Abstract
Introduction: Skin-whitening products, often containing mercury, are used worldwide for cosmetic purposes but pose significant health risks. Mercury, a melanotoxin, can cause severe dermatological, renal, and neurological complications. Case Presentation: We report the case of a 27-year-old woman who developed severe nodulocystic acne due to chronic use of a mercury-containing skin-whitening cream. Treatment with isotretinoin and prednisolone led to significant improvement within 3 months. Conclusion: This case underscores the need for public awareness and stricter regulatory actions to prevent mercury-related health hazards from skin-whitening products.
Introduction
Skin-whitening products, also called skin-lightening or bleaching products, are a type of cosmetic that is applied to the skin. They may be sold as creams, lotions, ointments, gels, and soaps [1]. These products, which promise a fairer complexion and a smoother, whiter skin tone, have gained popularity in various cultures and communities, especially in African, Asian, Latin, and Middle Eastern countries [2]. Most cosmetics are widely used and have an excellent safety record. However, concerns have emerged regarding the ingredients of certain skin-whitening products, such as mercury. Mercury, a naturally and artificially occurring potent heavy metal, is known for its toxicity. Agriculture and industry are the primary anthropogenic sources [3]. The health hazards associated with chronic mercury poisoning include neuropathy, encephalopathy, interstitial kidney disease, dermatological problems, and fertility problems [4, 5]. Therefore, consumers may be unknowingly exposed to the detrimental health effects of mercury toxicity in their pursuits of beauty. A recent systematic review concluded that mercury is found in 24.9% of the skin-lightning products analyzed, with significant variability in mercury concentrations across different products and geographic regions [6]. The Saudi Food and Drug Authority (SFDA) has established local guidelines and warnings against the severe repercussions associated with mercury exposure. However, such items are still available for purchase online and in local mini-markets. Herein, we report the case of a 27-year-old woman who developed severe nodulocystic acne vulgaris induced by the chronic use of a high level of mercury-containing skin-whitening cream.
Case Report
A 27-year-old Asian woman presented at the outpatient dermatology clinic with pronounced facial skin lesions that progressed in severity within days. Initially, she experienced mild erythema, which progressed to nodulocystic lesions. She had no previous history of acne or other dermatological disorders. However, a thorough examination of her medical history revealed that she had been consistently using a commercial skin-whitening cream for nearly 3 months preceding the onset of her acne. Further investigation revealed that the applied product contained elevated levels of mercury. Cutaneous examination revealed severe nodules and cysts against an erythematous background on both right and left cheeks and extended to the temples and neck (Fig. 1). Laboratory tests revealed elevated levels of mercury in the blood and urine, confirming mercury toxicity. The patient was diagnosed with severe nodulocystic acne vulgaris secondary to the chronic use of mercury-containing skin-whitening cream. She was treated with isotretinoin 30 mg. In addition, prednisolone 50 mg was administered for 1 week and reduced to 25 mg the following week. At a detailed 3-month follow-up, the patient exhibited notable clinical improvement of the facial lesions (Fig. 2). Long-term monitoring of patient outcomes included regular liver function tests and lipid profiles, as well as continued dermatological assessments.
Discussion
Our case highlights the urgent need for public awareness and regulatory action to prevent mercury-related health hazards, including the non-direct forms of mercury purchased as a commercial skin-bleaching product. During the diagnostic process, differential diagnoses such as acne mechanica, drug-induced acne, and chloracne were considered. However, the patient’s history of mercury-containing cream use and elevated blood mercury levels confirmed mercury-induced acne. The prevalence of skin-whitening product use has substantially increased in specific cultures and communities, driven by the perceived benefit of achieving a lighter complexion and a whiter skin tone. This trend is particularly prominent in African, Latin, Asian, and Middle Eastern communities, as evidenced by the case of our patient of Asian ethnicity [2]. These products contain various active ingredients such as hydroquinone, corticosteroids, mercury, and lead [7].
