‘Fairness mania’ is fueling a dangerous drug dependence in India

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A message notification from a stranger. That was all it took for Soma Banik to be transported back to her teenage years, and for the memories of all the “horrific things” she went through to come flooding back.

The stranger in question was Janet James, who reached out to her one afternoon in June 2018. “I need your help,” James messaged Banik on the social networking platform Quora. She described how she had been using a cream containing the steroid Betamethasone for over two years to lighten her skin and was experiencing disturbing side-effects. “Whenever I stop using it, my face starts itching and small blisters arise,” she wrote.

James had stumbled upon Banik's skincare blog, in which she documents her own painful experience with topical steroid creams and had sent her an urgent plea for guidance.

Banik, who is now a 33-year-old state government employee from the suburbs of Kolkata, replied instantly. She gave James the advice she wished someone had given her: “Stop right away.”

 

Soma Banik documents her experience with topical steroid creams on her skincare blog.

Betamethasone is a potent topical corticosteroid medication habitually used to treat a wide range of skin conditions, including psoriasis and eczema, but one of the potential side effects is lightening of the skin.

Creams containing Betamethasone should only be used on the advice of a doctor and are typically acquired with a prescription. But in India, as CNN learned from doctors and users around the country, Betamethasone, and other corticosteroid creams, are regularly being misused as a skin lightening agent -- mostly by women.

In 2003, when Banik was just 14, a neighbor told her mother how much their child had “benefitted” from becoming “fair” by using a new cream. “Your daughter will also become fair,” they said.

Wanting Banik to have the best prospects in a country where lighter skin is seen as desirable and associated with success, Banik’s mother took her neighbor’s advice. “I was disappointed that it came in a tube so unappealingly medicated,” Banik recalls, “but it held the secrets toward my fairer future.”

School friends were the first to notice, commenting on Banik’s newly acquired “good looks,” but within two months of using the steroid cream, she started to feel a burning sensation whenever she was out in the sun. She says she accepted this as part of the process: no pain, no fairness.

But one morning, the teenager forgot to apply the cream and within hours, a zit appeared on her chin. Though it quickly settled on applying the cream, Banik’s face started itching all the time. She soon developed acne and then, a year after the zit appeared, hair began to grow all over her face.

 

Banik, 33, is now a state government employee living the suburbs of Kolkata. She started using a topical cream to lighten her skin when she was 14.

A drug dependent face

CNN spoke with multiple Indian dermatologists all of whom confirmed that Banik’s symptoms -- itching, acne, and hirsutism (hair on the face) -- are signs of Topical Steroid Damaged/Dependent Face (TSDF), caused by the excessive or prolonged use of steroid creams.

Topical corticosteroids, such as Betamethasone, have several medical benefits, including anti-inflammatory effects, but they should only be used for short durations and under the supervision of a doctor, ideally a dermatologist. Extensive use can cause a range of side effects, including pustules, where big rashes appear on the face, dryness, hypopigmentation (lighter skin), hyperpigmentation (darker skin), or photosensitivity (reactions to sunlight).

It is the potential for hypopigmentation that is thought of as desirable by many women, and leads to misuse of the drug, in turn, fueling a dependency.

Once the skin is dependent on a steroid cream, explains Dr Rajetha Damisetty, it is difficult for a person to stop using it. Every attempt to stop will lead to an eruption of pimples, rashes, and redness. “That’s why people go back to using it,” says Damisetty, chairperson of the Indian Association of Dermatologists, Venereologists and Leprologists’ (IADVL) task force against topical steroid abuse.

What steroid abuse can do to your skin

The long-term use of topical corticosteroids can lead to severe skin damage. Here are just some of the symptoms that can arise.

Note: These photos are blurred as they may be disturbing for some readers. Switch the toggle to make them visible.

 

Blurred

Most common side effects

• Erythema

  
  An immune reaction in the skin, resulting in a red, raised rash.

• Acneiform Eruptions

  
  Severe acne-like eruptions in the skin.

