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).

HEALTH KNOWLEDGE AND ATTITUDE REGARDING BLEACHING AGENTS IN WEST SAUDI ARABIA 103 The harms caused by using skin beaching products result from acute or chronic long-term exposure to some hazardous chemical agents that may be present in these products (14). With this globally growing phenomenon studies from Saudi Arabia are still very few (15, 16) to assess the magnitude of the problem and to explore the knowledge, attitudes, and patients’ practices toward using TPAs among Saudi women. There may be a high use of skin-lightening products (containing mercury) in Saudi Arabia (15). Alghamdi confi rmed the importance of evaluating skin bleaching practice in Riyadh (central Saudi Arabia) to protect women’s health (16). Our study is the fi rst report from west Saudi Arabia to investigate the patients’ need toward education and counseling regarding the use of TPAs. The main objectives of this study were to estimate the prevalence of the use of TPAs, potential health effects, and to explore the knowledge of women attending governmental hospitals clinics at Al-Madinah Al-Munawwarah city (west Saudi Arabia). PATIENTS AND METHODS This is a cross-sectional study aiming at investigating the patients’ attitudes and needs toward health education and counseling regarding the use of TPAs. The study was carried out at Al-Madinah Al-Munawwarah city. It is located at the northwestern region of the Kingdom of Saudi Arabia (KSA) and is considered to be the second holiest Islamic city after Makkah. Al-Madinah is the city of peace and tranquility and is a place of numerous historical and archaeological sites. In Al-Madinah Al-Munawwarah city, there are three general hospitals belonging to the Ministry of Health King Fahad, Ohud, and Al-Ansar hospitals where the study was carried out. POPULATION AND SAMPLING The study was conducted in three hospitals King Fahad tertiary care hospital, 680 beds Ohud Secondary care, 250 beds and Al-Ansar secondary care with 100 beds. All women aged between 16 and 60 years, attending outpatient clinics at the three general hospitals, were involved in this study throughout the period of study conduction (March–April 2016) and constituted the study population. The minimum sample size for this study has been decided according to Swinscow (17) as follows: n = Z2 × P × QD2 (1) where: n: Calculated sample size Z: The z-value for the selected level of confi dence (1-- ) = 1.96. P: The estimated prevalence of using TPAs in the population = 38.9%, i.e., 0.389 (16). Q: (1 - P) = 61.1%, i.e., 0.611 D: The maximum acceptable error = 0.04. So, the calculated minimum sample size was: n = (1.96)2 × 0.389 × 0.611 = 571. (0.04) (2)