ORIGINAL ARTICLE

The use of topical bleaching agents among women:a cross-sectional study of knowledge, attitude andpractices

KM AlGhamdi*

Dermatology Department, Vitiligo Research Chair, College of Medicine, King Saud University, Riyadh, Saudi Arabia

*Correspondence: KM AlGhamdi. E-mail: kmgderm@yahoo.com

AbstractBackground Although the practice of bleaching is common worldwide, there are few studies that discuss

knowledge, attitudes and practices towards bleaching.

Objective The aim of this study was to explore the knowledge, attitudes and practices towards the usage of

topical bleaching agents among women.

Methods A self-administered questionnaire on the use of bleaching creams was distributed randomly to women

attending the outpatient clinics at a university hospital in Saudi Arabia during 2008.

Results Five hundred and nine of 620 women responded (82% response rate). All the participants had dark skin

(skin type 4–5). The mean age was 29.22 ± 9 years. Of the participants, 38.9% (197 ⁄ 506) were current users of

bleaching agents. Only 26.7% (106 ⁄ 397) of the respondents used bleaching agents for medical purposes to treat

localized abnormal skin hyper-pigmentation; 20.8% (101 ⁄ 485) were ready to use any bleaching cream that gives fast

results, even if the components were unknown. Of the respondents, 30% (152 ⁄ 509) used more than 100 g of

bleaching creams monthly. These products were applied to the whole body in 7.3% of the cases. While 10.3%

(28 ⁄ 271) continued applying the bleaching products during pregnancy, 20.8% (54 ⁄ 260) did so during lactation. No

associations could be found between the various sociodemographic variables and differences in the attitude

towards and practice of using bleaching creams.

Conclusion A major proportion of our sample respondents have overused and ⁄ or misused bleaching agents. This

was regardless of age, income, education or marital status. There is a need to educate women about the possible

risks.

Received: 7 November 2009; Accepted: 26 January 2010

Keywordsattitudes, bleaching agents, de-pigmentation, knowledge, misuse, overuse, practices

Conflict of interestNone declared.

IntroductionBleaching agents have been used to lighten skin colour for decades.

It has been a common practice throughout the world, especially in

the sub-Saharan Africa, starting in dark-skinned women, but

recently spreading to fair-skinned women to tone their skin col-

our. The use of bleaching agents is very common in Asia and

Africa, because a having fair skin is linked to beauty and high

social class. In Africa, the use of cosmetic bleaching agents has

been a long-standing practice that chiefly aims to change one’s

skin colour and is a socially acceptable habit.1 It is common

among both men and women.2

Previous studies demonstrated a spectrum of complications

ranging from dermatitis and skin rashes to the development

of diabetes mellitus and renal problems associated with the misuse

of such products. Bleaching products were mainly composed of

mercury, corticosteroids and hydroquinone.2–10 A majority of skin

diseases observed in the users of bleaching products seemed to be

induced, aggravated or modified by these products,3 whereas the

long-term use of these agents was responsible for a high rate of

cutaneous and systemic side-effects.2,5

We feel that the frequency of use of bleaching agents in Saudi

Arabia has been increasing. Bleaching products seem to be highly

ª 2010 The Author

JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology

DOI: 10.1111/j.1468-3083.2010.03629.x JEADV

overused, although the constitutional skin colour is relatively light

(skin type IV–V). Bleaching products are legal in Saudi Arabia; the

government has not banned any of the bleaching products sus-

pected to be harmful. However, no studies have estimated the

prevalence of use or examined the motives and attitudes behind

using them. The general knowledge of women about the risks of

using skin bleaching agents must be evaluated and the side-effects

of such products should be observed to control this habit. The

aims of this study were to estimate the prevalence of use of bleach-

ing agents among women, to assess the knowledge and practice of

bleaching and to examine attitudes towards this issue.

MethodsA cross-sectional survey was conducted on women who attended

various outpatient clinics at King Khalid University Hospital in

Riyadh, Saudi Arabia, which is a tertiary referral hospital open to

the general public. Data were collected by a trained research assis-

tant between July and September of 2008 from patients as well as

their companions during their wait in the pharmacy area.

The specially designed questionnaire used for data collection in

this study was initially tested three times on 30 subjects each time

to estimate the time taken to complete the questionnaire, deter-

mine the comprehension of questions by the participants and

refine it accordingly. These questionnaires were excluded from the

final analysis. The final self-administrated questionnaire included

27 questions, which required approximately 8 min to answer com-

pletely. It was approved by the ethical committee at King Khalid

University Hospital. It was made clear to the participants that the

research concerned bleaching agents and not regular cosmetics or

make-up. Personal information, including age, marital status, edu-

cational level, occupation and household average monthly income,

was collected. In addition, the questionnaire requested detailed

information regarding the use of bleaching agents such as the

duration and frequency of bleaching product usage, the age at

which the participants started using them, where they obtained

those products from and the reason behind using such products.

