Complications of Chronic Use of Skin Lightening Cosmetics

International Journal of Dermatology

2008,

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, 344–353 © 2008

The International Society of Dermatology

344

Abstract

Skin lightening (bleaching) cosmetics and toiletries are widely used in most African countries.

The active ingredients in these cosmetic products are hydroquinone, mercury and

corticosteroids. Several additives (conconctions) are used to enhance the bleaching effect.

Since these products are used for long duration, on a large body surface area, and under hot

humid conditions, percutaneous absorption is enhanced. The complications of these products

are very serious and are sometimes fatal. Some of these complications are exogenous

ochronosis, impaired wound healing and wound dehiscence, the fish odor syndrome,

nephropathy, steroid addiction syndrome, predisposition to infections, a broad spectrum of

cutaneous and endocrinologic complications of corticosteroids, including suppression of

hypothalamic-pituitary-adrenal axis. In this era of easy travels and migration, African patients

with these complications can present to physicians anywhere in the world. It is therefore critical

for every practicing physician to be aware of these complications.

Blackwell Publishing LtdOxford, UKIJDInternational Journal of Dermatology0011-9059Blackwell Publishing Ltd, 2007XXX

Report

Complications of skin lightening cosmetics

Olumide

et al.Case report

Complications of chronic use of skin lightening cosmetics

Yetunde M. Olumide,

MD

, Ayesha O. Akinkugbe,

MD

, Dan Altraide,

MD

, Tahir Mohammed,

MD

, Ngozi Ahamefule,

MD

, Shola Ayanlowo,

MD

, Chinwe Onyekonwu,

MD

, and Nyomudim Essen,

MD

From the Dermatology Unit, epartment of Medicine, College of Medicine, Lagos, Nigeria

Correspondence

Y. Mercy OlumideDepartment of MedicineCollege of Medicine of the University of LagosP M B 12003, Lagos, NigeriaE-mail: [email protected]

A middle-aged Nigerian lady was recently brought home todie from a Western European country because she developed anuncontrollable diabetes mellitus and evidence of hypothalamic-pituitary-adrenal axis suppression. On clinical examination,the lady had dense stigmatas of chronic use of skin lighteningcreams, which was confirmed through history. Majority ofmedical practitioners outside subsaharan Africa may not befamiliar with this habit of bleaching the skin nor the cutaneousand extra-cutaneous complications of this widespreadcosmetic habit of black Africans. Furthermore, these cosmeticsand toiletries are not sold in the regular departmental stores norpharmacy shops in Europe and North America. They are eithermanufactured purely for export to Africa or are exportedfrom Africa to Europe and N. America so that they are sold onlyin local shops in ghettos patronized by the black Africans.

This paper sets out to give a brief review of this problem sothat practitioners worldwide would be aware of these compli-cations which may at times be fatal.

Literature review

The use of skin bleaching agents or lighteners has beenreported in many parts of the world, such as Kenya,

1

Ghana

2

South Africa

3,4

Zimbabwe

5

USA

6,7

Great Britain

8

and Saudi-Arabia.

9

Various chemicals have been used with consequentundesirable side-effects. While phenols were reported to have

been associated with ochronosis

10

the mercurials wereimplicated in nephropathy.

1,9

Addo in Ghana has alsoreported squamous cell carcinoma associated with prolongedbleaching.

11

A survey done in Mali reported that 25% of two hundredand ten women developed 74 different side-effects from theuse of bleaching creams.

12

Similarly, in a refugee camp inBalkan, 22.3% of the inhabitants including children werefound to have high concentrations of urinary mercury, whichwas traced to the use of mercury containing bleachingointments, supplied.

13

Exogenous ochronosis was first reported in 1906.

14

Itcommonly presents as asymptomatic blue-black macules onthe malar areas, temples, inferior cheeks and neck.

15

Thiscondition resembles endogenous ochronosis in the skinhistologically, but does not exhibit any systemic complicationsor the urinary abnormality. Hydroquinones are by far themost common offending agents, but phenol, quinine injectionand resorcinol have also been implicated.

16

In South Africa, where the first reports of complications ofhydroquinone abuse was reported, the government was pre-vailed upon in 1980 to set an upper limit of 2% hydroquinonecontent in cosmetic products.

17

Britain and the United Statesof America also limit the concentration of hydroquinone incosmetic products to a maximum of 2%, and in dermatologicalpreparations to 4%. Although it was originally believed that

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The International Society of Dermatology International Journal of Dermatology

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Report

only high concentrations of hydroquinone were causal therehave been reports of ochronosis after use of 2% hydroquinonepreparations.

