A Cross-Sectional Study of the Knowledge, Practice, and Attitude Towards Skin-Lightening Products Among the General Population in the Western Region of Saudi Arabia

Introduction Skin bleaching is a growing phenomenon worldwide and is becoming an increasing problem. Several skin-lightening products (SLPs) containing mercury, hydroquinone, and corticosteroids have impacted serious dermatological, nephrological, and neurological side effects. There is relatively little regulation, and the products are easily accessible and inexpensive. Justifications and beliefs for the use of these products vary from culture to culture, and there is little previous research on the use and abuse of skin-lightening cosmetics among Saudi women. This study examines the knowledge, attitudes, and practices of the public in the western region of Saudi Arabia regarding SLPs to understand the situation better. Methodology An observational, cross-sectional, questionnaire-based study was conducted over two months between July and August 2022. A 29-question survey was used to collect data from the general population. The study included all women residing in the western region of Saudi Arabia. Non-Arabic speakers were excluded. RStudio (R version 4.1.1) was used to analyze the data. Results A total of 409 participants were included in this study; In general, 146 (35.7%) of the participants said they had ever used an SLP. More than two-thirds (67.1%) had been using them for less than a year. In terms of the most common site of SLPs application, women reported applying the products to the skin of their face (74.7%), elbows (47.3%), and knees (46.6%). Use of SLPs differed significantly across participants' ages, with the proportion of SLP users in the 20-30 age category significantly higher than non-users (50.7% vs. 36.9%, p=0.017), and non-users were more common than users within the age category >50 years. In addition, the proportion of SLP users relative to educational level was significantly higher among participants with a bachelor's degree than the proportion of non-users (69.2% vs. 54.0%, p = 0.009). Conclusions The results of this research show that Saudi women frequently utilize topical lightening products. Therefore, regulation and controlling the use of bleaching products is essential, as is educating women about the risks involved with this practice. The misuse of bleaching products should decline with greater awareness.


Introduction
Skin bleaching is referred to as skin whitening, skin fairness, skin lightening, skin depigmentation, skin toning, and skin lighting. It is a cosmetic method that includes the use of harmful substances (e.g., mercurials) or using skin-whitening chemicals (such as topically applied steroids) to alter an individual's biological skin tone [1][2][3]. Several research papers have looked into the female's reasons for being involved in skin bleaching. Those studies concluded that the most common reasons are to become light-skinned, pretty, and more European in appearance. Other motivations include getting rid of pustules, redness, and skin problems, and impressing peers and males [4].
Skin bleaching is a growing worldwide phenomenon and is becoming a more significant issue. According to the World Health Organization, dangerous skin bleaching without professional counseling has become a public health crisis [5]. Several skin-lightening products (SLPs) contain mercury, hydroquinone, and corticosteroids and have influenced serious dermatological, nephrological, and neurological side effects [6].

Materials And Methods
This observational, cross-sectional analytical study was conducted using a self-administered questionnaire. The study targeted the general population of the western region of Saudi Arabia and spanned two months between July and August 2022. We included adult females aged 18 and above. Individuals who didn't speak Arabic were excluded from the study. Participants were selected using a non-sampling convenience sampling technique. Based on a review of similar studies, the research team developed a 29-item questionnaire divided into four sections to accomplish the research objectives. The first section (four questions) focused on sociodemographic characteristics (age group, educational level, marital status, skin tone). The second section (four questions) covered perceptions toward a lighter skin tone. The third section (16 questions) is about the prevalence of the use of SLPs and knowledge of SLPs, reasons for use, application practice, and product sources. The fourth section (five questions) assessed the usage of a triple mixture. The data were collected through an online Google survey distributed through social media platforms. Participants completed the survey anonymously and voluntarily. The questionnaire was designed in English and translated into Arabic to fit the country's native language. We used OpenEpi (Version 3.0, www.OpenEpi.com) for sample size calculation: a minimum sample size of 385 was required for the study, considering a 95% confidence interval (CI) and anticipated frequency of 50%, and design effects of 1.

