Skin lightening: India’s obsession that is becoming a medical problem

“It starts when children are young. The moment a child is born, relatives start comparing siblings’ skin colour. It starts in your own family. But people don’t want to talk about it openly.”

Kavitha Emmanuel is the founder of Women of Worth, an Indian NGO that is standing up to an ingrained bias toward lighter skin. The Dark is Beautiful campaign, launched in 2009, is not “anti-white,” she explains, but about inclusivity – beauty beyond colour. It carries celebrity endorsement, most notably the Bollywood actor Nandita Das. A blog provides a forum for people to share their personal stories of skin colour bias. And the campaign runs media literacy workshops and advocacy programmes in schools to convey messages of self-esteem and self-worth to young children. This is to counteract what Emmanuel says she has seen even in school textbooks, where a picture of a fair-skinned girl is labelled “beautiful” and a darker one “ugly”.

“Some children are really shocked that this is something that has affected them so intensely. Some are in tears,” Emmanuel says.

The perfect life from perfect skin, a life that’s only bestowed upon those of the right shade – that’s the message, the attitude, the mindset that’s being passed down. It’s spawned a multibillion-dollar industry encompassing not just cosmetic creams but invasive procedures such as skin bleaching, chemical peels, laser treatments, steroid cocktails, “whitening” pills and intravenous injections – all with varying effectiveness and health risks. It’s more than a bias, it’s a cultural obsession, and one that’s becoming dangerous.

Multinational cosmetics brands have found a lucrative market: global spending on skin lightening is projected to triple to US$31.2 billion by 2024, according to a report released in June 2017 by the research firm Global Industry Analysts.

The driving force, they say, is “the still rampant darker skin stigma and rigid cultural perception that correlates lighter skin tone with beauty and personal success”.

“This is not bias. This is racism,” says Sunil Bhatia, a professor of human development at Connecticut College. Bhatia has recently written in US News & World Report about “deep-rooted internalized racism and social hierarchies based on skin color”.

In India, these were codified in the caste system, the ancient Hindu classification in which birth determined occupation and social stratum. At the top, Brahmins were priests and intellectuals. At the bottom, outcastes were confined to the least-desired jobs, such as latrine cleaners. Bhatia says caste may have been to do with more than occupation: the darker you looked, the lower your place in the social hierarchy.

This preference for fair skin was perpetuated and strongly reinforced by colonialism, not just in India but in dozens of countries where a European power established its dominance. It’s the idea that the ruler is fair-skinned, says Emmanuel. “All around the world, it was a fact that the rich could stay indoors versus the poor who worked outside and were dark-skinned.”

The final wave of influence is modern-day globalisation. “There is an interesting whiteness traveling from the US to malls [in other countries] featuring white models,” Bhatia tells me. “You can trace a line from colonialism, post-colonialism and globalisation.” Western beauty ideals, including fair skin, predominate worldwide. And with these ideals come products to service them.

In Nigeria, 77 per cent of the country’s women use skin-lightening agents, compared with 59 per cent in Togo and 27 per cent in Senegal. But the largest and fastest-growing markets are in the Asia-Pacific region.

In India, a typical supermarket will have a wall of personal care products featuring “whitening” moisturiser or “lightening” body creams from recognisable brands.

Pooja Kannan, a 27-year-old from Mumbai, spent years buying cosmetics that promised to lighten her complexion. For a while she put her faith in a cream, face wash and soap for treating “skin fairness problems”. She used the products sparingly, since buying new ones still cost her Rs 200 – 300 every two months – equivalent to a week’s worth of travel to her college campus. Over four years of use, she tells me, her skin did lighten up a little, though she wonders whether that was due to the cream or her taking more care when going out in the sun.

Kannan’s natural skin tone looks a healthy light brown to me, but when she was growing up, her elder aunts would shake their heads in disappointment over her complexion. A tan would lead some relatives and classmates to admonish her. “You’ve turned black,” they said. And in India, where skin tone often defines a person’s success in society and their ability to find work or a spouse, that sort of thing matters. Kannan says she brushed off her relatives’ criticism as being from a different generation, but her classmates’ comments made her feel insecure.

“It didn’t affect me right then but when I was getting dressed up to go out, I would remember what they said and put on more make-up,” she says. “Especially when I was in 11th and 12th grades, there were two or three girls who would say these things a lot. They were trying to be helpful but to me it sounded condescending. And it was hypocritical too because it wasn’t like they were fair or beautiful or perfect themselves.”

Society reminded Kannan of it too. She is a professional dancer, and says, “The prettier, skinnier and fairer girls are positioned at the front of the stage. That gets to you.”