18–20

It has also been suggested that the percentageof hydroquinone quoted by a manufacturer may not representthe true concentration of hydroquinone in a product.

21

It maybe that it is not the high concentration of hydroquinone, butrather, extended use of this substance, which causes thedisease. An analysis of 41 bleaching creams available over thecounter in the UK in 1986 by Boyle and Kennedy revealedthat eight contained more than 2% hydroquinone.

22

The scenario in Nigeria

23–33

The use of skin lightening creams has become a seriousphenomenon widely practiced by both men and women inNigeria. In a study of four hundred and fifty Nigerians whoconfessed the use of bleaching creams, 73.3% were womenand 27.6% were men. The use of bleaching creams cutsacross all sociodemographic characteristics. People of allreligious groups, single or married, rich and poor, literate andilliterate, low, middle and upper class use the products.

Various reasons were given for using the products. Some ofthese are to look more attractive; to go with existing fashiontrend; to treat skin blemishes like acne or melasma; to cleanseor “tone” the face and body; or to satisfy the taste of ones spouse.Although the men also use the products for the above reasons,some of them claimed they use the creams because their wivesuse them; and some male marketers of female cosmetics andtoiletries claim they use the products to advertise their wares.Some of the men are homosexuals. The habit of bleaching theskin is most rampant among commercial sex workers whocamouflage their occupation in the clinic data as “fashiondesigner” because of the opprobium attached to prostitution.It is noteworthy that even some people who are naturally fairin complexion, still use the bleaching creams to “maintain” thelight skin color and prevent tanning or blotches from sunlight.

As a result of both medical and public outcry against thedamaging effects of the skin lightening creams, the NationalFood and Drug Agency of Nigeria (NAFDAC) had initiallyallowed a maximum of 2% hydroquinone in bleachingcreams. However, due to the adverse side-effects associatedwith long-term hydroquinone use and also lack of compliancewith content and labeling requirements, all forms of bleachingagents were prohibited in cosmetics and toiletries. However,in spite of the ban on these products, both the importationand manufacture of the products have continued unabated.This situation has been fostered largely by the vulnerabilityof the consumers, the inexpensive nature of some of theseproducts, and the advertising agencies, who use light-complexioned ladies to advertise most consumer products(e.g. alcoholic and nonalcoholic beverages, toiletries, cosmetics,textiles, telephone handsets, etc.) both on the electronic andprint media. Hence, the dominant signal being sent to an

undiscerning mind is that light complexioned people arethe beautiful ones.

In regard to ingredient labeling of cosmetics and toiletriesin Nigeria, most products are not registered by NAFDAC,and bear no ingredient labeling nor address of manufacturers.Some are even misbranded, e.g. a product which was labeledas “Betnovate-N” was found to contain Mercury. Further-more, the concentrations of chemicals on the labeledproducts were largely found to be inaccurate on analysis asmost products exceeded the concentrations displayed on theproducts. Since hydroquinone and mercury in cosmetics andtoiletries have been prohibited and have gained some notoriety,manufacturers have now resorted to using synonyms ofhydroquinone to camouflage the products. Some of thesesynonyms include 1, 4-Benzenediol, Quinol, Benzene-1,4-diol, p-Diphenol, p-Dihydroxyl benzene, Hydrochinone,p-hydroxylphenol, Hydrochinonium, Hydroquinol, and

Tequino

l. All corticosteroid preparations can be purchasedover-the-counter in Nigeria. Hence, these products are readilyavailable not only in the pharmacy shops but also amongdrug vendors in the open market place.

Chemicals often used and methods of use

The list of some of the bleaching creams used are given inTable 1, and the contents of some analyzed products are onTable 2. The same products are largely available in the Africancountries mentioned above because of easy cross countrytrade links. The active ingredients commonly used are hydro-quinone, mercury, and a broad spectrum of the very potent

Table 1 A list of some of the bleaching creams used by patients in Nigeria and ingredients as labeled

Cream Ingredients

Movate Betamethasone dipropionateCrusader Vitamed B3 toner 2%, Escalol UV 507, Vit E AllantoinLooking Good 2% hydroquinone, Allantoin, Sunscreen, Vit EPeauclair Hydroquinone, Clobetasol propionateMic Hydroquinone, Dimethicone, D-methyl-PABATura Octyl-Dimethyl PABA, Dimethicone,