Participants were also asked if they used bleaching creams during

pregnancy and lactation, how much they spent monthly on

bleaching creams and what parts of their bodies was it applied to.

The questionnaire also elicited information about the amount in

grams of bleaching creams used monthly. To help the subjects

express the amount used per month, three empty jars of 30, 60

and 120 g were shown to each subject. For those who did not use

jars, two different tubes of 15 and 30 g were shown. The patients

were also asked about the safety of the bleaching agents, whether

or not they believed that bleaching creams obtained at herbal

stores were safe, whether they thought bleaching creams might

harm their skin or general health, and whether they were willing

to use bleaching creams even if the components of the cream were

unknown. From the given components such as corticosteroids,

hydroquinone and mercury, they were asked to choose the most

dangerous component to human health. They were finally asked

an open-ended question about self-reported side-effects or compli-

cations.

Statistical analysis

The Statistical Package for the Social Sciences Program (SPSS) ver-

sion 16 (SPSS Inc., Chicago, IL, USA) was used for statistical anal-

ysis. Numerical variables were reported as mean ± standard

deviation. A chi-squared test was used for the assessment of associ-

ation between different categorical variables. Results with a P-value

of less than 0.05 were considered statistically significant. Multiple

logistic regression analysis was used to relate the use of bleaching

creams with various sociodemographic variables.

ResultsThe questionnaire was distributed to 620 women. In total, 509

women aged 10–59 years (mean ± SD 29.22 ± 9.07) returned the

questionnaire (82% response rate). The sociodemographic charac-

teristics of the participating females are shown in Table 1.

Knowledge

About 55% (269 ⁄ 492) of the respondents believed that using

bleaching creams could harm their skin, whereas 45.4% (223 ⁄ 492)

did not think so. Approximately 20% (98 ⁄ 498) agreed that using

bleaching agents could harm their general health, whereas 80%

(400 ⁄ 498) did not. When asked to select the most harmful com-

ponent of bleaching agents, 47.3% (238 ⁄ 503) chose corticoster-

oids, while only 38.2% (192 ⁄ 503) selected mercury.

Table 1 Sociodemographic characteristics† of the participantsin the survey

Variables Count Percentage

Age group (years)

Below 20 61 ⁄ 490 12.40

20–29 210 ⁄ 490 42.90

30–39 136 ⁄ 490 27.80

40 and above 83 ⁄ 490 16.90

Marital status

Single 180 ⁄ 502 35.90

Married 305 ⁄ 502 60.80

Divorced 9 ⁄ 502 1.80

Widowed 4 ⁄ 502 0.80

Separated 4 ⁄ 502 0.80

Education

Illiterate 17 ⁄ 486 3.50

High school or lower 246 ⁄ 486 50.60

University or higher 223 ⁄ 486 45.90

Household average monthly income

Less than 2000SR‡ 37 ⁄ 490 7.60

Between 2000 and 5000SR‡ 131 ⁄ 490 26.70

Between 5000 and 10 000 SR‡ 208 ⁄ 490 42.40

More than 10 000SR‡ 83 ⁄ 490 16.90

More than 20 000 SR‡ 31 ⁄ 490 6.30

†Some of the variables are missing. ‡3.74 Saudi Riyals = 1 US Dollar.

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JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology

2 AlGhamdi

Attitude

In this study, 26.7% (106 ⁄ 397) of the respondents reported that

they used bleaching products for medical purposes to treat local-

ized abnormal skin hyper-pigmentation. While 73.6% (363 ⁄ 493)

of participants desired a lighter skin colour, only 19.9% (98 ⁄ 493)

did not. Of the participants, 56.8% (289 ⁄ 509) believed that lighter

skin colour made them more beautiful, whereas only 15.9%

(81 ⁄ 509) believed that lighter skin colour made them more self-

confident.

Non-medical preparations sold by street vendors and at herbal

shops were considered by 15.3% (77 ⁄ 503) as safe to use, while

69.8% (351 ⁄ 503) disagreed. Of the participants, 14.8% (75 ⁄ 506)

reported that they would recommend the use of those non-medi-

cal preparations to others, whereas 75.1% (380 ⁄ 506) reported that

they would not do so. About 20.8% (95 ⁄ 485) stated that they

would use bleaching creams that gave fast results, even if the com-

ponents were unknown.