This preference for fair skin is reinforced in movies, television programmes and especially advertising. In 2016, actor Emma Watson (of Harry Potter fame) had to issue a statement saying she would no longer endorse products which “do not always reflect the diverse beauty of all women” after criticisms of her earlier appearance in ads in Asia for Lancôme’s Blanc Expert line, used for skin lightening. (In a statement, Lancôme emphasised the product’s “evening” rather than lightening properties, saying that it “helps brighten, evens skin tone, and provides a healthy-looking complexion. This kind of product, proposed by every brand, is an essential part of Asian women’s beauty routines.”)

The Advertising Standards Council of India has attempted to address skin-based discrimination in 2014 by banning ads depicting people with darker skin as inferior, but the products are still marketed. Ads for skin-lightening creams still appear in newspapers, on television and on billboards, featuring Bollywood celebrities such as Shah Rukh Khan and Deepika Padukone. In multiple Facebook posts in April 2017, actor Abhay Deol called out several of his colleagues for endorsing fairness creams, following it up with an opinion piece in the Hindustan Times in which he wrote that “advertising preaches that we would get a better job, a happier marriage, and more beautiful children if we were fair. We are conditioned to believe that life would have been easier had we been born fairer.”

Skin lightening is not the sole preserve of the modern cosmetics industry.

India’s traditional Ayurveda medical system teaches that pregnant women can improve their fetus’s complexion by drinking saffron-laced milk and eating oranges, fennel seeds and coconut pieces. In early 2017, an Ayurvedic practitioner in Kolkata led a session for expectant couples, promising that even dark-skinned, short parents could have tall and fair children.

And a 2012 study by a women’s health charity in India found that childless couples often insisted on and paid more for surrogates who were beautiful and fair, though the woman contributed no genetic material to the baby.

Arguably, nowhere is the fair skin preference as ingrained as in classified ads placed in newspapers seeking a marriage partner. Along with requirements for the prospective bride’s or groom’s caste, religion, profession and education, physical characteristics are listed too. Someone described as “dusky” may be skipped in favour of one who is of a “fair” complexion.

In April 2017, the Times of India media group placed its own notice exhorting parents to emphasise a daughter’s profession and educational qualifications ahead of whether she was “fair”.

“Potential brides spend a lot of money, it’s really unlimited, in the months before the wedding,” says Ema Trinidad, a Filipina beautician who runs a spa in Bengaluru. “I was so surprised when I came here that your chances of getting married depend on your skin colour. We don’t have that in the Philippines.”

The mindset is so normalised that people accept treatments as a part of wedding preparations – men as well as women. When Karthik Panchapakesan got married in 2001, he was intrigued by ads for a “complete makeover” and decided to try it out before his wedding reception, along with his brother-in-law.

“I had never gone to a salon before,” says Panchapakesan, a 50-year-old media specialist working in community radio. They went to an unnamed salon in Hyderabad where, he told me, “The massage felt really good. Then they put this fruity and flowery white paste all over my forehead, cheeks, nose and chin. They promised it would even out my skin.”

Panchapakesan says his eyes started burning after about five minutes and he got an irritation around his nose because the sweet smell turned to acrid fumes. He suspected it was based on ammonia.

“It was more chemical than horseradish,” he says. “I didn’t know what it is because they were pumping it out of toothpaste-like tubes. I say, ‘I’m not liking this.’ They say it will rejuvenate the skin and kept it on for 20 minutes.”

When it was all done, the two men’s faces looked as if they had been dusted with talcum powder. When they arrived at Panchapakesan’s wedding reception, his wife asked him, “Why are you both looking so strange and funny? What have you done to yourselves?” He says, “It was not a transformation, it was a deformation.”

To cool the burning sensation and moisturise his dry skin, he applied coconut oil as a healing balm for three days. He has sworn off beauty parlours ever since.

Bleaching is a common treatment that lightens not the skin itself but the fine hairs on the face. Most skin-lightening treatments target the skin’s ability to produce pigment, or melanin, which gives your skin, hair and eyes their colour. Everyone has about the same number of cells to make melanin but how much you actually produce is down to your genes. Darker-skinned people produce more. When exposed to the sun, the body produces more melanin to absorb harmful UV rays and protect skin cells. And having more natural melanin also means that darker-skinned people tend to develop fewer wrinkles and are less at risk of skin cancer.

Skin-lightening creams often aim to interrupt the production of melanin or just improve the general health of the skin. They can contain a natural ingredient such as soy, liquorice or arbutin, sometimes combined with the medical lightening agent hydroquinone (though not all creams contain this – hydroquinone is a potentially carcinogenic ingredient and products containing it are banned or restricted in Ghana, South Africa, Côte d’Ivoire, Japan, Australia and the European Union, though they are still used illegally). Vitamin B3 is another common ingredient, but another previously found in lightening creams and soaps is mercury, the World Health Organization has warned. Mercury suppresses the production of melanin but it can also damage the kidneys and brain if it is absorbed by the skin and accumulates in the body.