• Hirsutism

  
  Excessive hair growth, including dark or coarse hair on the face.

• Photosensitivity

  
  Skin sensitivity to sunlight, caused by an immune reaction to ultraviolet rays.

See more

Source: Topical steroid damaged/dependent face (TSDF): An entity of cutaneous pharmacodependence

Even though numerous painful and visible side effects could develop from topical corticosteroid misuse, dermatologists told CNN that the practice is rampant in India -- despite the introduction of restrictions in 2018 to limit access to these drugs.

In 2017, the IADVL filed a lawsuit called a Public Interest Litigation in the Delhi High Court seeking a ban on the sale of steroid skin creams without a valid prescription. The petition stated that the unregulated sale of corticosteroids had caused “serious adverse effects on the health of millions of Indians.”

While the Court has yet to rule, the government took action in March 2018, with the Health Ministry adding 14 topical steroid creams, including Betamethasone, to the list of Schedule H drugs which cannot be purchased without a doctor’s prescription.

But despite this reclassification, CNN has found that little has changed in the sale or use of these so-called “fairness creams.”

 

Banik’s husband, Biswadweep Mitra, uses an epilator to help her remove facial hair that continues to grow after she stopped using topical corticosteroids.

A silent epidemic of “astronomical magnitude”

India is a vast country with a large rural population and health services managed at the state level. As such, painting a complete, up-to-date picture of the misuse of steroid creams is challenging.

Still, there is enough evidence to show that whether in large cities or in rural areas, these restricted substances continue to be easily accessible, used as a skin-lightening agent and predominantly by women, and their perceived benefits promoted to users by friends, family, neighbours, TV commercials and even pharmacists.

In recent months, CNN has been able to buy four types of topical steroid creams over the counter in 16 pharmacies across the subcontinent: in the northern city of Delhi, Kolkata in the east, Ahmedabad to the west and Hyderabad in southern India.

Of six staffers in as many stores CNN spoke to, just one acknowledged being aware of the need for a prescription to buy the creams and continued to sell the product without one. The remaining five people appeared unaware of the reclassification and sold the creams, even after being questioned. Staff at the 10 other stores visited avoided questioning but sold CNN the creams, also without prescription.

According to doctors and users of steroid creams, the products are also readily available at grocery stores.

When asked what he thought about the continued over-the-counter availability of topical steroids, Dr Abir Saraswat, a dermatologist with 20 years of experience, says he believes India’s powerful pharmaceutical lobby is to blame, citing threats to strike and shut up shop. “Surely, no government wants to countenance that,” he says, adding that unless there is deep reform and regulation, there is no way to stop people from flouting the rules.

 

Two examples of corticosteroid creams commonly prescribed by dermatologists for short durations to treat skin conditions such as eczema and psoriasis in India. The creams should be purchased at pharmacies with a valid prescription, but CNN has found they are being sold over the counter in pharmacies across India to women hoping to lighten their skin, which is one of the potential side effects if used for extended periods of time.

Dr Shyam Verma, a dermatologist who has published extensively on topical steroid misuse, agreed but told CNN that the problem goes beyond the pharmaceutical lobby. “There also seems to be a lack of will, and manpower, to implement the law by the governments’ drugs control departments, both at the central and the state level.”

CNN contacted the Indian Pharmacist Association, a trade group that represents pharmacy stores, which identified a different reason for the unregulated sale of steroid creams. “Technically, every pharmacy in the country should have a registered pharmacist sitting at the counter as long as the shop is open,” Abhay Kumar, the Association’s president says. But “there is no national count on who are at the counters.”

Kumar insists that his organization has been pressuring the Pharmacy Council of India, a central government body that regulates the licensing of pharmacists and pharmacy education, to make a list of registered pharmacists around the country to weed out the fraudulent ones. “So far, our demands fizzle into thin air,” he says.

Verma agrees that there is some truth that registered pharmacists are often not at the counters, but he explains that pharmacies with registered pharmacists are also known to sell these creams without a prescription.

The Pharmacy Council of India did not respond to CNN’s requests for comment.

