Skin bleaching formulas refers to the use of the chemical product to lighten skin color sometimes for therapeutic purposes but more common for cosmetic purpose [1]. There is a high prevalence (25-96%) of skin bleaching use in African and Asian people for several previous decades [2,3]. A significantly higher proportion of skin-lightening product users believed that lighter skin tone plays a role in self-esteem, the perception of beauty and youth, marriage and employment chances when compared with non-user, the colonial legacy in South Asia is said to be one of the contributory factors for the belief that white is dominant and white is beautiful as normally the white race was the director and the dark natives were the directed [4]. Several fairness cosmetics may include skin bleaching products like hydroquinone, high potent steroids, mercury, hydrogen peroxide and magnesium peroxide among others. These may cause many side effects including dermatological, neurotoxicity, mercury induced nephropathy and immune-toxicity [5].

It is reported that up to 60% of those who practice skin lightening may suffer from at least one complication [6]. Health problem related to skin lightening products add a burden on health care services and on the economy of many developing countries. In a Saudi study conducted in Riyadh region, only 26.7% of the women used bleaching products for medical purposes to treat abnormal skin hyperpigmentation, 20.8% were ready to use any skin lightening product that gives quick effects [7]. Evidence showed that about 45% of the tested skin-lightening cream in Saudi Arabia contained mercury at levels well above the FDA's acceptable limit of 1 ppm [8]. There is no previous study aimed to assess the prevalence skin lightening use among female in Taif area, thus this study aimed to investigate the extent of use of bleaching agents among women as well as the determinants of this use.

This was a cross-sectional study design that carried out in Prince Mansour Military Hospital in Taif city. Prince Mansour Military Hospital founded in 1951 and accommodates 210 beds. The hospital provides a high-quality care in family and community medicine. Taif City is a city in the Makkah Province of Saudi Arabia at an elevation of 1,879 m (6,165 ft.) on the slopes of the Sarawat Mountains. It has a population of ≈ 993.8 (General Census of Population and Housing in 1435 AH). This study recruited the Saudi female attendees of family medicine clinics at Prince Mansour hospitals. The sample size was determined according to the statistics of the patient’s affairs Prince Mansour Military Hospital in Taif where the researcher found that the average number of monthly attendees of female clinics of family medicine department is 5500 attendees/month. Using EPI info version 7, sample size of population is determined by calculation of expected frequency of participant’s awareness =50% with 95% confidence interval; thus sample size was 359 participants. The participants to see each day was selected using “systematic random sampling”technique with spacing unit (K) between sample fractions equal to 3 (40÷12 ≈ 3). The first patient to select at the beginning of each working day was randomly selected from the first arriving 3 patients, and then every 3rd patient was invited until the entire 12 patients had been interviewed, by the end of the day. The procedure was repeated daily in each clinic until the entire sample population has all been covered over.

The instrument of the data collection was an Arabic language selfadministered questionnaire with a letter explaining the need for the study without mentioning names to ensure confidentiality. The questionnaire consisted of personal information such as age, education level, marital status, job, and income. Prevalence of use of skin lightening products, knowledge of skin lightening products, reasons for use, application practice, and products source. Respondents’ perceptions about lighter skin use, side effects. In order to calibrate the questionnaire, the researcher distributed the questionnaire to three consultants included a family medicine physician, a dermatologist consultant and a public health consultant.

Data were collected and verified, variables were coded and entered to Statistical Package for Social Sciences (SPSS) software version 20, developed by IBM Corporation, with a help of a biostatistician. Descriptive statistics, e.g., number, proportions, cumulative proportions, mean and standard deviation, etc. will be displayed, as appropriate. Analytically, parametric and nonparametric techniques were used as required. All results of tests with pvalue equal or <0.05 were considered “statistically significant’’.

The Regional ethical committee approved the study protocol. Written consent was obtained from Prince Mansour Hospital administration before starting the study. Also, a consent was taken from each participant to voluntary participate in the study. Each participant was kept anonymous, and all information was used with respect the confidentiality and only the researcher and the statistician had access to the completed questionnaires.

This study was done on females aged between 18-55 years old, with mean age 34 years ± 10.6. The amount of monthly used cream was ranged between 20-180 grams with mean 41.7 ± 28 grams. The mean cost of monthly use was 210 SAR (Table 1).

Table 1: Background characteristics of the respondents.

This study found that about a quarter of women were currently using creams, while 39.6% were previously use creams (Figure 1).

Figure 1: The prevalence of use of skin bleaching agents among Saudi women in Taif area.

Approximately, 53% of females were either current or previous users of skin bleaching creams, while 12% of females were previous users and still creams at the time of the study. The source of bleaching cream was reported as 38.1% of users obtain creams by medical prescriptions, 27.8% of them bought creams from pharmacy without prescriptions, while 23.2% of them bought them from markets and 10.8% from beauty shops (Table 2).

Table 2: Practices of women using bleaching creams of the skin.

In regards to chemical composition of these bleaching creams, they were ready-made compounds found in the pharmacy in 55.4% of the cream users, while a pharmacist’s prepared formula was used in 3.6% of cream users, 21.8% were prepared from a traditional formula and 19.2% were cosmetic products not medications. About 31% of females used bleaching creams as treatment for hypo or hyperpigmented skin, 29.4% used them only for cosmetic purpose, while 29.4% of them used skin bleaching creams for both curative and cosmetic purposes.