Other lightening methods include a chemical peel, which removes the top layer of your skin. This leaves fresher skin exposed to harmful solar radiation and environmental pollutants. Laser treatments offer an even more aggressive approach by breaking up a skin’s pigmentation, sometimes with skin-damaging results.

Dr Mukta Sachdev, a clinical and aesthetic dermatologist in Bengaluru, recalls two cases of Indian men who came to her after undergoing laser treatments while working in South Korea. They were each in their late 20s and getting ready for marriages. One man developed redness on his face and the other had little white dots – “confetti-like” depigmentation. Sachdev suspects the technicians in South Korea weren’t used to working with darker skin. “You need to use less aggressive settings when doing laser. It’s very hard when losing pigmentation,” she says. She was able to treat the redness, but the white patches remained despite her efforts to stimulate the pigment to return.

Many prospective patients come to her seeking skin lightening, but before offering them any treatment she counsels them to think less about light and dark and more about evenly toned, healthy skin. “I’m trying to get away from this fairness obsession,” she explains. “Being hung up on dark skin can lead to low self-esteem and lower on the quality of life index.”

“There’s a pressure on Indian men and women, among themselves,” says Dr Sujata Chandrappa, a Bengaluru-based dermatologist. “They have some role model in their head and they want to get there no matter what. That’s the wrong concept.” Chandrappa says clients often come in wanting the skin tone of a favourite Bollywood celebrity.

“If your obsession is just with colour, then I would outright tell them that I’m more worried that you’re unnecessarily seeking something you don’t need,” she tells me. “If I encourage them too much, I get the sense that I’m promoting racism.”

Shannah Mendiola spends Rs 3,200 (about $50) a month on skin-lightening supplements – a lot by local standards, but Mendiola has a well-paying job with a multinational company. Originally from the Philippines, but now working in Bengaluru, Mendiola says she has been taking the pills for the last five years, not just for lighter skin but for their antioxidant properties.

“I like going to the beach and I feel really dark after a holiday,” she tells me by email. “I would always prefer to buy and use skincare products that contain skin-whitening ingredients – like my body lotion, face wash and moisturizer. In the Philippines, it’s always a plus if you are fair.”

Mendiola describes herself as morena – not too fair and not too dark – and says that her skin returns to its natural colour faster when she uses the pills. “Having an even skin tone that’s healthy and glowing gives me more self-confidence when I meet people for work. Why not? Don’t we all want to look good?”

The pills she takes are glutathione, an antioxidant naturally produced by the liver that can protect the skin from UV rays and free radicals, which contribute to skin damage and pigmentation.

A more direct form of treatment is glutathione injections. These are commonly used to counteract the side-effects of chemotherapy, such as nausea, hair loss or difficulty breathing, but their growing popularity for skin lightening has led to official concern.

In 2011, the Philippines Food and Drug Administration issued a public warning about an “alarming increase in the unapproved use of glutathione administered intravenously,” reporting on adverse effects which included skin rashes, thyroid and kidney dysfunction, and even potentially fatal Stevens–Johnson syndrome, in which the skin peels from the body as if burned.

And in 2015 the US Food and Drug Administration warned of the potentially significant safety risk to consumers: “You’re essentially injecting an unknown substance into your body – you don’t know what it contains or how it was made.”

Nevertheless, there is growing consumer demand. Mendiola has taken two treatments of injectable glutathione but mostly relies on pills.

Dr Mukta Sachdev refuses to administer the injections despite repeated requests from her patients – “I practise on evidence-based dermatology and there’s not enough literature supporting the use of injectable glutathione.” Worryingly, there are YouTube videos showing how to self-inject glutathione.

Dr Sujata Chandrappa does administer glutathione injections. She says she has seen no side-effects so far, but is nonetheless wary, always starting with the lowest possible dose. I ask if it really works. She tells me of a woman who dreaded injections but whose yearning for lighter skin overrode her fear. Three months after the injections, her entire body was about two shades lighter and any dark spots had lessened. It lasted for a year. Chandrappa says the woman is considering repeating the procedure.

“From a medical perspective, it is not possible to lighten skin permanently, but you can even it out,” Sachdev tells me. In fact, many of Sachdev’s and Chandrappa’s patients are actually people seeking treatment for problems with other skin-lightening procedures – primarily the use of topical steroid creams.

India’s pharmaceutical regulator has approved at least 18 different corticosteroids for topical skin use, ranging from mild to super-potent. These usually cost less than $2 or Rs 130 a tube and most pharmacies across the country will dispense them, even without a prescription.