Statistical analysis
In the current study, statistical analysis was carried out using RStudio (R version 4.1.1). We used frequencies and percentages to express the categorical data, and numerical data were presented as the median and interquartile range (IQR). A multiple-response analysis was used to analyze items with more than one available selection. A one-sample proportions test with continuity correction was used to express the prevalence of using SLPs and the respective 95% CI. Factors associated with SLPs were assessed using Pearson's Chi-squared test or Fisher's exact test, whenever applicable. The significantly associated variables from the association analysis were entered in a binary logistic regression model to assess the predictors of using SLPs, and the results were presented as odds ratios (ORs) and 95%CIs. A p-value indicated statistical significance.

Ethical considerations
The Medical Research Ethics Committee approved this study at Umm Al-Qura University (approval number: HAPO-02-k-012-2022-06-1123). Consent to participate was taken from participants electronically.

Results
Initially, we received responses from 559 participants. One participant declined to participate, and the responses of 29 males were received on the online platform. These responses were excluded before the analysis. Additionally, we excluded the records of 120 participants with missing responses to the primary outcome variable (use of SLPs). Eventually, the records of 409 participants were analyzed.

Sociodemographic characteristics and their association with using SLPs
Less than half of the participants were aged 20 to 30 years (41.8%), and all of them were residing in the western region. More than half of the respondents were single (60.6%) and had obtained a bachelor's degree (59.4%). The most common skin tones were light brown (46.2%) and light (39.4%, Table 1).
In general, 146 participants indicated that they had ever used an SLP, representing 35.7% (95%CI, 31.1% to 40.6%) of the overall sample. The use of SLPs differed significantly based on participants' age, where the proportion of SLP users was significantly higher than non-users within the 20-to-30-year age category (50.7% vs. 36.9%, p = 0.017) and non-users were more frequent than users within the >50-year-age category. Furthermore, based on the educational level, the proportion of SLP users was significantly higher than nonusers among the participants who had obtained a bachelor's degree (69.2% vs. 54.0%, p = 0.009). No significant differences in SLP use were noted based on marital status and skin tone ( Table 1).

Use of SLP
We incorporated age and educational levels as independent variables in a multivariate logistic regression model to further reveal the independent predictors of SLP use. Results showed that participants aged >50 were less likely to use SLPs (OR = 0.30, 95%CI, 0.09 to 0.91, p = 0.045, Table 2).

Participants' perceptions towards lighter skin tone
More than half of the respondents (58.7%) agreed or strongly agreed that a lighter skin tone increases a woman's chances of getting married, whereas 44.7% agreed or strongly agreed that a lighter skin tone is more beautiful. On the other hand, 61.1% of the respondents disagreed or strongly disagreed that a lighter skin tone helps a woman get a better job opportunity ( Figure 1).

Patterns of using SLPs
More than two-thirds out of 146 (total number of participants who ever used SLPs) have been using these products for less than a year (67.1%) and used to buy these products from the pharmacy (72.6%). Additionally, more than half of them were using the products in the evening (63.7%), and these products were primarily used for hyperpigmentary disorders (such as melasma) among 58.9% of the respondents.
Notably, physicians' advice was the most common source of using SLPs (49.3%), followed by advice from pharmacists (47.9%) and friends (36.3%, Table 3). Regarding the most common site of SLPs application, women stated that they applied the products on the skin of the face (74.7%), elbows (47.3%), and knees (46.6%, Figure 2A). The applied skin products were mainly composed of vitamin C (39.7%) and hydroquinone (30.1%), while 35.6% of the participants did not know the active ingredients of SLPs ( Figure 2B).

Category N (%)
The period since SLPs have been used   SLPs: skin-lightening products

Women's attitudes towards SLPs
The majority of SLP users (n=146) agreed or strongly agreed that sunscreen should be applied while going outside, particularly during the use of SLP (94.6%), and that the active ingredient is a crucial element for the selection of SLPs (90.4%). On the other hand, approximately one-quarter of the participants disagreed or strongly disagreed that the product price is an essential criterion while selecting an SLP (28.8%) and that the used SLP gave the anticipated results (24.6%, Table 4).

