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Cosmetic Agents Causing Endocrinopathy in an African Immigrant

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Cosmetic Agents Causing Endocrinopathy in an African Immigrant Case Report Cosmetic agents causing endocrinopathy in an African immigrant Jamie Nathan Rozen MD CM CCFP Eiman Alseddeeqi MB BS ABIM FRCPS(C) Juan Rivera MD FRCPC t has become common practice for African men and women to chemically alter their natural skin tone for aesthetic Ipurposes. This is realized by the use of cosmetic skin-bleaching agents, which are sold without regulation. These products have potential for adverse health effects, including nephrotoxicity, neurologic symptoms, and suppression of the hypothalamic-pituitary-adrenal (HPA) axis. We report a case of a woman using one such preparation, presenting with exogenous Cushing syndrome and uncontrolled diabetes. Case EDITor’s kEY POINTS Alisha was a 46-year-old woman who had been living in Canada for 1 year. • Cosmetic skin-bleaching agents are She was an immigrant from Africa. Alisha presented to the emergency sold without regulation. These products department with a several-day history of weakness, polyuria, polydipsia, have potential for adverse health effects, and new-onset hyperglycemia (blood glucose level of 41.1 mmol/L). Her including nephrotoxicity and neurologic past medical history included a 6-year positive HIV status, and she was symptoms. receiving highly active antiretroviral treatment at the time of admission. Her CD4 cell count from 3 months earlier was 804 cells/mm3 of blood. Other • Most medical practitioners outside of past medical history included pulmonary tuberculosis, hepatitis C, pancrea- Africa are unaware of the widespread use titis secondary to isoniazid therapy, and ovarian abscess. Her medications of skin-bleaching products. Physicians included abacavir, atazanavir, moxifloxacin, folic acid, cycloserine, and need to be aware that patients of African pyridoxine. There was no family history of diabetes mellitus or other endo- descent might be using these treatments to crinologic disorders. lighten their skin tone. On history, Alisha reported a 5-kg weight loss in recent weeks and com- plained of fatigue, generalized weakness, and blurred vision without diplopia. • This report highlights the importance She did not have symptoms of concurrent infection. She had had difficulty of taking a detailed social and drug climbing stairs and standing from a seated position for months to years. history, as some of the cosmetic agents Further questioning elicited a history of easy bruising and oligomenorrhea. are responsible for causing exogenous Alisha denied observing a darkening of her skin tone; rather, she told us that Cushing syndrome. her skin had become lighter secondary to a bleaching cream she had been using for several years. Upon arriving in Canada she had changed brands of bleaching product. Alisha showed pictures taken at the time of her arrival in POINTS DE REPÈRE DU RÉDACTEUR Canada in which her skin colour was considerably lighter than at presentation. • Les agents cosmétiques de blanchiment On examination, the patient was obese, with supraclavicular and de la peau sont vendus sans être dorsal-cervical fat fullness. Her blood pressure was 100/75 mm Hg, and réglementés. Ces produits peuvent her pulse rate was 86 beats/min. There were no skin striae, bruises, hirsut- avoir des effets néfastes sur la santé, ism, wasting, or lipodystrophy. The thyroid gland was not palpable. Mild notamment la néphrotoxicité et des proximal muscle weakness was present. Laboratory data revealed the symptômes neurologiques. • La plupart médecins praticiens en dehors following: a hemoglobin A1c level of 13.2%; a morning serum cortisol level of 14 nmol/L (reference range 120 to 535 nmol/L); undetectable serum de l’Afrique ne sont pas au courant de corticotropin levels; and a 24-hour urine cortisol level of 27 nmol/L (ref- l’utilisation très répandue de produits de erence range 100 to 250 nmol/L). The patient was then sent for dynamic blanchiment de la peau. Les médecins testing with 250 μg of cosyntropin. At time zero, the cortisol level was doivent savoir que les patients d’origine 17 nmol/L; 30 minutes later it was 149 nmol/L, and at 60 minutes it africaine sont susceptibles d’utiliser ces was 202 nmol/L. A normal response is a cortisol level of greater than traitements pour pâlir la couleur de leur 550 nmol/L. This response, although brisk, is subnormal, reflecting peau. adrenal gland reduced cortisol reserve. • Ce rapport met en évidence The diagnosis of exogenous Cushing syndrome was made. Alisha l’importance de faire un bilan détaillé de discontinued the bleaching cream. She was started on a tapering dose la situation sociale et des médicaments of hydrocortisone, as well as insulin for management of hyperglycemia. des patients, car certains de ces agents