J. Cosmet. Sci., 69, 101–120 (March/April 2018) 101 Health Knowledge, Cosmetic Interests, Attitude, and the Need for Health Education Regarding the Use of Topical Bleaching Agents Among Women in West Saudi Arabia: A Cross-Sectional Study MARIAM EID ALANZI, RIYADH A. ALGHAMDI, OSAMA MOHAMMED ALSHARIF, KHALED S. ALGHAMDI, KHALID EID ALANZI, and SALAH MOHAMMED EL SAYED, Family Medicine Postgraduate Program, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia (M.E.A.), Family Medicine Postgraduate Program, Al-Madinah Al-Munawwarah, Ministry of Health, Saudi Arabia (M.E.A., R.A.A., and K.S.A.), Department of Dermatology, King Fahd Hospital, Al-Madinah Al-Munawwarah, Ministry of Health, Saudi Arabia (O.M.A.), Dermatology trainee, Alexandria Faculty of Medicine, Alexandria University, Egypt (K.E.A.), Department of Clinical Biochemistry and Molecular Medicine, Taibah Faculty of Medicine, Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia (S.M.E.L.), Department of Medical Biochemistry, Sohag Faculty of Medicine, Sohag University, Egypt (S.M.E.L.) Accepted for publication January 28, 2018. Synopsis We aimed at investigating the cosmetic interests, public confi dence in cosmetic industry, health knowledge, practice, and need for health education regarding using topical bleaching agents (TPAs) among a relatively big sample size in Al-Madinah (west Saudi Arabia, a conservative eastern society that acquires its social customs from Islam). Islamic values increased women respect and esteem in this society. This is refl ected on cosmetic practices and attitude, e.g. women use face cover outdoors. This issue is vital for both women health and beauty, and is rarely discussed. TPAs use is affected by culture, social customs, and health awareness regarding TPAs chemical constituents, e.g. hydroquinone, mercury, steroids that may harm skin and general health. Ethical committee approval was done for our study that included 531 women (attending the outpatient clinics in March–April 2016) of targeted 571 (response rate was 89.8%). 43.3% (230 women) are current TPAs users. Three hundred and eight-nine women (73.3%) regularly used TPAs to heal pigmented areas like freckles (75.8%) and just to lighten skin color (58.7%). Side effects of discontinuation were restoration of normal skin color (44.3%) or even darker skin (27%), skin dryness (20%) and rash (9.6%). Mercury is recognized as harmful to human health by 30.2%, whereas cortisone was chosen by others (53.2%). Unexpectedly, minority of investigated women (10%) considered using TPAs safe and recognized harms of some ingredients as mercury whereas the majority (70.2%) does not encourage others for TPAs use although they themselves kept Address all correspondence to Salah Mohammed El Sayed at salahfazara@yahoo.com.

JOURNAL OF COSMETIC SCIENCE 102 using TPAs for different reasons. Cosmetic interest is high among women using TPAs, highest among the middle age (26–40 years), and lowest among women more than 40 years (50% versus 17.9%) (p 0.001). Using skin TPAs in west Saudi Arabia is comparable with international standards, higher among educated women, house wives and employed women. This denotes care of married employed women to use TPAs to express beauty to husbands. This is not reduced by work duties and is controlled by conservative Islamic modesty. Health education is mandatory regarding TPAs components and use during pregnancy and lactation. Cosmetic science and industry needs more research to improve TPAs use through providing better safe alternatives for many TPAs components, e.g. mercury and hydroquinone. INTRODUCTION Dermatologists defi ne skin bleaching as “the practice of using chemical substances or any other products with a depigmenting potential in an attempt to lighten the skin tone or improve skin complexion by lessening the concentration of melanin to obtain a reduction of the physiological skin pigmentation” (1). The Saudi society is a conservative Islamic society in general and in Al-Madinah Al- Munawwarah (west Saudi Arabia) in particular where the society acquires its customs from the Islamic manners and values. There, women are well-respected receiving a lot of care by family and society during all her life as a daughter, sister, wife, mother, and grand- mothers. Use of skin topical bleaching agents (TPAs) is an important issue among female patients attending the outpatient dermatology clinics in Al-Madinah. As for expressing the beauty of women (e.g. using TPAs and other cosmetics), this is limited to fi rst-degree relatives, e.g. the husband, father, sons, and brothers but not to other men. Women in Al-Madinah are keen to use a face cover outdoors. That really maintains respect and moral protection from the Islamic point of view. However, there is no study from west Saudi Arabia to shed light on the health issue of using TPAs. We aimed to investigate the cosmetic interests, public confi dence in cosmetic industry, health knowledge, practice, and need for health education regarding using TPAs for cos- metic purposes among a relatively big sample size in Al-Madinah (west Saudi Arabia, a conservative eastern society). This issue is vital for both women health and beauty and is rarely discussed where studies from Saudi Arabia are scanty, especially west Saudi Arabia. Whiteness of the skin is considered an important element in constructing female beauty worldwide, particularly in cultures with black-colored skin (2). Skin bleaching prepara- tions are universally used by women with skin prototypes IV to VI on a cosmetic basis, primarily to lighten normally dark skin (3). Skin bleaching is a growing phenomenon around the world and is becoming a bigger business. The prevalence rates of using skin bleaching products are variable in different parts of the world. They ranged from 24% among Japanese women (4) and 30% among women from Ghana (5) to alarming rates in India (65%) (4) and also in Lagos, Nigeria (75%) (6). Both production and marketing of skin bleaching products are vital issues directly impact- ing female health. Both issues have become a worldwide multibillion dollar industry (4) making it one of the most common forms of potentially harmful body modifi cation prac- tices worldwide (7). That is because the active ingredients used in skin bleaching creams include hydroquinone, (8, 9) highly potent corticosteroids, and mercury salts (10). That can be potentially dangerous and harmful and may carry out several complications rang- ing from dermatologic consequences, e.g. epidermal atrophy, ochronosis, eczema, dermatitis, acne, in addition to more serious health risks, e.g. diabetes, skin cancer, fetal toxicity, renal, and liver impairment and failure (8–13).