The Ministry of Health and Family Welfare asked CNN to take the matter up directly with the current Drugs Controller General of India, Dr VG Somani. Somani’s office, in turn, declined to comment without official approval from the health ministry. The Ministry has not responded to CNN’s request for approval.

At the state level, the Deputy Drugs Controller for Delhi, Atul Nasa, did speak to CNN, but says unregistered pharmacies and the over-the-counter sale of steroid creams are not problems in his state. “In Delhi, we only give licenses to pharmacies with a registered pharmacist. Now, if at a certain point they are not at the counter, we should be informed.”

He adds: “We have got no tip that Schedule H creams are being sold over the counter in our territory. If we do find evidence, we will surely take action.”

When informed that CNN was able to purchase creams at multiple sites without a prescription, Nasa simply reiterated: “Our team has no such information that these creams are being sold over the counter.”

While the ability to buy creams without prescription is causing many people in India to develop a dangerous dependence on topical corticosteroids and suffer from its multiple adverse effects, another factor is further adding to the problem.

According to Damisetty, corticosteroids are also present in many cosmetic creams, marketed explicitly as skin-whitening products and, alarmingly, steroids are often not listed as an ingredient. She tested one of the most popular products available and found it contained 0.056% Betamethasone. “That amount can surely cause drug dependence if used for a prolonged period,” says Damisetty.

“The findings were published in local media,” she says, adding that the company manufacturing the cream then sent her a legal notice disputing the findings. There was no further development, however, following the onset of the Covid-19 pandemic, Damisetty explains.

Now, Damisetty and the other dermatologists CNN spoke to want to raise the alarm before the problem gets any worse.

“Fairness mania-induced use of topical steroids” is a silent epidemic of “astronomical magnitude,” says Dr Koushik Lahiri. He highlights a 2020 article in the BMJ Open, which listed “public and professional ignorance, legal ambiguity and government inaction” as contributing factors to the epidemic.

“Action must be taken to curb the sale and use of such creams as fast as possible,” he says.

 

Dr. Koushik Lahiri sits in his office at Wizderm, a skin-care clinic in Kolkata.

Eligible groom seeks fair bride

At the root of the wide-spread misuse of topical corticosteroids in India is the deep-seated belief that lighter skin tones are better than darker ones. And nowhere is this more visible than in India’s marriage culture.

In 2014, in Gurugram, a city southwest of Delhi, a woman killed herself. Her sister told reporters that the woman had been “fed up [with] the taunting [she received from her husband] regarding her skin colour.”

A year later, a schoolteacher from Kolkata set herself on fire. Before she died in hospital, she is reported as having said that putting up with constant humiliation for her complexion, and being told no-one would marry her, was the reason she did it.

Matrimonial advertisements in the press clearly show the societal link between fair skin and desirability.

CNN analyzed ads posted in the Sunday editions of three of India’s biggest English-language newspapers -- Times of India, The Telegraph and Hindustan Times -- throughout the month of August, counting how many times the word “fair” was used, as well as similar terms such as “wheatish” or “medium complexion”. Of 1332 ads, 301 (22%) explicitly used these words, either as a selling point or as an attribute sought in a prospective match.

All’s 'fair' in love and marriage

A sample page from the Sunday Times of India, the country’s largest English language daily (by circulation), shows how common mentions of fair skin are in matrimonial ads.

• ↓ Scroll down for ads ↓
• HINDU/ AGARWAL/ UNMARRIED/ 29 YRS/ 6FT/ Very handsome/ very fair/ Harvard Business School educated well established entrepreneur from high status family looking for tall, extremely beautiful and well educated match from India & Abroad. XXXXXXXXXXXXXXX@XXXXXXXXX Whatsapp: 0000000000
  WANTED BRIDES

  BY CASTE

  AGARWAL-BISA
• SEEKING matrimonial alliance for a fair and Beautiful Jatt Sikh Girl, 1995 Born, 5'8, Doctor by Profession (MBBS). NZ PR, Seeks well established businessman or Professionally qualified well educated Tall Boy (aged between 25-29) from well affluent settled family. Contact- 0000000000
  WANTED GROOMS