Strongly disagree Disagree Agree Strongly agree
The price is an important criterion for selecting the skin-lightening product you use 1 (0.7%) 41

Women's practice of using the triple mixtures and hydroquinonecontaining SLPs
Only 13.7% of women who used SLPs corroborated that it is possible to apply a bleaching product containing hydroquinone for >3 months, while a considerable proportion of them did not know about that possibility (65.1%). Regarding the use of triple mixtures for skin lightening (which contain Hi Quin cream, Acretin cream, and Alfacort cream), 30.8% of women indicated using these mixtures. Of them, 55.6% used the mixture without physicians' consultation, and 75.6% knew the types of active ingredients in the mixtures ( Table 5). Importantly, out of the women who had used the triple mixtures (n=45), 24 participants experienced at least one adverse event (53.3%). The most common adverse events included redness (75.0%), sun sensitivity (58.3%), and skin cracks (41.7%, Figure 3). Interestingly, half of the women with an adverse event ignored the complication (50.0%), whereas 20.8% visited a physician, 16.7% went to a pharmacy, and 12.5% talked to a friend/relative to discuss how to deal with the complication.

Parameter Category N (%)
It is possible to use a bleaching product containing hydroquinone for more than three months

Discussion
Given the limited information on skin-lightening use in our region and our knowledge of the indexed literature, this examines skin-lightening practices and perceptions in the western region of Saudi Arabia. This study found that about a third (35.7%) of Saudi women engage in skin-lightening practices. Therefore, this study's finding underscores the importance of investing in primary prevention to reduce a potential long-term psychological, medical, and economic burden on population health and healthcare.
In the current study, there were significant differences in the number of people using SLPs depending on the age of the participants, while in the 20-30 age group, the percentage of SLPs users was significantly greater than non-users (50, 7% vs. 36.9%, p = 0.017). In the over-50 age group, non-users were more common than users. This finding is consistent with a study conducted in Ghana, which showed that participants under the age of 40 were 1.42 times more likely to use skin-lightening cosmetics than those over that age [18]. However, these results do not support previous research reported in the northern region of Saudi Arabia, where the study showed no significant correlation between those who use SLPs and those who don't, according to their age group [6].
In addition, the proportion of SLP users among bachelor graduates was significantly higher than among nonusers in relation to educational level (69.2% vs. 54.0%, p = 0.009). Consistent with the present results, previous studies have shown a significant difference in education level; out of a total of 375 collegeeducated participants, 65.7% were skin whitening users, comparable to a total of 230 students using 34.3% skin whitening users [6].
In our study, among those who reported using SLPs (n=146), more than two-thirds (67.1%) had been using them for less than a year. In a study conducted in South Africa, the majority (62%) used a lightening cream for many years. A quarter of the women said they had used a lightning cream for more than three to six months [19]. Additionally, in this study, more than half of the SLP users used the product only in the evening (63.7%), a quarter (27.4%) of the SLP users used the product twice daily, morning and evening, only a minority used the product only in the morning. Compared to the South African study (40.1%) of the women reported using the product in the morning, and almost half (55.1%) used the product both morning and evening [19].
In a study conducted in Jordan, most users of SLPs get their products from pharmacies (52.6%) or from small cosmetics and skin care shops (31.8%) [20], which is similar to the results in our study where (72.6%) formerly bought these items from pharmacies. Given the well-known mercury, mercury products are readily available in pharmacies, online retailers, and beauty shops. Approximately 45% of the SLPs tested were found to have excessive levels of mercury well in excess of Food and Drug Administration (FDA) guidelines and have been marketed in the Saudi markets for over a decade [21]. This highlights the critical role pharmacists play in advising patients on skin-lightening treatments and providing them with instructions on how to use them.
Most of our participants (71.2%) agreed or strongly agreed that product price is an important criterion when choosing an SLP. A previous study in Saudi Arabia reported that the monthly cost of the bleaching products varied between 5 and 3000 Saudi Riyals (SR). Of the women, 16.7% reported spending more than SR200 per month on bleaching products ($53.4) [15].
In the current study, most SLP users (89.8%) believe that the effects of sun exposure counteract the effects of SLPs and (94.6%) that sunscreen should be applied when going outside, particularly while using SLPs. This awareness was higher than in previous studies in South Africa (69%) and the Middle East (63.5%) [19,20].
