Skin lightening cream: An Emerging Medical Challenge — ASN Events

Skin lightening cream: An Emerging Medical Challenge (#117)

Rebecca F Goldstein 1 , Helena J Teede 1 , Carolyn A Allan 1
  1. Endocrinology, Southern Health, Melbourne, VIC, Australia

A 24-year-old Sudanese woman presented with one month of fatigue, dizziness, abdominal distension and facial oedema. Hypocortisolaemia was present: morning cortisol 13 nmol/L (RR 240-620nmol/L), afternoon cortisol 9 nmol/L (RR 100 -280nmol/L). 

She appeared Cushingoid (moon facies, central obesity, skin fragility, striae) with skin depigmentation on face, back and hands. Blood pressure was 130/80 mmHg, fasting glucose 7.3 mmol/L (RR 4-6 mmol/L) and HbA1c 7.0% (RR<6.0%). ACTH was < 2pmol/L (RR 0–10pmol/L), with inadequate cortisol response to ACTH (169nmol/L at 60 minutes). Screening for exogenous glucocorticoid exposure revealed prolonged use of three skin lightening creams containing hydroquinone, 0.05% clobetasol proprionate and 0.05% betamethasone respectively. She was advised to cease the creams, and weaning treatment with short-term glucocorticoid replacement and hypoglycaemic therapy was initiated.

Skin lightening product use in African women is common (~25%)¹. These may contain potent corticosteroids, eg. clobetasol propionate and betamethasone dipropionate (super potent; class 1), and fluticasone propionate (potent; class 3)².  Corticosteroids decrease propriocortin (precursor for melanocyte signalling hormone) and cause epidermal cytostasis; prolonged use may reduce epidermal turnover, with fewer and less pigmented melanocytes³.

Severity of complications depends on potency, quantity, duration and extent of application.  Cutaneous complications include atrophy, telangiectasia, dermatitis, acne, striae, purpura, hypopigmentation and skin addiction syndrome². Endocrine complications include Cushing syndrome, diabetes mellitus, hypertension, oedema, menstrual irregularities and osteoporosis. Prolonged inhibition of HPA-axis may result in hypoadrenal crisis if the product is withdrawn abruptly. Application of 50g/week of clobetasol proprionate (3.5g applied twice daily) may cause secondary adrenal failure⁴: this equates to 500g/wk of 1% hydrocortisone⁵.

Lightening creams are exported to, and manufactured locally within, African countries (eg Nigeria) with high usage³. 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.



  1. Mahe A, Blanc L, Halna JM et al. An epidemiologic survey on the cosmetic use of bleaching agents by the women of Bamako (Mali)]. Ann Dermatol Venereol. 1993; 120 (12): 870-3.
  2. Hennge UR, Ruzicka T, Scwartz RA et al. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol 2006: 54: 1-15.
  3. Olumide YM, Akinkugbe AO, Altraide D et al. Complications of chronic use of skin lightening cosmetics. International Journal of Dermatology 2008; 47: 344-353.
  4. Allenby CF, Main RA, Marsden RA et al. Effect of adrenal function of topically applied clobetasol propionate. Br Med J 1975: 4: 619-621.
  5. Derm NZ: The dermatology resource. The website of the New Zealand Dermatological Society Incorporated, 2012. (accessed 15/04/2012).