People apply them indiscriminately to treat pimples or for fairer skin, but steroid creams take off the protective outer layer of the skin so it is more exposed to UV rays and environmental pollutants such as smog and cigarette smoke. But more worrying is that they can be addictive, says Dr Shyamanta Barua, a dermatologist and honorary secretary general of the Indian Association of Dermatologists, Venereologists and Leprologists.

“The moment the patient stops using the cream, the skin reacts, gets irritated, develops rashes,” he says. “So the patient starts the cream again and it’s a vicious cycle. They become psychologically addicted.” He thinks users should be counseled as if they were addicted to recreational drugs or alcohol.

The dermatologists’ association is lobbying for topical steroid skin medications to be added to the Schedule H list, which would restrict their availability in pharmacies by requiring a doctor’s prescription. They met with the Drug Controller General of India in March 2017, though Dr Shyam B Verma, the dermatologist who heads these efforts, seems pessimistic as to whether any action would be forthcoming. “These products are just a minuscule part of the overall drug industry so it’s not a priority,” he tells me.

“[Pharmacies] dispense them like boxes of cookies. The drug companies know this is a drug and it’s not supposed to be used to lighten constitutive skin. But they label them with suggestive names like Skin Bright, Skin Light, Skin Shine, Look Bright.”

Furthermore, only around 35 per cent of pharmacies have a legitimate pharmacist on staff, so there is often no one to counsel the buyer on appropriate dosage and use of the cream.

Even worse, there are signs that improper steroid prescriptions – often in cocktails containing a mix of steroids, antibiotics and antifungals – may be fueling a surge in bugs resistant to normal treatments. An editorial in the dermatologists’ association’s online journal last year says, “Today, we are facing an onslaught of chronic and recurrent dermatophytosis [fungal infections] in volumes never encountered previously. Over the last three to four years, the frequency of such cases has increased alarmingly.”

Dr Rajetha Damisetty, a cosmetic dermatologist based in the southern city of Hyderabad, tells me of one combination containing clobetasol – the most potent steroid known to man, which is used to treat inflammatory skin conditions like eczema – mixed with two antibiotics and two antifungals. “Only India has this crazy combination,” Damisetty says, and the result is a “nightmare”.

Normally, she says, “around 70–90 per cent of those affected by fungal infections would have used topical steroids for treatment and they would respond within two weeks. Now we have to give four times the dosage for eight to 12 weeks. It’s an epidemic across the entire country.”

The dermatologists’ association is trying to educate physicians, especially general practitioners who indiscriminately prescribe steroid creams, about proper prescriptions. They are also engaging with pharmaceutical companies, which has borne some fruit – in April 2017, one company distributed flyers to 50,000 pharmacies warning: “Steroids are potentially harmful. Do not use without a prescription.”

But they’re fighting more than just bad medical practice or even consumer habits. They’re fighting millennia-old preferences for lighter skin. Erasing those will require a change of mindset. This is perhaps easier to do in the young – after all, social signals about the value of fair skin begin as soon as they are born.

Kavitha Emmanuel believes that people are more aware of the issue than ever before and hopes that the next generation will see things differently – not just in India but across the world. In 2016, three students at the University of Texas, Austin, started an Instagram campaign called Unfair & Lovely – a play on India’s most popular fairness cream, Fair & Lovely. The #unfairandlovely hashtag invited darker-skinned people to share their photos. And in 2013, a young woman in Pakistan, Fatima Lodhi, launched the country’s first anti-colourism movement, called Dark is Divine. Lodhi has written about the prejudice she faced as a child: “I never got a chance to become a fairy in my school plays because fairies are supposed to be fair-skinned!” Now, she leads sessions at schools to make students more aware about skin colour discrimination.

Attitudes are already starting to change, some say, especially among girls, who are gaining confidence with education, employment and financial independence outside the home. Emmanuel tells me of one Dark is Beautiful session at an all-girls middle school in the southern Indian city of Chennai last January. A dark-skinned teen – “stunningly beautiful but with deep self-esteem issues” – came up front. She was weeping because just that morning her brother had taunted her about her skin tone. But Emmanuel was more surprised when another, lighter-skinned, girl stood up. She said she’d believed dark was ugly until that moment, but apologised to her classmates with a promise to treat them better. “They all started clapping,” Emmanuel says. “That’s a big move for a teenager. She really had the bigness of heart to say something like that.”

But activists fear the market for skin-lightening treatments will endure as long as they are available. Beautician Ema Trinidad recalls one woman who came to her spa. Her fiancé had lighter skin and her future in-laws wanted her to be lighter before their wedding. “I felt sorry for her. She wasn’t really dark, she just had very dry skin, so I gave her a moisturising treatment,” Trinidad says. She advises clients about which products and treatments are effective and safe, but adds, “I cannot judge that it’s bad that you want to be white. My job… is to give you what you want.”

This article was first published on Mosaic.