# Spreading of Dangerous Skin-Lightening Products as a Result of Colourism: A Review
## 5 Corticosteroids  
Topical corticosteroids are among the most widely prescribed drugs in clinical dermatology; they are used in the management of a wide range of medical conditions, due to their anti-inflammatory, antimitotic and immunomodulatory actions [56]. Abuse of topical corticosteroids, with the aim of achieving lighter skin, is a widespread practice in many countries, such as India and sub-Saharan African states, especially among women [57; 58; 6; 50]. The misuse of these products is facilitated by their availability as cheap over-the-counter (OTC) drugs [58].  
They are used as skin brighteners due to their potent depigmenting action and anti-inflammatory effects, which are useful in reducing the irritative potential of other whitening products that might be applied in combination [57]; clotetasol propionate, betamethasone dipropionate and fluccinonide (fluccinolone acetonide) are the most commonly used agents [12]. However, the mechanisms of corticosteroid-induced skin depigmentation are not yet fully understood. Several explanations have been proposed, including a direct cytotoxic effect, vasoconstriction, mechanical effects of oedema or an alteration in the regulation of melanogenesis [59]. Their lightening effect is initially thought to be mediated by local vasoconstriction, which gives the impression of an immediate reduction in skin pigmentation [20]; finally, corticosteroids lighten the skin by inhibiting pro-opiomelanocortin (POMC), a protein synthesised in the anterior pituitary that produces, by proteolytic cleavage, several biologically active peptides, including \(\alpha\)-melanocyte-stimulating hormone (\(\alpha\)-MSH), which regulates melanocyte function [34; 50].  
In order to exert their lightening action, corticosteroids are applied at high concentrations and over a large area of the body for prolonged periods (from a few months to a few years); long-term use and the conditions of application favour their dermal absorption [50]. The cosmetic use of corticosteroids is associated with a wide range of side effects, both dermatological and systemic; these adverse effects are directly connected to the potency of the compounds, since steroids used as lighteners are generally classified as potent or very potent [57]. Skin complications include acne vulgaris, allergic contact dermatitis, skin atrophy, hypertrichosis and telangiectasias. In addition, topical corticosteroids predispose to skin infections, such as dermatophytosis, folliculitis, ergysipelas, scabies and viral warts [34]. Systemic adverse effects due to chronic corticosteroid use include Cushing's syndrome, diabetes mellitus, immunosuppression, hypertension, and suppression of the hypothalamic-pituitary-adrenal axis with adrenal suppression, the latter being the most alarming complication, as it can lead to death [34].  
This side-effect should not come as a surprise, since literature has shown that the maximum monthly amount of clotetasol propionate cream (0.05%) applied to the skin for whitening purposes could reach 480 g [60]; more than 50 g of this cream per week can induce a profound suppression of the hypothalamic-pituitary-adrenal (HPA) axis [61]. Finally, chronic daily application of steroids can lead to the so-called \"steroid dependency syndrome\", characterised by an intense burning and potentially permanent erythema (\"_Honme rouge_\") following the discontinuation of steroid treatment [34]; this syndrome occurs more frequently in male users and can only be alleviated by reapplication of the drug [50].  
The mechanisms of action and the most common undesirable and toxic effects of the banned lightening agents examined are summarised in Table 2.