Aqua glyceryl, propylene glycol mubberyA3 A-hydroxyl acids, methyl p-benUltra Vitamed B3 toner 2%, Escalol UV 507, Vit E AllantoinVenus Benzophone 3-Dimethicone, CyclomethiconeSwiss collagen Triethanolamine, Carbomer, DimethiconeFashion Fair Betamethasone dipropionateIKB TriethanolamineShirley Natural Essences from botanyAmbi 2% hydroquinone padimateSkin Success 2% hydroquinone OctisalateSivoclaire 2% hydroquinone, Vit E 1.0Fashoin Fair Clobetasol propionate 0.05Tony Montana Stearic Acid, MPG, Sorbitol Jelly, Fragrance


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corticosteroid preparations containing, e.g. Betamethasonevalerate and Clobetasol propionate.

Furthermore, the products are hardly used as marketed andvarious additives are used to “enhance” the bleaching effect.Some of the additives (concoction) are lemon juice, potash,tooth paste, liquid milk, pulverized Naphthalene (camphor)balls – a mothproofing agent, Vitamin C, peroxides andchlorates used in hair dyes. At times detergents are added to theconcoction. Some of the creams have equivalent soaps withsame chemicals incorporated. Indeed, the above listed additivesare not exhaustive.

At the initiation of the bleaching habit, a total body surfaceimmersion “bath” is often used for maximum effect. Thebleaching is then maintained with daily applications of thecreams. Most of the creams are very cheap so it is possible tospend as little as 2 US dollars (about 300 Nigerian Naira) amonth on the bleaching creams to

maintain

the light com-plexion. Continuous use of the chemical is mandatory so thatthe skin does not repigment. Even when the complicationsappear, the bleachers often intensify the use of the chemicalswith the hope that the skin complications would eventuallybe bleached away. Multiple products containing differentchemicals may be used concurrently or sequentially.

The duration of use of the bleaching creams before theonset of complications vary from 6 to 60 months. However,history from patients is often inaccurate, and some even denyuse of the bleaching creams, or pretend not to know theirfunctions due to a guilt complex, because various religiousgroups and the press continue to condemn the practice ofchanging the color of the natural skin.

Pathogenesis and complications

Hydroquinone

Hydroquinone is a dihydric phenol that has two importantderivatives

viz

monobenzyl and monomethyl ether of hydro-quinone. Hydroquinone is known to competitively inhibitmelanin production by inhibiting sulfhydryl groups and actingas a substrate for tyrosinase. The melanosomes and ultimately

the melanocytes are damaged by semiquinone free radicalsreleased during the above reaction.

34–36

With prolonged application and sun stimulation, themelanocytes recover from the damaging effect of the hydro-quinone which passes down into the papillary dermis of theskin. Hence they are actively taken up by fibroblasts and leadto altered elastic fiber production and excretion of abnormalmaterial into new fiber bundles.

37

Furthermore, benzoquinoneacetic acid formed during the oxidative processes in whichhydroquinone is involved, bind and cross link collagen fibersleading to degenerative changes due to altered physico-chemicalbonds.

Histologic examination of exogenous ochronotic lesionsreveals yellow-brown banana-shaped fibers in the papillarydermis. Homogenization and swelling of the collagen bundlesis noted and a moderate histiocytic infiltrate may be present.Sarcoid-like granulomas with multinucleated giant cellsengulfing ochronotic particles have been noted.

38

Transfollicularelimination of ochronotic fibers has also been described.

39

Fibers stain black with Fontana stain and blue-black withmethylene blue stain.

18,40

Ultrastructural examination revealshomogenous electron-dense, irregular structures embeddedin an amorphous granular material infiltrating adjacentcollagen fibril bundles.

42,43

The source of these ochronoticfibers is not clear. Topical hydroquinones may inhibithomogentisic acid oxidase in the skin, resulting in the localaccumulation of homogentisic acid that then polymerizes toform ochronotic pigment.

37,44,45

Pigmented particles may beelastic or collagen fibers.

19,46

Melanocytes may be involved;most cases involve sun-exposed sites and one case is reportedof ochronosis that avoided areas of vitiligo.

19,47

The changesin the collagen bundles may be responsible for the loss ofelasticity and poor wound healing.

Complications of hydroquinone use that have beenreported are dermatitis, exogenous ochronosis, cataract,pigmented colloid milia, scleral and nail pigmentation andpatchy depigmentation.