Practice

Of the participating women, 38.9% (197 ⁄ 506) were current users

of topical bleaching agents. The age of the participants when they

first started using bleaching creams varied from 10 to 57 years

(mean 23.1 ± 7.3 years). The duration of usage varied from 1 to

150 months (12.5 years) (mean 12.3 ± 23.7 months); of the

respondents, 18.6% (90 ⁄ 486) had used bleaching creams continu-

ously for more than 6 months. Bleaching creams were used by

80.6% (297 ⁄ 368) of participants at least once daily.

About 30% (105 ⁄ 376) of participants reported that they

obtained the bleaching products from herbal shops (Fig. 1) and

22.20% (81 ⁄ 365) stated that they used herbal non-medical bleach-

ing products (Fig. 2). The monthly cost of the bleaching products

varied from 5 to 3000 Saudi Riyals (SR) (mean 223.0 ± 368.9SR,

i.e. about US$60 ± 100). Of women, 16.7% (81 ⁄ 486) reported

that they spent more than 200SR per month on bleaching prod-

ucts (US$53.4).

The amount of the bleaching creams used per month varied

from 2 to 600 g (mean 90.0 ± 80.9). More than 30% of the

respondents (152 ⁄ 486) used more than 100 g of bleaching cream

per month. These products were applied to the whole body in

7.3% of the cases. While 64.6% of the participants (329 ⁄ 509) used

the products on their faces, 26.7% (136 ⁄ 509) used them on their

necks and 17.1% (87 ⁄ 509) used them on their hands. It was self-

reported by 24.4% (124 ⁄ 509) that the colour of their skin returned

to normal once they discontinued the use of bleaching creams

(Fig. 3). In addition, 10.3% (28 ⁄ 271) of women continued apply-

ing the bleaching products throughout pregnancy, while 20.8%

(54 ⁄ 260) did so during lactation.

Non-medicalcosmetic

shops

Herbal shops

35.00

30.00

25.00

20.00

%

15.00

10.00

5.00

0.00Over thecounter

Medicalprescription

24.50%

34.80%

27.90%

12.80%

Figure 1 How the bleaching products were obtained among acohort of 509 Saudi females.

Ready madecosmeticcreams

25.00

17.50%

22.20%19.70%

40.50%

20.00

15.00

%

10.00

5.00

0.00Herbal or

non-medicalpreparations

Medicalpreparations

at pharmacies

Ready made atpharmacies

Figure 2 Types of bleaching products used by a cohort of 509

Saudi females.

Skin dryness

25.00

10.00%

24.40%

11.20%

16.10% 20.00

15.00 %

10.00

5.00

0.00RashSkin returns

to its normalcolor

Skin becomesdarker than

before

Figure 3 Self-reported complications caused by discontinuing

use of bleaching creams among a cohort of 509 females.

ª 2010 The Author

JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology

The use of topical bleaching agents among women 3

Associations between sociodemographic variables and

the use of bleaching creams

Statistical analysis did not reveal any significant associations

between various sociodemographic variables and details of the use

of bleaching creams or the knowledge of or attitudes towards the

use of them (Table 2).

DiscussionThe results of this survey indicate that the use of bleaching agents

is very common among women visiting outpatient clinics in Saudi

Arabia. In this survey, 38.9% of the participating women are

current users of bleaching agents. The results are of great

importance as the overuse of cosmetic bleaching agents has

various complications.

Bleaching agents are composed of various products, many of

which are still unidentified.1 The most common pharmacological

compounds used are hydroquinone, corticosteroids and mercuri-

als.5 Hydroquinone is the most prescribed skin-lightening agent

worldwide despite its inconsistent effects and safety concerns.11

Hydroquinone, a metabolite of benzene, which is leukaemogenic,

is a bleaching agent that can burn skin, especially when it is

exposed to ultraviolet light. One of its side-effects is ochronosis;