Regarding use of creams during pregnancy, it was found that only 8% of females used skin bleaching creams during pregnancy, while 92% did not use them. Concerning use of skin bleaching creams during lactation, it was found that 31.4% of females used creams during lactation, while 68.6% did not use them during lactation. The frequency of use among studied women varied widely, 30.2% used skin bleaching creams once a day, and 45.5% used them twice a day, while 7.4% used these creams three times a day (Table 2).

The knowledge and attitudes among women towards using bleaching creams was explored in this study, 34.8% agreed with use of skin bleaching creams prepared by traditional methods, while 28.9% disagreed. In addition, about 33% of women agreed to recommend the use of these creams prepared by traditional methods (Itara), while 30.8% did not agree to recommend this type of preparation (Table 3).

Table 3: Knowledge and attitudes towards using bleaching creams.

Reason behind the use of skin bleaching creams were differed among cream users, about 31.3% of women used skin bleaching creams to increase beauty, 20.1% used them as a new look, 8% use them to increase self-confidence, 1.9% use them to increase stability of marriage and 52% because the use of such creams has perceived as a trend. About 33% of these women used creams that achieve quick whitening effect, while 67.3% did not use this kind of cream. Approximately 24% of cream users strongly agreed that they have a desire of white skin, 51% just agreed, while 15.2% disagreed and 4.2% strongly disagreed. This study found 33.3% of females thought that skin bleaching creams cause skin problems, 41.1% thought they did not, while 25.6% did not know that creams cause skin problem (Table 3).

In regards to the associations between demographics and (current or previous use) of skin bleaching creams, the association between marital status in one side and the current or previous use in another side was not statistically significant (P-value=0.438). However, the association between educational level and current or previous use was statistically significant (P-value=0.00). About 62% of women with university or postgraduate degree were either current or previous users of skin bleaching creams in comparison to 41% of women with secondary school or less or only 13% of illiterate women.

In addition, the association between occupation and current or previous use was significant (P-value=0.024). Women who were employed were had the highest either current or previous prevalence of skin creams use. The association between income and current or previous use was significant (P-value=0.002). Women with income more than 1000 SAR had the highest percentage of bleaching cream use currently or previously. While the association between age group and current or previous use was not statistically significant (P - value=0.245) (Table 4).

Table 4: Associations between demographics and (current or previous use) of bleaching creams.

The cosmetic use of skin bleaching products is a common practice in dark-skinned women [9]. The use of skin lightening creams is common and widespread in the Sub-Saharan African population [10]; also it has been reported in many parts of the world such as Saudi Arabia [11]. The long-term use of these products for several months to years may cause cutaneous or systemic side-effects [12]. The prevalence of the current use of topical bleaching agents in our study (12%) is comparable with other prevalence studies carried out in Nigeria and Senegal. The studies conducted in Nigeria and Senegal showed that the use of cosmetic bleaching products ranged from 53-59% of people surveyed [6,13]. About 31.3% of females use bleaching creams to increase their beauty, this is because of that even skin color is considered a universal sign of youth and beauty [14].

The mean monthly cost of bleaching agents was 210 SAR among studied women; the cheaper cost of such uncontrolled products is likely to be the main reason for their trade [15]. The mean duration of use was 2.44 months; this was not in agreement with Del Giudice et al. [15], in which the mean duration of use was 50.5 months while a few women had used bleaching creams for longer periods, e.g. 20 years. The possible result of such extensive use is the occurrence of cutaneous adverse effects. The number of bleaching products used each month in our study ranged between 20 and 180 g (mean 41.7 g⁄month), which was compared with another study conducted in Saudi Arabia in which the amount of bleaching products used each month was ranged between 2 and 600 g (mean 90.09 g⁄month) [7]. In Nigeria, the quantity varied from 60 to 150 g/month, while in Senegal, the quantity ranged between 15 and 350 g/month [6,13]. The resultant mean of 41.7 g in our study seems quite enough, as 45 g of cream is required on average to cover the whole body [7].

Among the female adult population the use of bleaching creams was higher in single females this was not in agreement with a study done by Pitche et al. 1997 [10], this may be because of that they want to increase beauty to increase their chance of getting marriage. Use of bleaching creams was also higher (50%) in females with higher income; this was in agreement with a study done by Pitche et al. [10]. While it was disagree with Alghamdi et al. where there was no association between income and the use of bleaching products. However, it was expected that women with higher incomes would be the ones capable of paying for such cosmetic products [7]. About 35% of women in this study were agreeing to use cream from Itara (traditional formula); it may be attributed to easy accessibility and availability of traditional products on the streets or in market places. They are sold without any medical prescription and control, and imported from neighboring countries [10], in comparison with Alghamdi et al. study where 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 highlights the importance of managing the problem [7].

Only 8% were use skin bleaching creams during pregnancy, while 92% did not use it during pregnancy, that’s because pregnancy is associated with a particular risk for skin-bleaching use, especially in the last trimester [16]. About 31% of women used bleaching creams during lactation. The pictures were more gloomy in Senegal where 81% of the women carried on with their use during pregnancy and 87% did so during lactation [6,13]. About one third of females were aware that bleaching creams cause skin problems, 41% disagree with the statement that they can cause skin problems, while 25.6% of women did not know whether it can cause skin problems or not. However, the nature and methods of use of skin-lightening products, which are often applied to the whole body over a number of years, expose users to certain additional risks, connected with the passage into the systemic circulation of the active constituents in question. Thus, it appears increasingly clear that the cosmetic use of such products for the purpose of skin bleaching carries serious general risks and some behaviors appear particularly dangerous [16].