3,4,15,20,26

The pigmented exogenousochronotic lesions are most marked on sun-exposed areas ofthe body namely, face, upper chest and upper back. Dogliotte

48

described 3 stages of this condition: (1) Erythema and mildpigmentation; (2) hyperpigmentation, black colloid milia andscanty atrophy; and (3) papulonodules with or withoutsurrounding inflammation. Figures 1–3 show exogenousochronosis. Since most commercial sex workers use these skinlightening creams, some of them are HIV positive; and in anattempt to bleach away the pruritic papular eruption (PPE)commonly seen in HIV/AIDS patients, the skin of the extre-mities appear scruffy with the excoriated papules on abackground of ochronotic pigmentation on bleached skin asshown in Figs 4 and 5. A patient developed squamous cellcarcinoma on the site of chronic exogenous ochronosis(Fig. 6). It is not clear if this is a chance finding or an expectedsequelae of hydroquinone induced exogenous ochronosis

Table 2 Contents of some creams analyzed25

Cream Hydroquinone (mg%) Mercury (mg/kg)

Looking Good 1.36 0.17Movate 5.10 0.20Crusader 3.45 0.26Sivoclaire 0.06 0.22Peauclaire 0.06 0.21Mercury 1.68 0.82Mic 0.06 0.22Tura 1.45 0.23A3 0.42 0.18

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with superimposed chronic sun damage on the vulnerableskin. Coalescence of multiple colloid milia may give rise to bignodular lesions particularly on the upper back. The fawncolored pigmentation of all 20 nails may mimic the yellownail syndrome – hence the authors call the phenomenon“

pseudo

yellow–nail syndrome.” Abnormal repigmentationof depigmented skin has also been reported on discontinuingtherapy. This abnormal repigmentation has been attributedto the Meirowsky effect of long wavelengths of ultravioletlight darkening melanin already present in the skin and leadingto a skin color darker than that prior to bleaching. Because ofthis repigmentation, users find it compelling to continue touse the bleaching creams to maintain the newly acquired lightcolored skin. Hence, the inevitable complications fromprolonged use. A more serious complication is loss of elasticityof the skin and impaired wound healing. When cuttingthrough the skin, either for incisional biopsy or other surgicalprocedures, it is as if one was cutting through the skin of acadaver. There is difficulty in apposing the edges of thewounds when stitching, hence the skin often tears through thesuture material. Furthermore, there is often delayed woundhealing. After major abdominal surgeries like Caesariansection, myomectomy, hysterectomy, etc., there may becatastrophic wound dehiscence, burst abdomen, and deathfrom overwhelming infection.

The chronic bleachers also exude an offensive fish odor inthe sweat like the “fish odor syndrome.”

39,40

The “fish odor

syndrome”, also known as trimethylaminuria, is characterizedby body odor of rotten fish. This is due to excretion of achemical, trimethylamine in the breath, urine, sweat, saliva,and vaginal secretions.

41

Trimethylamine (TMA) is produced in the gut mainly bybacterial degradation of choline and lecithin-rich foods, such

Figure 1 Exogenous ochronosis (EO)

Figure 2 Exogenous ochronosis in man

Figure 3 Exogenous ochronosis (EO)


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as salt water fish, eggs, offals (such as intestines, liver, andkidney), and leguminous vegetables such as soya beans.Normally, this compound is converted by TMA oxidase intoa stable nonodorous trimethylamine N-oxide (TMA-oxide)that is then excreted in the urine. In the presence of a defectiveTMA oxidase activity, the accumulated TMA is eliminated asa volatile product in the urine, sweat, and breath, giving theaffected individual the characteristic fishy smell.

The TMA oxidase activity may be defective because of acongenital, inherited impairment of N-oxidation (

primarytrimethylaminuria

) or for other acquired reasons thatinterfere with the action of the enzyme (

secondary trimeth-ylaminurias

). Some of these causes are: (1) overload withTMA precursors, such as choline and lecithin, leading tothe formation of an increased burden of TMA throughenterobacterial degradation; (2) intake of inhibitors ofTMA oxidase, both dietary (e.g. Brussels sprouts) andpharmacologic (e.g. thiourea), and (3) liver and kidneydiseases. In all these cases, the causative agent may actrather as an inducing, precipitating factor in predisposedsubjects, who are carriers of the potential defect as heterozy-gotes. Other causes of fish odor are bacterial vaginosis, andpemphigus vulgaris or foliaceus due to muco-cutaneousbacterial degradation of body fluids.