  BY RELIGION

  SIKH
• 29 /5'8" FAIR, AFFABLE, MAHARASHTRIAN, MBBS DOCTOR, RUNNING COMPANY IN DIAGNOSTICS, WITH MULTIPLE CENTRES IN MUMBAI SEEKS GENIAL BEFITTING GRADUATE GIRL. Contact: 0000000000 XXXXXXXX@XXXXXXXXX
  WANTED BRIDES

  BY RELIGION

  HINDU
• SM4 Sheikh Sunni V. Fair, Slim & Attractive, never married 36/5'2" Interior designing graduate girl. E: XXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY RELIGION

  MUSLIM
• SM4 Srivastava girl fair feb 86/5'8.5" B.E+MBA 30lpa, wkg HYD seeks prof. qlfd. tall boy , f'ther retd. E.D.,PSU #0000000000. XXXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY CASTE

  KAYASTHA
• HARVARD, Masters USA, V'Fair H'some boy Sept 81/5'6", 50 LPA Very bright future, High Net Worth Investor, Only son Parents Doctor, 0000000000
  WANTED BRIDES

  GENERAL

  SECOND MARRIAGE
• MUMBAI-BASED-WELL settled Unmarried Sindhi Boy, 40/5'7", B.Sc. Seeks Slim, Fair and Decent Sindhi Girl. Contact : 0000000000
  WANTED BRIDES

  BY LANGUAGE

  SINDHI
• SM4 Gursikh Bhatia B'ful slim fair I'less Divorcee (marriage not consumed) 40,5'4" MBA wkg girl. Seeks PQM TT Gursikh in job Wa 0000000000
  WANTED GROOMS

  BY RELIGION

  SIKH
• KYSTH fam seeks allians for sis 27/5.1, vryfair, B.Jrnlsm, wrkg, look for groom tlf: 0000000000 XXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY CASTE

  KAYASTHA
• FAIR, Slim, B.E. Punjabi girl, Mumbai, working MNC 5' 5" Oct'93, Caste no bar. +000000000000 , XXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY LANGUAGE

  PUNJABI
• SM 4 bful/fair Pb Delhi girl 89/5'3"/9:02am, Master from USA wkg in S'pore based Co. 27 LPA, S. Delhi well settled family.Ct: 0000000000
  WANTED GROOMS

  GENERAL

  CASTE NO BAR
• SM4 H'some fair 32/5'11 B.Tech IIT Roorkee Sr Software Engineer 67Lpa Father Rtd Army officer elite family cast no bar 0000000000, 0000000000
  WANTED BRIDES

  BY CASTE

  BRAHMIN
• WANTED Brahmin professional grooms, good families for cultured pretty, fair, homely vegetarian daughter 29 year, height,161cm, BTech MBA working in MNC.10 lakh package.Father Retd Colonel from Bihar - 0000000000.
  WANTED GROOMS

  BY CASTE

  BRAHMIN
• JAISWAL SW engr 28/5' fair Working in MNC Banglore 12 LPA, Looking PQM All Vaishy community, educated family in UP 0000000000, 0000000000
  WANTED GROOMS

  BY PROFESSION

  ENGINEERS
• B.TECH, MBA top B-School Delhi bsd Agarwal B'ness family is L'king SM for their daughter Sept 88/5'6" very fair,tall,b'ful,wrkg MNC high pkg.Seek IIT/IIM/Bnesman/Civil Srvcs. only#0000000000 E: XXXXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY CASTE

  AGARWAL-BISA
• W.B Kayastha 33+,5'4" Makar Rashi Norgon B.A fair good looking wanted suitable Bengali Groom. M: 0000000000
  WANTED GROOMS

  BY LANGUAGE

  BENGALI
• MBBS, MD (Anaesthesia), Delhi bsd B'FUL fair, Punjabi, 27/5'2" seek, h'Some Boy from affluent family. # 0000000000 E: XXXXXXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY PROFESSION