Regarding the participants' awareness of possible side effects caused by SLPs in the current study, most women (76%) believed that SLP could have adverse consequences and unwanted side effects on the skin. This result is similar to a study conducted in South Africa. Most respondents (89%) agreed that SLP could adversely affect the skin [22]. In contrast, a study conducted in northern Saudi Arabia reported that only 39.2% believed SLPs could harm their skin [6]. This discrepancy could be due to increasing awareness nowadays or the time frame of the study.
The use of SLP was associated with a very high level of satisfaction among respondents. In the current study, 75.4% of users are satisfied with the product's effectiveness. The rate found in our study is similar to that among Jordanian (70.9%), African, and Indian women [20,22]. In the other study conducted in Northern Saudi Arabia, respondents' satisfaction with the outcomes of their SLPs was 49.2% [6].
The role that lighter skin tone plays in mate choice, men's likely perception that lighter skin tones are more attractive, and the belief that lighter skin tone is seen as more beautiful are motivating factors responsible for using SLPs. Most respondents in various previous studies said they believed lighter skin was more attractive to men than darker skin and reduced their chances of marriage [6,20]. This roughly similar rate was found in our study, where more than half of respondents (58.7%) believe that lighter skin tone is perceived as more attractive by men and increases women's chances of getting married.
According to a recent study, the location of skin lesions, particularly in people with pigment disorders, is a key element affecting identity development, anxiety and depressive disorders, and depression [23]. Unlike populations in other nations [15,22], participants in this study tended to use creams on their faces (74.7%) and on non-sun-exposed areas (45%), consistent with another study conducted in Saudi Arabia, where participants used SLP on the face (36%) and non-sun-exposed areas (31%) [6].
Although hydroquinone is a commonly used skin-lightening agent, it is characterized by the side effects such as irritant dermatitis, contact dermatitis, melanocyte destruction, and ochronosis, which discolors the skin with repeated use over a long period [24]. Unfortunately, almost 80% of skin lightener users do not know if it is possible to use a hydroquinone bleaching product for over three months, making them more susceptible to these side effects.
According to our research, 44.4% of participants used the triple blend without a prescription. This result is similar to another survey when only 26% of the participants took it as recommended by the doctor [25]. There has been much discussion in most publications about the use of topical steroids without a prescription. For example, Jha et al. observed that 42.9% of patients bought topical corticosteroid (TC) creams without a prescription [26]. The literature has reported several side effects associated with TCs. They can be generally classified as local and systemic side effects. The immediate effects include stinging and irritation. In addition, the epidermis may be affected by atrophy, hypo/hyperpigmentation, photosensitivity, loss of skin barrier, and premature aging. Several factors can contribute to preventing these adverse effects of topical steroids, including prescribing, appropriate drug use, and proper counseling [27].

Study limitations
There are a few limitations in our study that should be taken into account when interpreting the results. First, some women may have provided misleading or false information in response to survey questions due to a variety of factors, including embarrassment over their honest reasons for using skin lighteners and possible knowledge of the illegality of some of the items used. Second, recall bias may have affected the results. Third, the study covered only one region in Saudi Arabia and, therefore, cannot be generalized to the whole country.

Conclusions
This research shows that Saudi women frequently utilize topical lightening products. Many participants agreed that a lighter skin tone increases a woman's chances of getting married, and helps a woman get a better job opportunity which increases the consumption of those agents, and leads to several health issues. Therefore, regulation and controlling the use of bleaching products is important, as is educating women about the risks involved with this practice. The misuse of bleaching products should decline with greater awareness.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. The Medical Research Ethics Committee approved this study at Umm Al-Qura University issued approval HAPO-02-k-012-2022-06-1123. The Medical Research Ethics Committee approved this study at Umm Al-Qura University (approval number: HAPO-02-k-012-2022-06-1123). Consent to participate was taken from participants electronically. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.