Hydroquinone is an antioxidant, it may cause the fish odorby reducing the ability to oxidize trimethylamine in chronicbleachers, or hydroquinone may act rather as an inducing,precipitating factor in predisposed subjects, who are carriersof the potential defect as heterozygotes.

Treatment of exogenous ochronosis has been disappointing.Tretinoin gel, cryotherapy, and trichloroacetic acid havebeen tried without benefit. Cases of exogenous ochronosissuccessfully treated with dermabrasion and CO

2

laser

16

andQ-switched ruby laser

49

have been reported.

Figure 6 Squamous cell epithelioma on exogenous ochronosis

Figure 4 Exogenous ochronosis in a patient with PPE

Figure 5 Exogenous ochronosis in a patient with PPE

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Mercury

Mercury exists in three forms: organic, inorganic andelemental. Mercury is a protoplasmic poison, which can beabsorbed by the respiratory tract as vapor or through theskin and gastrointestinal tract as finely dispersed granules,and excreted through the kidneys and colon. Cole

50

observedthat the amount of mercury excreted by the kidneys wasproportional to the quantity applied on the skin. Until somedecades ago, mercury was ubiquitous in medicinal productssuch as those used for treating syphilis, psoriasis, ringworm,ophthalmic solutions, teething powders, and diuretics.Though it is no longer commonly used in medications.

Mercury toxicity after topical applications was noted in1923.

51

Mercury toxicity may manifest in an acute or chronicform. Acute toxicity usually manifests as a pneumonitis andgastric discomfort. Chronic toxicity may be evidenced byneurological manifestations and nephrotoxicity. Both organicand inorganic preparations of mercury have been associatedwith acute and chronic toxicity. Nephrotic syndrome due totopical or systemic use of mercury has been well docu-mented.

1,52

Both membranous glomerulonephritis andproliferative glomerulonephritis were found in patientswho had used mercury containing skin lightening creams.

Mercurious chloride, oxide and ammoniated mercury werefirst introduced into the market during the first decade of the20th century as the active ingredient in cosmetics and toiletries.They eventually became popular as skin lighteners. Followingstudies with electron microscope, mercury bleaches the skinby probably inactivating the sulfhydryl enzymes.

34,53

Theseenzymes, which are called mercaptans due to their ability tocapture mercurial ions, then replace copper by competitiveinhibition leading to inactivation of the tyrosinase moleculeand interrupting melanin production. Paradoxically, chronicuse of mercury can also lead to increased pigmentation,due to accumulation of mercury granules in the dermis.These granules are absorbed via the skin appendages suchas the hair follicles and sebaceous glands into the dermis.Deposition of mercury in keratin also leads to discolorationand brittleness of the nails.

51

Goeckermann

54

noted that abrown-gray discoloration of the face and neck (especially theskin folds and eyelids) was associated with prolonged use ofmercury containing creams.

Corticosteroids

Corticosteroids bleach the skin. It is believed that they lightenthe skin due to inhibition of endogenous steroid productionand thus a decrease in precursor hormone levels. This precursorhormone, propiocortin is also the precursor for melanocytestimulating hormone and thus, such negative feedback willlead to decreased amounts of the hormone. Topical steroidsare also cytostatic to the epidermis. When used over aprolonged period, they decrease the rate of epidermal turnover,with fewer, abnormal, and less pigmented melanocytes on

histology. The skin lightening properties of these prepara-tions have been found to be directly proportional to theirvasoconstrictor (blanching) effect.

Fluocinonide (Topsyn gel), Betamethasone dipropionate(Diprosone), and Clobetasol propionate (Temovate) rate assome of the strongest topical corticoids, and are among thecommonly used bleaching agents in Nigeria. They are readilyavailable in the market place among the battery of bleach-ing creams. When used as cosmetics, they are applied overa large surface area for prolonged periods – several monthsto years. This factor, coupled with the occlusive effect ofenvironmental heat and humidity, promote percutaneousabsorption, and hence, complications. The possible com-plications of chronic corticosteroid use are shown in Table 3.All these complications have been observed among chronicbleachers in Nigeria.