Imaging was undertaken to rule out an adrenal tumour, which had nega- cosmétiques sont à l’origine du syndrome tive findings. de Cushing exogène. VOL 58: FEBRUARY • FÉVRIER 2012 | Canadian Family Physician • Le Médecin de famille canadien 169 Case Report Follow-up blood tests completed 2 months after These products have potential for adverse health discontinuation of the bleaching cream demon- effects; however, most medical practitioners outside of strated normalized corticotropin and cortisol levels. Africa are unaware of their widespread use. According to Accordingly, Alisha was able to use half the ori- dermatologists practising in Nigeria, these products are ginal dose of insulin to control the hyperglycemia. sold solely in local shops patronized by Africans, rather Later follow-up blood tests, however, showed than traditional pharmacies or cosmetic shops.3 Most are cyclical low corticotropin and morning cortisol lev- sold as cosmetic products in nonmedical stores without els (Table 1). warning about adverse effects or contraindications.4 Many skin-bleaching creams contain hazardous com- T able 1. Timeline of activity or laboratory investigations pounds. Analysis of the products consumers reported Date ACTIVITY OR LABORATORY INVESTIGATION using in the Togo questionnaire revealed that 18.5% con- May 2-4 (2007) • Patient presented to emergency tained topical corticosteroids. In 25.6% the composition department of the product was not specified.2 Sales of these sensitive • Cortisol level measured at 9 nmol/L products are unregulated and they can be obtained with- (random level) out prescription, leading to potential abuse by consumers. May 10 • Patient advised to discontinue use of Complications of skin-bleaching creams depend on the bleaching cream the active ingredients and are considerably influenced May 14 • 24-hour urine cortisol level measured by the extent and duration of use. The creams are often at 30.7 nmol/L applied to the whole body (large surface areas) and June 4 • Corticotropin level measured at under hot and humid conditions in which percutaneous < 2 pmol/L absorption is enhanced. Furthermore, continued use of the product is necessary to maintain the light com- • Cortisol level measured at 3 nmol/L (morning level) plexion. With long-term abuse, chronic adverse effects become increasingly prevalent. July 19 • Corticotropin level measured at With regard to cutaneous adverse effects, includ- 8 pmol/L ing hypopigmentation, hyperpigmentation, and atrophy, • Cortisol level measured at 217 nmol/L dermatologists studying patients who use such products (random level) found an adverse effect rate of 69.2%.2 Unfortunately, • Patient admitted to resuming use of the bleaching cream when cutaneous complications occur, rather than dis- continuing use of the bleaching products, most individ- September 21 • Corticotropin level measured at uals actually intensify their use, hoping to bleach away 3 pmol/L the imperfections and even out the skin tone. November 23 • Corticotropin level measured at More serious complications abound. Potent cortico- < 2 pmol/L steroids are well known to cause infections, exogen- • Cortisol level measured at 8 nmol/L ous Cushing syndrome, and suppression of the HPA (morning level) axis. Other adverse effects include nephrotoxicity5 and • Patient was again encouraged to neurologic manifestations.6 discontinue use of the bleaching cream Our patient’s clinical case was consistent with January 23 (2008) • Corticotropin level measured at adrenal insufficiency in the setting of Cushing syndrome 7 pmol/L secondary to exogenous glucocorticoid steroid adminis- • Cortisol level measured at 262 nmol/L tration and withdrawal. Systemic absorption of a non- (morning level) cortisol steroid would suppress the HPA axis, resulting • 24-hour urine cortisol level measured in low corticotropin and cortisol levels. The level of at 202 nmol/L novel steroid in her blood would not be detected by test- ing, which is specific to the cortisol molecule. Discussion In Nigeria, Cushing syndrome is more commonly Several social pressures favouring lighter skin tone encountered in chronic skin bleachers. Patients among Africans have been previously identified,1 present with overt features of Cushing syndrome, such including media advertisements in Africa (which as moon facies, truncal obesity, and the character- glorify lighter skin tone) and the rating of skin colour istic wide erythematous striae and folliculitis of the as a determinant of social class. A study from Togo lower axillae.3 Patients might present with systemic illustrated how broadly skin-bleaching products are manifestations of Cushing syndrome, including glu- used in African countries, revealing that 58.9% of the cose intolerance and hypertension. 910 female participants used cosmetic skin-bleach- In regard to the cyclically low cortisol
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