A centuries old practice, skin lightening is the use of injections, topical ointments, creams, lotions, gels, soaps, oral formulations, and household chemicals to de-pigment or lighten skin complexion, produce an even skin tone, and remove blemishes, freckles, or scars (de Souza 2008: 28; Jablonski 2012; Street, Gaska, Lewis, and Wilson 2014: 53). (1) Today, skin lightening is a multi-billion dollar, globalized industry, and over the past several decades it has emerged as an increasingly popular practice in many parts of the world (Charles 2003; Coopernov 2016; Glenn 2008).
Skin lightening is often driven by an array of factors, including the structural and societal elevation of light skin, as well as dermatological issues. A significant amount or work has found that skin lightening is associated with numerous and considerable adverse effects and complications (Hunter 2011). While many studies have been conducted on skin lightening, exploring the topic within various contexts around the world, including across Africa, to date, there have been no studies conducted of skin lightening in Eritrea. Using in-depth, semi-structured interviews and focus group discussions, as well as a survey of undergraduates, this paper explores the practice of skin lightening in Eritrea and also examines attitudes, knowledge, and perceptions surrounding the practice.
Significantly, this paper provides an important baseline for the current practice of skin lightening in the country, helping to reveal associated factors and ultimately contributing to and supplementing existing literature. Furthermore, this paper increases awareness about the dangers of skin lightening, and also encourages the development of appropriate prevention and intervention efforts or campaigns.
The outline of the paper is as follows. The next section presents the literature review, and it is followed by the methodology. Subsequently, the results and discussion are presented. The last section presents the conclusion, notes potential steps for policymakers, and offers recommendations for future study.
Skin lightening is the use of injections, topical ointments, creams, lotions, gels, soaps, oral formulations, and household chemicals to de-pigment or lighten skin complexion, produce an even skin tone, and remove blemishes, freckles, or scars (de Souza 2008: 28; Street et al. 2014: 53). Skin lightening products often contain active ingredients, such as hydroquinone, mercury, lead, or corticosteroids, which break down the top layer of skin to lighten skin or disrupt and impede the synthesis and production of melanin, a natural pigment which defines skin color. The application or use of skin lightening products may be daily (or less frequently), and may be to the face, neck, hands, or to other parts of the body. While skin lightening is practiced by both genders, research suggests that it is more prevalent among females (Counter and Buchanan 2004; Fokuo 2009; Hunter 2011: 143; James et al. 2016).
Skin Lightening Around the World
Although skin lightening is a centuries old practice, it has increased in recent years (Charles 2003; Del Giudice and Yves 2002; Hunter 2011: 153; Jablonski 2012; Lewis et al. 2013; Oumeish 2001). Currently, skin lightening is a multi-billion dollar global industry, and it is quite popular within the Caribbean, South America, Asia, the Middle East, and Africa, as well as among dark-skinned populations within Europe and North America (Charles 2003; Coopernov 2016; Glenn 2008).
In India, approximately 60 to 65% of women engage in skin lightening. Skin lightening is estimated to be a multi-million dollar industry that comprises the largest segment of the country's considerable dermatological market, and it is difficult to find beauty products that do not claim to have lightening or whitening properties (Glenn 2008; Nadeem 2014; UNEP 2008; Verma 2010). In Jordan, skin lightening is a common practice among women. For example, in a study exploring skin lightening among Jordanian women, Hamed et al. (2010) randomly distributed questionnaires to a total of 318 women. The researchers found that approximately 61% reported using skin lightening products, with users including women from different age and socioeconomic groups. Similarly, in a study investigating skin lightening and health consequences among female students in Malaysia, Rusmadi, Ismail, and Praveena (2015) found that approximately 61% of respondents utilized skin lightening products. Other parts of Asia where skin lightening is popular include Japan, where the use of skin lightening products has remained at consistently high levels (Ashikari 2005), the Philippines, and South Korea, where white skin has long been preferred and skin lightening has an extensive history (Glenn 2008; Li et al. 2008).
