can account for the success of campaigns. These campaigns target to advise people not to bleach their skin. For example, in Africa, the government had a series of anti-skin lightening messages. They were broadcasted on television for decades. As a result, there were less of these cases of dangerous side effects arising from these illegal skin lightening procedures. From the 1970s, it was noted that there was the regulation of these skin lightening ingredients. In fact, these later prompted the prohibition of the use of hydroquinone in over-the-counter products, a practice extended to East Asia as well. Though the sale of hydroquinone in over-the-counter cosmetics is banned, we still find many cosmetics online that still contain hydroquinone, mercury and steroids.
Chelsea: That makes sense, there definitely should be more campaigns whether on social media or through public advertisements raising awareness on the harmful effects of skin lightening procedures. Especially since the availability of these over the counter products are still so widespread
Socio-cultural influences
Dr. TWL: I feel that as an Asian, living and growing up in this part of the world, that this cause of skin lightening beauty trend in this part of the world is a lack of public education on the relevance of melanin in terms of it being photoprotective, preventing sun damage. This is why we find that there can be a lot of misconceptions about altering your natural skin tone. In South Asia, India for example, darker skin associates with caste systems. Legally, these no longer exist. However, we find that these same biases and prejudices that link to your skin color are still quite prevalent in South Asia.
Chelsea: Yes, there are definitely a lot of socio-cultural influences at play here regarding the skin whitening phenomenon.
Can you tell us more about the different skin whitening measures available out there and how they might be dangerous?
Dr. TWL: The main ingredients used in skin bleaching products are hydroquinone and mercury. These work by inhibiting the production of the skin pigment melanin. Recent research shows that in the long term these ingredients can be toxic. In fact, these ingredients can darken skin and cause premature aging if used for extended periods of time. Other studies have also found that hydroquinone, in particular, can remove the top layer of skin. Increasing the risk of skin cancer, and may even cause fatal liver and kidney damage in the concentrations of these unregulated cosmetics.
One very relevant issue is that these skin whitening creams that target body skin lightening can lead to women actually smearing a lot of these creams on their body. Applying these compression materials with hydroquinone bleach and even hydrogen peroxide, creates an occlusive environment. Furthermore, because the absorption is via a large surface area such as the body, it affects the body system with what we call systemic side effects. This can cause paradoxical darkening and hyperpigmentation of skin.
Side effects of hydroquinone
Ochronosis is an example of a type of hyperpigmentation that results from use of hydroquinone inappropriately. It is a black-bluish hyperpigmentation disorder that occurs after skin exposure to hydroquinone. Besides, all these inappropriate skin lightening processes will increase your risk of developing skin cancers. For example, squamous cell carcinoma because it removes melanin that is naturally present in the skin for protection. When these medications absorb through the skin to the body system, it can even cause organ damage. For women who are pregnant and lactating, it will affect the unborn infant.
Chelsea: You mentioned the use of corticosteroids and other prescription medicines briefly before.
Can you explain how these corticosteroids work in dermatology, and potential complications that can arise from misuse?
The use of corticosteroids for reducing inflammation is relevant in dermatology and has been a critical part of the treatment of various skin diseases. However, when incorporating in whitening skincare, we find that local immunosuppression occurs. This can lead to increased skin infections and in fact the lightening effect that occurs, is not an intended effect of the medication, we do not use it for that reason in dermatology practice. It is a side effect tying to other potentially irreversible side effects such as skin thinning, what we call dermal atrophy. This is where there can be an increase in deep blood vessels in the skin.
Side effects of corticosteroids
Besides, topical steroids when it is applied over a large body surface area such as in these illegal bleaching creams, when they are absorbed into the blood circulation, it can result in adrenal complications which are hormonal problems such as Cushing syndrome, diabetes and high blood pressure. When applying onto areas near the eyes, it can lead to glaucoma, cataracts and even blindness.
In South Asia, preparations containing mercury have been found in these cosmetics being sold to the public, and that’s well known to cause neuropsychiatric toxicity, and also kidney damage. Something worthy to mention at this juncture is glutathione injections which are infusions that we sometimes hear about from our Southeast Asia counterparts, these are not approved or evidence-based for skin lightening and significant complications can occur in the liver, the nervous systems, as well as the kidneys.
The main point here is why are we even talking about lightening your skin tone, we are not talking about removing hyperpigmentation here, we are talking about wanting to whiten your skin, changing the skin color that you are born with. I think it’s very important for us to take this moment to reflect on our personal perspectives and perhaps our prejudices have been formed by these societal biases there in the first place.