  DOCTORS
• SM4 fair beautiful Delhi (SC) girl December 1988 5'2" B.Tech, MBA working in MNC NOIDA, Contact : 0000000000
  WANTED GROOMS

  GENERAL

  SC/ST
• SM Brahmin/Professionally qualified wkng,Girl smart B'ful, 34/5'4"& Boy fair,H'some, 29/6',scale -2 officer in PSU em: XXXXXXXXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  BY NATIONALITY

  BRIDES & GROOMS
• SM4 Kayastha, fair convent b'ful girl 27/5'3" BE/MBA, wkg in MNC seeks IAS, IPS, Allied, Engrs, MBA, Doctors. Parents doctor with Govt of India. 0000000000,0000000000
  WANTED GROOMS

  BY CASTE

  KAYASTHA
• B.TECH IIT MBA ISB FAIR H'SOME 87/171 FOUNDER TECH STARTUP >5 CRORE FROM AFFLUENT S. JAIN FAMILY. M. NO. 0000000000
  WANTED BRIDES

  BY CASTE

  JAIN
• BRAHMIN bengali girl fair 28/5'3"phD(ENG) pursuing kol father and brother Doctor look for well educated match preferably in WB 0000000000
  WANTED GROOMS

  BY LANGUAGE

  BENGALI
• IPS superintendent of police (UP cadre) Jaiswal boy fair 33/5'6" well-qualified match required, caste no bar 0000000000, 0000000000
  WANTED BRIDES

  BY PROFESSION

  IAS/ALLIED SERVICES
• BUDDHIST 35 yrs', fair, tall, beautiful, Mah Gov' class 1 Engineer, fresh bride seek right groom. Caste/ age, faith no bar. 0000000000. 0000000000
  WANTED GROOMS

  BY RELIGION

  BUDDHIST
• GROOM for Jadon Rajput, Fair girl, 1996/5'3", Lawyer (HNLU) seeks suitable match. Business Family from UP, settled in Raipur (CG) 0000000000
  WANTED GROOMS

  BY PROFESSION

  LAWYERS
• 1994 /5'3 slim fair b'ful Brahmin girl B.E IT Programmer at MNC, no Siblings, Father Class 1 Officer Elite fmly Cast no bar 0000000000, 0000000000
  WANTED GROOMS

  GENERAL

  CASTE NO BAR
• SM4 NM fair smart 35 (Aug 86 born)/5'7" /BE,MBA boy wkg in MNC in NCR 25LPA. South Delhi based reputed fmly. Parents doctors. # 0000000000, E: XXXXXXXXXXXXXXX@XXXXXXXXX
  WANTED BRIDES

  BY CASTE

  AGARWAL-BISA
• BENGALI-MASTER-ENGG Australian Citizen, 30/5'5", Fair, Non-Manglik, Narogon, Caste General Category. Only Hindu, Bengali, Decent Girl within 25-28 yrs. working in IT, Pharma, Mktg., R&D living in around Mumbai, Pune. Call or Whatsapp on 0000000000
  WANTED BRIDES

  BY LANGUAGE

  BENGALI
• KHATRI PUNJABI Family, 24, 5ft 7", fair girl, studied fashion designing, lives in Ahmedabad posh area. Belongs to good business family, looking for good like minded business family. Contact: XXXXXXXXXXXXX@XXXXXXXX
  WANTED GROOMS

  BY LANGUAGE

  PUNJABI
• SM4 Fair, B'Ful Girl, 27/156 Cms, MBA well settled family. Looking for Mum based well educated & settled Boy. Call: 0000000000
  WANTED GROOMS

  BY LANGUAGE

  PUNJABI
• SM4 B'ful fair slim Brahmin Widow I'less 42/5'3 Mcom Govt officer Caste no bar # 0000000000, 0000000000
  WANTED GROOMS