while the full degree of its side-effects is still unknown, studies

have associated it with liver damage and thyroid disorders.11

Treatment of rats with hydroquinone caused mutations in devel-

oping fetuses and decreased female fertility11,12 and leukaemia was

observed in female rats. Although leukaemia in rat and human

leukaemia have different origins, with human leukaemia originat-

ing in the bone marrow and leukaemia of rat originating in the

spleen, the FDA could still not rule out the leukaemogenic risks of

hydroquinone.11,12

Topical corticosteroids clearly lighten the skin, but the mecha-

nism of melanogenesis inhibition is still imprecise.9 Corticoster-

oids lighten the skin either by initial blanching as a result of

vasoconstriction which slows down skin cell turnover, decreasing

the number and activity of melanocytes, or by reducing produc-

tion of precursor steroid hormones.13

The damage produced by steroid-containing bleaching products

included skin atrophy, thinning and breaking of the skin giving

rise to acneform eruptions, hypertrichosis, telangiectasias, and fun-

gal ⁄ bacterial infections. Less common damage included unusual

presentation of scabies, pediculosis and warts.1–15 Medical condi-

tions associated with the use of steroid-containing bleaching

products were diabetes mellitus, hypertension and obesity. The

side-effects depended on the period of the use and the nature of

the products used.1–15

Mercury was used as mercurious chloride, mercurious oxide

and ammoniated mercury in many cosmetic products at the start

of the 20th century, before the serious toxicity of mercury was dis-

covered. Mercury toxicity can cause psychiatric and neurological

problems as well as renal impairment and a paradoxical increase

in skin pigmentation.16–20 As the daily uptake from skin absorp-

tion is up to 20 times more than that taken from food, toxicity is

a major concern and legislation prohibits the use mercury in many

countries. However, it is still used in some skin whitening prod-

ucts, as mercury deactivates the enzyme that causes the production

of melanin.15 Long-term usage of mercurial products makes the

skin and nails darker, because mercury accumulates in the epider-

mis, hair follicles and dermis.12

The prevalence of the current use of topical bleaching agents in

our study (38.9%) is comparable with other prevalence studies

carried out in Nigeria and Senegal. The studies conducted in Nige-

ria and Senegal showed that the use of cosmetic bleaching prod-

ucts ranged from 53% to 59% of people surveyed.2,3 In our study,

only 7.3% of the cases applied the bleaching products to their

whole body, while this percentage was as high as 81.3% and 92%

in Nigeria and Senegal respectively.2,3 In Saudi Arabia, 10.3% of

the participating women continued applying bleaching products

throughout pregnancy, while 20.8% did during lactation. The

results were more drastic in Senegal where 81% of the women

carried on with their use during pregnancy and 87% did so during

lactation. In our study, the duration of the bleaching practice

varied from 1 to 150 months (12.5 years), while in Senegal, the

duration varied from 1 to 420 months (35 years). The amount of

bleaching products used each month in Saudi Arabia ranged

between 2 and 600 g (mean 90.09 g ⁄ month). In Nigeria, the

Table 2 Current use of bleaching products associated with

demographic characteristics

Demographicvariables

Current use Chi-square P-value

Yes No

N (%) N (%)

Age (years)

£ 30 131 (40.2) 195 (59.8) 0.36 0.39

> 30 66 (36.1) 117 (63.9)

Educational level

Illiterate 8 (47.1) 9 (52.9)

High school or lower 100 (40.7) 146 (59.3) 2.46 0.29

University or higher 77 (34.5) 146 (65.5)

Marital status

Single 80 (44.4) 100 (55.6)

Married 109 (35.7) 196 (64.3) 4.3 0.12

Divorced ⁄ widowed ⁄separated

5 (29.4) 12 (70.6)

Occupation

Student 53 (42.7) 71 (57.3)

Unemployed 22 (48.9) 23 (51.1)

Home maker 71 (37.0) 121 (63.0) 3.84 0.43

Employed 42 (35.3) 77 (64.7)

Others 6 (33.3) 12 (66.7)

Household average monthly income (SR)

£ 10 000 150 (39.9) 226 (60.1) 0.06 0.80

> 10 000 44 (38.6) 70 (61.4)

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JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology

4 AlGhamdi

quantity varied from 60 to 150 g ⁄ month, while in Senegal, the

quantity ranged between 15 and 350 g ⁄ month.2,3 The 600 g maxi-

mum used in our study seems quite outrageous, as 45 g of cream

is required on average to cover the whole body. Although it

appears that the results of our study are less dramatic than those

from the African studies, considering differences in skin colour,

they are still extreme. In Africa, skin colour is dark black or skin

type VI, while in Saudi Arabia, it is lighter (skin type IV–V).

Moreover, our study sample was from all outpatient clinics, while

the African studies drew their participants from dermatology

clinics where patients presenting with cutaneous complications of

this practice were probably found.

It was expected that more educated women, knowing the risks

of bleaching products, would avoid their use. It was also expected

that the use of bleaching products would be most prevalent among

participants in their teens to late 20s. The results of our study con-

tradict our expectations; women in Saudi Arabia use bleaching

products extensively regardless of age, educational level, income or

marital status. Multiple logistic regression analysis did not detect

any correlations between sociodemographic variables and the use

of bleaching products, indicating that bleaching products are

widely used by women in general, even older and educated ones.

