KARACHI: Troubled by an acne breakout that has ruined her wedding preparations, Sadia is on her first visit to a dermatologist. Waiting for her turn at a skin hospital in Saddar, she appears distressed. “I get a shock every morning when I look up in the mirror. My pimples are getting worse and I am too scared to think about my marriage scheduled for next week,” she says with worry writ large on her face.

Her consultation with the doctor revealed that the breakout was the result of a prolonged use of a ‘beauty’ cream.

“I couldn’t believe that the cream caused this. It did give good results for a while and improved my complexion,” she recalls, adding that she had started using the cream on a friend’s advice.

Facing similar predicament is 25-year-old Sadaf. Her face is spoiled by patchy rashes and acne. “I have no idea what has ruined my face but the doctor is insisting it’s the skin whitening cream that I have been applying on my face for the past two months,” she says.

‘My pimples are getting worse and I am too scared to think about my marriage scheduled for next week’

Conversations with dermatologists at public sector hospitals of the city suggest that these are not isolated cases. A significant number of female patients report at health facilities with complaints of acne breakouts, pigmentation, skin atrophy (thinning of skin) photosensitivity and excessive hair growth after using fairness/whitening creams.

“The kind of acne they have and a detailed history of their cases indicate that they have used some kind of topical steroid-based creams,” says Dr Humaira Talat, a senior dermatologist at the Civil Hospital Karachi.

According to her, often these products are purchased from the market but there are also patients who report with damaged skin following their visit to a beauty parlour.

“Women going for whitening facials have no idea what kind of creams are being applied on their faces at beauty parlours,” she says.

Dr Mahwish Noorani at the Sindh Institute of Skin Diseases in Saddar examines five to 12 such cases daily at her outpatient department of over 200 patients.

She believes that steroid-based fairness/whitening/bleaching creams may also contain harmful metals. “There needs to be a scientific analysis of all fairness creams currently available in the market and those found containing steroids or any harmful ingredient should be completely banned. As a doctor, I feel sorry for young women ruining their skin in their desire to get fair.”

Explaining how steroids affect the skin, she says: “The affected area becomes red with prolonged use [from four weeks onward if a potent steroid is being used in concentrated form]. Small bumps and pustules appear that may be scaly and itchy. At times, enlarged blood vessels develop. The skin becomes sensitive to anything applied to it and the steroid-induced rosacea [skin redness, dilated blood vessels] may become severe when the topical steroid is discontinued.”

High cost

According to doctors, patients that also include men, though their number is much less, pay a high cost for using topical steroids on their faces. Not only the treatment for their damaged skin is expensive, the scars left by pimples are permanent.

“The skin becomes resistant to regular treatment and takes a long time to recover. At times, the skin pigmentation lasts for good,” says Dr Noorani.

She added that patients were asked to immediately stop using the cream, avoid sun exposure and use a good quality sunblock along with medicines to treat acne.

The misuse of topical steroids, she said, was common across the country and there was a need for a regulatory mechanism to check sale of harmful creams.

A 2014 study conducted at the department of dermatology of the Nawaz Sharif Social Security Teaching Hospital in Lahore showed that the unwarranted cosmetic use of topical corticosteriods with or without fairness creams was quite common in facial dermatoses resulting in steroidal dermatitis resembling rosacea.

Seventy-six per cent patients out of 200 (who used such creams and were examined under the study) were female whereas 24pc male.

A majority of the patients, according to the research, belonged to the lower income urban group. Over 30pc patients used potent topical corticosteriods while 50pc used them in combination with various fairness creams and 34pc patients used fairness creams exclusively.

Citing other localized studies including the one by the World Health Organisation, the research pointed out that these creams (names mentioned in the study) had very high toxic levels of mercury and no warning was found on their leaflet or label.

“Another study revealed the presence of lead, cadmium, copper and other heavy metals,” it said.

Expressing similar concerns, Dr Zahra Yaqeen, the head of the pharmaceutical centre, Pakistan Council of Scientific and Industrial Research (PCSIR), Karachi, noted that a number of easily available fairness/whitening creams had been tested at their facility and were found to have corticosteroids (considered as the last resort therapy) and high level of mercury.

“Some other ingredients used in skin lightening/fairness creams are mercury, hydroquinone, ascorbic acid and tretinoin. All of them carry side-effects and, while some of them are suggested not be used at all [steroids and mercury] in cosmetics, others are recommended to be used under medical supervision.

“Mercury gets absorbed in the body and damages brain, kidneys and reproductive system. The same case is with corticosteroids, though they also make the skin thin. The latter must be used only on doctor’s recommendation,” senior scientific officer at the PCSIR centre Dr Shazia Yasmeen points out.

When contacted, Pakistan Standards and Quality Control Authority (PSQCA) director general Mohammad Khalid Siddiq said that the authority had revised standards for cosmetics upon receiving complaints against skin lightening products.

“A request has been sent to the ministry of science and technology to include cosmetics in the list of technical regulation. Once it is approved, the authority will start checking their sale in the market,” he says.

According to the revised PSQCA standards, corticosteriods and heavy metals such as lead, arsenic, hydroquinone and mercury shouldn’t be the part of cosmetic raw material at all.

Sharing her experience, seasoned beautician Masarrat Misbah, one of the complainants who approached the PSQCA on fairness cream issue and a social worker working for burn victims’ welfare, said that she came to know about these harmful creams when she saw their side-effects on the faces of some burn victims.

“I was shocked to see their faces. Their skin condition had worsened,” she said, emphasising the need for public awareness on the issue.

“The fact that prolonged use of creams containing toxic levels of mercury also affects reproductive health should raise an alarm among the public, especially parents and girls.

“Apart from the treatment cost, the emotional trauma girls go through after using such creams is huge and affects the whole family,” she says, suggesting that girls should eat healthy food and have positive thinking that would make their skin glow automatically.

“As a society, we must discourage the mindset that fair is beautiful.”

Published in Dawn, December 5th, 2016