This study is among the few studies conducted in Pakistan estimating the burden of an important and emerging health issue i.e. acne and other cutaneous side effects of using topical steroid and fairness creams. Moreover, this study also assessed the pattern of topical steroid and fairness creams use among patients presenting in a well-known private tertiary care hospital in Karachi. Hence this study provides a much needed evidence about irrational use of topical steroids and fairness creams in a megacity city with relatively better literacy rates.
This study found very high burden of inflammatory and non-inflammatory acne lesions among the study participants i.e. 83.6% Moreover, in this study acne was identified as the most common side-effect of using topical steroid or fairness cream as reported by previous studies. (15,17-19) However, the burden of acne in our study population is slightly higher than the frequency reported by previous studies conducted in similar settings. This high frequency of acne and all kind of side effects can be explained by the differences in research methodology particularly sample size and sample selection criteria.
This can be explained by biological and environmental differences in the population. In this study the burden of acne was significantly higher among study participants of age group 18 years or less. The relatively higher burden of acne among youngest age group in this study can be explained by the increased tendency and sensitivity of teens towards their outlooks leading excessive use of topical agents as well as puberty related bodily changes. Among other cutaneous side-effects identified in this study telangiectasia, hypertrichiosis and facial erythema were the most frequent observations. This finding also in line with previous evidence from the studies conducted in Pakistan and other populations with similar socio-cultural context. (11, 15-17)
This study found relatively higher frequency of fairness cream use followed by use of topical steroids alone. This finding is in contrast to previous studies conducted in similar populations and study settings. (11, 20). The higher frequency of fairness cream use in this study use can be explained by the cultural obsession for fair skin as well as strong role of media in promoting fairness products in Pakistan. (11,13) This finding is also supported by the fact that this study could not find any statistically significant difference in the frequency of men and women who were using steroids and fairness creams for the purpose to attain fairness. Similarly, this study could not find any statistically significant differences in the proportion of study participants reporting fairness as the reason for using steroids across three household income categories. Such findings indicate that in Karachi not only women but men are also equally obsessed with the desire to attain a fair skin tone. The increased desire of fair skin among men is supported with previous studies and can be explained by the strong marketing tactics of fairness product manufacturers and availability of a wide variety of male skin whitening products. (21,22)
Moreover, irrespective of the average household monthly income, the use of topical steroids and fairness products is equally prevalent and popular among people with different financial capacity. However, this study found statistically significant differences in the frequency of using topical steroids products for fairness on the basis of age, education and marital status. The study found that people of age between 20-25 years, people with higher education level and those who were single mostly reported desire for fair skin as the prime reason for using topical steroids and fairness products. These findings are well supported by the socio-cultural environment of Pakistan and other South Asian countries where skin color plays a crucial role in social acceptance and future prospects particularly for women. (1, 2, 11)
This study identified that family, friends or neighbours as the most common source for recommendation or advice regarding use of topical steroids or fairness cream. This finding is in line with previous studies conducted in Pakistan as well as Indian population due to similar socio-cultural background. (12, 20, 23, 24)
This study has few inherent limitations. First, as this study recruited study participants from one particular private tertiary care hospital in Karachi hence lacks capacity to measure the actual prevalence of topical steroid and fairness cream use in Karachi. Secondly, this study ascertained the burden of topical steroid and fairness cream induced acne and other cutaneous side effects, however, due to lack of temporality in this study we cannot rule out the other associated factors such as stress and life style factors. Moreover, the patients presenting in public sector hospitals and those going to aesthetic treatment centers (usually managed by non-medics) might be different in severity of exposure to topical agents and burden of acne as well as other related cutaneous complications. This also limits the generalizability of study findings.
Moreover, this study did not collect objective information regarding the exact amount or dose and frequency of dose for steroids or fairness creams for the total reported duration for use. While the subjective recall for total duration of topical steroid or fairness cream use might be affected by the severity of related medical complications or related health outcomes. However, despite few limitations this study provides valuable insights to develop and implement targeted control and prevention strategies or interventions for this particular population group.