23,24,31–35

Figs 7–14 show some of thecomplications of long-term use of topical corticosteroidsas skin lightening cosmetics. The lower part of the axilla isa favored site for steroid folliculitis (Fig. 7) and both sides

Table 3 Complications of topical steroids59,60

CutaneousAtrophy of the skin (thinning and fine wrinkling)Telangiectasia, purpura, persistent erythemaSkin fragilityHypertrichosisPerioral dermatitisPustular acneiform eruption (face) – steroid rosaceaFolliculitisStriaeHypopigmentationSteroid addiction syndromePredisposition and masking of cutaneous infection(e.g. Tinea incognito, multiple filiform warts)Allergic contact dermatitis

OphthalmologicGlaucomaCataracts

EndocrinologicCushingoid syndrome with moon facies, buffalo humps, supraclavicular fat padsHyperglycaemia and diabetes mellitusSuppression of hypothalamic-pituitary-adrenal axisSuppression of growth in childrenMenstrual irregularitiesEdemaElectrolyte imbalanceHypertensionPseudotumor cerebri

OthersAseptic necrosis of the head of femurPredisposition to infectionProtein catabolism with negative nitrogen balanceWeakness, vertigoThrombophlebitisOsteoporosis


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are usually symmetrically affected. The striae are oftenvery wide (gaping) and erythematous (Figs 8–10). Overtfeatures of Cushing’s syndrome – “mooning” of the faceand truncal obesity (Fig. 10) are frequently seen. Some ofthem, at the time of presentation, have already developedsystemic manifestations like glucose intolerance andhypertension.

Steroid addiction syndrome

The steroid addiction syndrome is the result of chronic dailyapplication for greater than a 1-month period of a potent ormoderately potent glucocorticosteroid preparation to thefacial skin, neck, scrotum or vulva. These tissues become“addicted” to the topical steroid, so that withdrawingthe topical steroid results in severe burning which is onlyrelieved by further steroid applications. As applicationcontinues, the patient experiences a rebound vasodilata-tion. Permanent redness of the facial skin eventuates,with thinning and fine wrinkling of the skin. Indeed theredness is so striking that the authors call the phenomenon“L’homme rouge.” For unexplainable reason, this perma-nent redness is more pronounced on male bleachers.Furthermore, the thinning and wrinkling of the skin onthe neck gives a rippling pattern like the neck of a pluckedchicken, rather reminiscent of pseudoxanthoma elasticum

Figure 7 Steroid folliculitis

Figure 8 Steroid folliculitis

Figure 9 Steroid striae

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Figure 10 Cushion’s syndrome

Figure 11 Tinea faciei and’Pseudo-pseudo xanthoma elasticum′ on the neck

Figure 12 Tinea corporis

Figure 13 Tinea incognito in a child


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– hence, the authors code this complication of steroid as“

pseudo

-pseudoxanthoma elasticum.” (Fig. 11) Somebleachers claim that they developed the habit of chronicsteroid use while trying to treat acne. They experiencedgood response initially due to the anti-inflammatory effectof the steroids. Abruptly stopping the topical steroidspreparation will result in increased numbers of papules andpustules over the subsequent days – a “rebound phenomenon.”The patient soon finds it difficult to stop the steroid and thefacial skin then develops persistent redness, and acneiformpapules and pustules located on the nose, chin, cheeks, andlower eyelids – acne rosacea.

Predisposition to infections

A very common observed complication of steroid onchronic bleachers is dermatophyte infection. Tinea faciei(Fig. 11) is common in these patients and may mimic cuta-neous lupus erythematosus or rosacea.

55–57

Very bizarre andextensive Tinea corposis and cruris (Fig. 12) are often seen,which are readily transmitted to the spouse and baby.Hence, it is common to find the trio of wife, husband andbaby with Tinea incognito. Older children are not part ofthis phenomenon. The wife often transmits the fungal infec-tion to husband and baby because of close body contact.Figure 13 shows a child with Tinea incognito on the fore-head, acquired from the infected skin of the mother whilefeeding on her breast. The clinical presentation of thesesteroid induced dermatophyte infections are often atypical– hence the term Tinea incognito. Tinea versicolor couldalso be very extensive, and is usually pigmented with dirtybrown scales.

Also, multiple histologically proven viral warts arefrequently found on these chronic bleachers. They oftenappear in an eruptive manner – rather reminiscent of eruptiveseborrheic keratosis (

Leser-Trélat sign

). Hence the authorscall this complication “

pseudo

-Leser-Trelat sign.” They are

multiple tiny filiform warts, common on the neck and uppertrunk (Fig. 14).

Paradoxically, topical corticosteroid preparations mayinduce allergic contact dermatitis.

58

This complication shouldbe considered in any patient with an eczematous dermatitiswho becomes worse or is refractory to topical steroidtreatment.

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Figure 14 Eruptive filiform wart (“Pseudo Lesser-Trélat sign”) note gaping striae

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Complications of Chronic Use of Skin Lightening Cosmetics