A previous study performed in Mali showed that bleaching agent-

related complications were particularly frequent in unmarried

women (39%), literate women (34%) and female students

(45%).21

Participants self-reported the complications caused after discon-

tinuation of bleaching practice. The reported complications

included skin dryness, skin rash and the return to the normal skin

colour or to a darker than normal colour (Fig. 3). Such side-effects

prevent the users from discontinuing this practice, as it is difficult

for them to cope with these symptoms. This dilemma stresses the

need to alert the public to seek medical help instead of continuing

the bleaching practice.

Mercury is the most dangerous constituent of bleaching prod-

ucts, as it is highly toxic. It was predicted that most of the partici-

pants would know about the toxicity of mercury and accordingly

would select it when responding to the most toxic component

question. However, only 38.2% of the respondents (192 ⁄ 503)

selected mercury, while more than 47% (238 ⁄ 503) selected corti-

costeroids. This was true regardless of education or age, indicating

the prevalent lack of knowledge in this regard.

It was expected that women with higher incomes would be the

ones capable of paying for such cosmetic products. This was also

contradicted by our results as there was no association between

income and the use of bleaching products. Three participants

claimed to spend 3000SR monthly on bleaching products (about

US$800), which is a surprising cost as the average monthly income

per capita in Saudi Arabia according to the 2008 CIA world fact

book is US$1708.22 On average, women spend US$59.47 monthly

on bleaching products, which is more than the average person

would earn for a whole day of work.

About 75% of the bleaching products used were not obtained

by a medical prescription. This surprisingly high percentage reveals

the inadequate ways of obtaining such products and further high-

lights the importance of managing the problem. The sources from

which the bleaching creams were obtained varied from pharmacies

to cosmetic shops and herbal markets (Fig. 1). Many bleaching

creams claimed to be composed of ‘natural herbs’. A Saudi study

conducted by Bogusz et al.23 examined some of the creams claim-

ing to be natural herbal preparations sold at the markets in Saudi

Arabia. Eleven preparations that claimed to treat skin pigmenta-

tion problems were studied. In most of the cases, the products

contained high concentrations of heavy metals; the mercury con-

centration was 0.57–12.6%, while the concentration of lead was

over 1.5%.22 Such results seem to agree with ours, as both studies

indicate the importance of educating the public about the dangers

associated with using herbal preparations, especially when the

components are unknown. Strikingly, more than 20% of partici-

pants were willing to use bleaching products even if the compo-

nents were unknown. Unfortunately, the marketing of such

products is legal in Saudi Arabia.

Several studies reported complications caused by the overuse

and misuse of topical bleaching agents.1–14 However, our survey is

the first to describe the level of knowledge that Saudi women par-

ticipants visiting outpatient clinics had of bleaching products as

well as their attitudes towards such products and their use of

them. Limitations of our work include the use of a convenience

sample, which might not be representative of the whole commu-

nity; however, a strength of the work is the use of a large sample

size (509).

Future research should investigate the prevalence and type of

cutaneous and systemic complications of bleaching agents in our

society. Furthermore, detailed pharmacological examination of the

components of these bleaching agents needs to be conducted.

Education of the public on the risks of bleaching product use is

clearly imperative and would mitigate the side-effects of their use.

Health education programmes should target women through vari-

ous media options including leaflets, television and radio. Within

hospitals, we suggest that education programmes about the dan-

gers of misuse and overuse of topical bleaching agents be inte-

grated into existing health education programmes. Health

regulators must focus on limiting the herbal preparations that

have unknown or harmful components. The sales and marketing

of bleaching products must be controlled, which could be done by

imposing fines and penalties on the marketers of such products.

There is a need for a nationwide health-education campaign to

tackle this issue.

ConclusionsThe results of this survey reveal that the use of topical bleaching

agents is very common among Saudi women. Numerous women

of different age, class and marital status are seeking lighter

complexions and are consequently using bleaching products

ª 2010 The Author

JEADV 2010 Journal compilation ª 2010 European Academy of Dermatology and Venereology

The use of topical bleaching agents among women 5

excessively, which could cause several health problems. It is impor-

tant to control the use of bleaching products and to educate

women about the dangers associated with this practice. Increased

awareness should reduce the abuse of bleaching agents.

AcknowledgementsThe author thanks Dr Davinder Parsad and Prof. Ahmed

Mandil, Professor of Epidemiology, Family and Community

Medicine Department, College of Medicine, King Saud Univer-

sity for kindly critically reviewing the paper.

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