Mercury is a potent neurotoxin and a well-documented melanotoxin that can be absorbed through the skin, which can lead to a range of adverse health effects. Mercury is added to lightening creams because it suppresses melanogenesis in epidermal melanocytes by inactivating mercaptans. This leads to the inactivation of tyrosinase, which is an important catalyst in melanin formation [8]. Studies have shown that prolonged exposure to skin creams containing mercury can result in skin rashes, discoloration, scarring, and increased epidermal thickness [9]. Moreover, toxic metals can accumulate in the body over time, which eventually affects the central nervous system and vital organs such as the ovaries and kidneys [4, 5]. The use of mercury-containing skin-whitening creams poses significant health hazards. The use of these products has caused concern from health professionals and regulatory bodies, and the lack of public awareness poses a great risk to the community. Some skin-whitening cream manufacturers in Thailand, China, and Taiwan are aware of the dangers of mercury exposure and have adjusted their products accordingly. However, some manufacturers continue to use mercury, despite the efforts of their local food and drug authorities to warn consumers against such products [10]. Over the past few decades, the SFDA has instituted comprehensive local guidelines, advisories, and product recalls to alert consumers to the profound health risks linked to mercury exposure [11]. Despite regulatory measures, these products remain illegally accessible for purchase. Moreover, people remain unaware of the potential adverse effects and health hazards associated with mercury-containing skin-lightening products. This may result in toxic complications following long-term use.
Recommendations for the International Food and Drug Authorities
Given the severity of the health hazards associated with mercury-containing skin-whitening creams, it is crucial for regulatory bodies, such as the SFDA and Saudi Ministry of Health, to take decisive actions. A comprehensive ban on the import, export, sale, and distribution of these products should be implemented to protect the health and well-being of the population. In addition to enforcing a ban, the SFDA should prioritize raising awareness of the dangers of mercury-containing skin-whitening creams. Public education campaigns can be instrumental in informing consumers regarding the risks associated with these products and in promoting the use of safe and regulated alternatives. Collaboration between dermatologists, healthcare professionals, and beauty industry stakeholders will enhance the reach and impact of awareness initiatives. Moreover, the SFDA should strengthen regulatory measures to ensure thorough screening of cosmetic products entering the Saudi market and screen imported products purchased from online shopping platforms. Stringent testing protocols should be established to detect and prevent the sale of skin-whitening creams containing mercury. Collaboration with international organizations and the adoption of best practices from countries that have successfully tackled this issue will contribute to the development of robust regulatory frameworks.
Conclusions
Addressing the health hazards associated with mercury-containing skin-whitening creams will require a multifaceted approach involving regulatory interventions, public awareness campaigns, and collaboration with various stakeholders. By taking proactive measures, the FDA can play a pivotal role in safeguarding the health of its citizens and promoting a culture of safe and responsible cosmetic use. Moreover, dermatologists should be aware that mercury-containing skin-whitening products are commonly used, understand the signs and symptoms of acute and chronic mercury toxicity, and be prepared to diagnose symptoms of mercury toxicity in patients who use skin-whitening cosmetic products. Future studies should investigate the long-term health effects of mercury exposure from skin-whitening products and evaluate the effectiveness of public health interventions in reducing the use of these hazardous products.
Statement of Ethics
Ethical approval is not required for this study in accordance with local or national guidelines. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000541141).
Conflict of Interest Statement
The authors declare that there are no conflicts of interest.
Funding Sources
The authors have no funding sources to declare.
Author Contributions
Sami Alsuwaidan: conceptualization, methodology, investigation, writing – original draft, review, and editing, and visualization. Khalid Nabil Nagshabandi: conceptualization, methodology, investigation, writing – original draft, review, and editing, and project administration. Abdulmajeed Alajlan: conceptualization, methodology, investigation, writing – original draft, review, and editing, and supervision.
Data Availability Statement
All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.