LIVERPOOL - Unsupervised use of skin-lightening products (SLPs) in the British Indian community has physical, psychological, and socially harmful effects and propagates internalised racism, shows the first study of its kind among this diaspora population.
"We recommend changing the mindset of fair skin bias and internalised racism within the [British Indian] community, said Divya Khanna, MBChB, a junior doctor from the University of Birmingham, presenting atthis year's British Association of Dermatologists 103rd annual meeting. "Some barriers are already being broken – with greater representation of darker skin tones in South Asian media outlets, however, changing age-old ideology about fair skin is difficult."
Dr Khanna's qualitative study looked at the causes and consequences of the use of non-prescription SLPs in the British Indian population, given that these products are still widely available through online and international supermarket vendors, despite being banned by the UK government.
Bias Towards Fairer Skin
Most participants agreed that the main reason for using SLPs was open internalised racism within the community, instilling shame and stigma against those with darker skin, Dr Khanna told Medscape News UK. "It was remarked that internalised racism was often seen with first generation British Indians, but it was less common amongst second- and third-generation British Indians, discouraging skin lightening product use, due to increased assimilation into British culture and slowly improving media representation of people of colour."
SLPs are used on and off prescription, she explained. On prescription, SLPs that contain hydroxychloroquine and corticosteroids, are used to reduce melanin production in conditions like melasma and post-inflammatory hyperpigmentation. Off-prescription, SLPs frequently also contain mercury. "Without medical oversight on dosage, strength, and method of application, these agents can cause permanent scarring, telangiectasia, steroid withdrawals, teratogenicity, renal, hepatic, or neurological impairment, and unwanted cosmetic outcomes," explained Dr Khanna. "An example of an unwanted cosmetic side effect is ochronosis, a condition causing a bluish-black darkening of the skin, which can be very challenging to treat."
In India, non-prescription SLPs are widely available, with such SLPs forming half of the skincare market. Dr Khanna highlighted that SLPs advertise fair skin bias amongst coloured communities, and this propagates further social trends rooted in race and colourism. Other streams of fair skin bias in the Indian community are incorporated into religion, music, Bollywood, and colonialism, she added.
"In India, studies show that fair skin bias manifests in its impact on self-esteem, marriage, beauty standards, and employability biases," said Dr Khanna, pointing out that "it is unknown if the impact is the same in Indian diaspora communities, such as the one in the UK."
With this research gap in mind, Dr Khanna then initiated her study to qualitatively explore experiences, perceptions, and beliefs amongst British Indian immigrants, and to identify the causes and consequences of unlicensed topical SLP use. She conducted 23 qualitative, in depth, semi structured interviews and thematically analysed the data.
The first overarching theme identified was 'causes of skin lightening product use', and included the sub-themes of: 'British cultural influence', 'product accessibility', and 'Indian beauty standards'. The second overarching theme was 'consequences of skin lightening product use' and includes the following sub-themes: 'financial', 'social', and 'intrapersonal'.
Dr Khanna highlighted some comments including, under the theme British cultural influence: "In the workplace, there is a magnifying glass held to my every mistake […] in contrast to the benefit of doubt sometimes my [white] colleagues get". Another participant commented in relation to product accessibility: "My mum has it […] it's not exactly a secret…when she put it on me as a kid it seemed totally normal".
The analysis revealed social implications too: "Maybe I get more hits on dating apps. I know people prefer lighter skin men, it matters less for men anyway, but I do want my partner to have light skin," said a participant.
There were also some generational differences noted: "I used it for some time, but I just thought, why? What a waste of money. Only my grandparents care, not me, nor my parents," said another participant.
Commenting more generally, Dr Khanna said: "Participants felt the Indian beauty standard derives from caste, religion, colonialism, Ayurvedic medicine, and the Indian media, which together heavily depict fair skin as superior, encouraging skin lightening product use," she said, adding that, frequent advertising on Indian television channels and social media, and their [SLPs] abundance and affordability in South Asian stores in the UK encouraged use.
She concluded that the study identified a need to control illegal SLP importation and sale.
Vanessa Pinder, MD, a dermatologist from Epsom General Hospital, and delegate at the session on psychodermatology, commented on Dr Khanna's study. "I thought it was a really interesting presentation and I'd be keen to see similar work done looking at different populations, such as the Afro-Caribbean population and asking do we see if the cultural influences identified in the Indian population also at play in other populations."
"I've mainly seen Black populations who use skin lightening in South London, so I wonder if they have the same pressures, but possibly for different reasons," Dr Pinder said, adding that her patients find the skin lightening products in local markets and Black hairdressing salons.
The study was funded by the University of Birmingham, Royal College of General Practitioners and Institute of Medical Ethics Dr Khanna and Dr Pinder have no financial disclosures.