Across much of Africa, skin lightening has "reached epidemic levels" (Hunter 2011: 143). In Nigeria, Africa's most populous country, a community study in Lagos by Adebajo (2002) found that an estimated 77% of women utilized some form of skin lightening product. Furthermore, in a transverse study on a representative sample of 600 women between the ages of 15 and 55 in Dakar, Senegal, Wone et al. (2000) found the prevalence of skin lightening to be 67.2%, with hydroquinone and topical corticosteroids being the most commonly utilized agents. Notably, recent research by Ahmed and Hamid (2017) finds significantly high rates of skin lightening in Sudan. Specifically, in a cross-sectional study of female university students (348 females between 16 and 33 years old), the researchers found that approximately 74% had utilized skin lightening products within the past year. Of note, studies conducted in Burkina Faso and Togo has also found considerably high rates of skin lightening (Koumbate et al. 2012; Traore et al. 2005).
Problems Associated with Skin Lightening
Despite its popularity, skin lightening is a dangerous practice associated with a range of serious health consequences and problems. The dangers associated with skin lightening include severe skin conditions, including eczema, warts, acne, and ochronosis, a form of hyper-pigmentation which causes the skin to turn a dark purple shade (Adebajo 2002; Ajose 2005; Lewis et al. 2011; Street et al. 2014: 63). In a relatively early examination of problems associated with skin lightening, Findlay, Morrison, and Stimson (1975) found that South African women who had used skin lightening products for an extended period suffered from exogenous ochronosis (Findlay, Morrison, and Stimson 1975). Skin lightening may also cause irreversible thinning of the skin, irritation and rashes, skin lesions, blistering, scabs, scarring, stretch marks, severe discoloration, and a reduction in the skin's resistance to bacterial and fungal infections (Ajose 2005; de Souza 2008; Durosaro et al. 2012: 43).
Other problems associated with skin lightening include kidney damage, hypertension, elevated blood sugar, immunosuppression, mercury poisoning, and the risk of cancer (Addo 2000; Ajose 2005; Glahder, Appel, and Asmund 1999; Harada et al. 2001; IPCS 2003; Kooyers and Westerhof 2006; Peregrino et al. 2011; Street et al. 2014: 54). Furthermore, the use of skin lightening products may be associated with anxiety, psychiatric morbidity, depression or psychosis and peripheral neuropathy (Glahder et al. 1999; Kpanake, Sastre, Sorum, and Mullet 2008; Karamagi, Owino, and Katabira 2001; Ladizinski, Mistry, and Kundu 2011; UNEP 2008). Of note, skin lightening by pregnant women can lead to significant consequences for offspring. A study in Senegal found that pregnant women who used skin lightening products had a statistically significant lower plasma cortisol level, a smaller placenta, and presented a higher rate of low-birth-weight infants (Mahe et al. 2007).
Although skin lightening products have been banned or heavily regulated in many countries, they often remain easily accessible over-the-counter or available via black market, unregulated channels, including from roadside vendors, within market districts and backstreets, and on the Internet (Ahmed and Hamid 2017; de Souza 2008: 28; Keane et al. 2001). Consequently, consumers often do not understand proper usage or application procedures (e.g. concurrent use of several products), lack information regarding potential adverse or harmful effects, and may be unaware of the product's concentration of toxic or chemical ingredients. For example, products obtained through unregulated or black market channels may contain anywhere from 4 to 25% hydroquinone, far exceeding recommendations of the World Health Organization (WHO), dermatologists, and other health agencies (de Souza 2008; Blay 2009). (2)
Causal Factors for Skin Lightening
There are many different reasons that individuals may seek to lighten their skin (Hunter 2011: 149). One often noted motivating factor for skin lightening is because light and white skin has historically been associated with beauty and attractiveness (Glenn 2008; Hunter 1998). In the US, for example, African Americans were long judged to be more attractive if their skin was light in color, and the country's ideal of female beauty "puts a premium on lightness and softness mythically associated with white women" (Kramer 2011: 76; Thompson and Keith 2001; West 2001: 130).
Notably, in many parts of the world, lighter-skinned individuals, particularly women, are considered more beautiful and more likely to find a spouse (Hall 1995: 176; Hunter 1998: 522). Within Indian matrimonial and mate-seeking websites, eligible brides and grooms regularly note that their skin is of "fair complexion" (Jha and Adelman 2009), while in a study exploring skin color and skin lightening in Ghana, Fokua (2009) found that women with lighter skin were perceived to be more attractive and more desirable to the opposite sex than those with darker skin. Interviewing 30 women, Fokua (2009) discovered...