  GENERAL

  RELIGION NO BAR
• SM4 Fair Pb Khatri girl 27/5'4"/Delhi. Living in US, SF on work visa, H'some package, ivy League MBA. Lkg for equally qlfd. match having family values. Parents business (Noida) # 0000000000.
  WANTED GROOMS

  BY NATIONALITY

  NRI/GREEN CARD
• SM for handsome Rajput boy, 5'10"/81 born MBA, Fair & Smart, Sr Mgmnt Prof, has own business in Mumbai too. Caste no bar. Email: XXXXXXXXXX@XXXXXXXXX / call 0000000000
  WANTED BRIDES

  GENERAL

  CASTE NO BAR
• STATUS match invited for b'ful,fair,slim,Gaur Brahmin M.B.A girl D.O.B. 02/02/96.Father Industrialist. 170 0000000000 / 0000000000
  WANTED GROOMS

  BY CASTE

  BRAHMIN
• HINDU Vaishnov fair, Girl - March 86/ 5.4", Post Graduate looking for well settled, educated Boy Mumbai: 0000000000 E : XXXXXXXXXX@XXXXXXXXX
  WANTED GROOMS

  GENERAL

  CASTE NO BAR
• BDS,MDS,ENDODONTIST Sr Lecturer Pvt Dental College NCR, Slim, Fair khatri girl 29, 5'5.5" family well placed. Contact 0000000000
  WANTED GROOMS

  BY LANGUAGE

  PUNJABI
• SM4 Kayastha, B'ful, Fair girl, Jan 94/5'4, Australian PR, Masters in I.T, Working in Aust. Govt. , Sydney, Caste no bar, Call/W'app : +000000000000
  WANTED GROOMS

  BY NATIONALITY

  NRI/GREEN CARD
• ↑ Scroll up for ads ↑

 

Source: Times of India, Mumbai edition, Aug. 29, 2021

Dhruba Mukherjee, CEO of ABP Pvt Ltd, the media group that owns The Telegraph, told CNN that while “the publishing house does not endorse the use of these terms, unless a word breaches the law, we cannot ask people to stop using any specific term”. He added that the ads “reflect the socio-cultural mindset of people”.

The Times of India did not respond to CNN’s request for comment and The Hindustan Times declined to comment.

Explaining the phenomenon, feminist activist and researcher Reena Kukreja says: “In large part, [the desirability of fair skin is] due to the association of dark skin with manual labour undertaken outdoors — dark skin was emblematic of low caste status”.

In an article published at the start of 2021, Kukreja outlined how “fairness as ‘capital’ conjoins with both regressive patriarchal gender norms governing marriage and female sexuality and the monetization of social relations, through dowry, to foreclose local marriage options for darker-hued women.” In other words, the darker-skinned and poorer you are in India, the harder it is for you to find a husband, and society reserves many privileges for married women.

“One thing I keep hearing is parents asking me to ‘fix their daughters’ skin problems fast,’” says dermatologist Dr Pallavi Kashyap. “Parents fear their daughter won’t find a prospective suitor unless they are fair.”

Relating this to her own experience and her mother’s decision to take their neighbor’s advice 20 years ago, Banik says: “Our country has this unfair beauty standard and I believe my mother wanted me to become fair so that people think that I am worthy of attention.”

“That’s what we all had seen and experienced all around us,” she adds.

 

Hair growth on her face is something Banik has had to live with since she stopped using topical corticosteroids.

A cautionary tale

It took Banik six years for her face to be weaned off topical corticosteroids, but she had been determined to stop. “One day, I woke up and decided not to use the cream anymore -- I was ready for all consequences,” she says.

Those consequences included being mocked about her appearance. “My self-confidence dropped. I remember overhearing a classmate discussing how I looked worse than a pig and that stayed in my head for far too long. It took me years to rebuild my confidence.”

The burning sensation, acne and other symptoms eventually stopped, but the hair on her face is something Banik has to live with.

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CNN odu mana desapu asalu sisalaina culture ni batta bayalu chese daaka oorukunetattu ledu kadaa. 

Good going