Harms of Hydroquinone and Mercury Creams: Symptoms, What to Do

What could be in these creams?

Some of the creams sold as lightening, 'whitening', 'brightening' or 'spot-removing' contain active ingredients that are banned in cosmetic products or should only be used under a physician’s supervision. The World Health Organization (WHO) states that skin lightening products that do not contain mercury may also contain other harmful substances such as hydroquinone. Three groups of substances stand out in these products:

• Hydroquinone: a substance that reduces the production of pigment (colouring matter). It can be used under a physician’s supervision in the treatment of dark spots; however, selling it as a cosmetic cream is not permitted in Turkey, the EU or the United Kingdom.
• Mercury compounds: lighten the skin by suppressing melanin formation. Because they can cause serious poisoning, they are banned in cosmetics in many countries; even so, they are reported to be easily available.
• Cortisone (corticosteroids): powerful medicines that suppress inflammation. Their use in cosmetic products is banned in Turkey, the EU and the United Kingdom; even so, they have been reported in some 'whitening' products.

The core of the problem is this: the person using these products often cannot know what is in them. The WHO emphasises that companies selling products containing mercury do not always list mercury as an ingredient. For the types of dark spots, sun protection and the treatments a physician can recommend, see our article “Dark Spots and Melasma”; this article focuses only on the risks of non-prescription creams of unknown origin.

If you have one of the emergency symptoms in the table, call 112 (or your local emergency number) without waiting. For symptoms that require consulting a physician, stop the cream and see a physician, taking its packaging with you.

Harms of hydroquinone: why does ochronosis matter?

Hydroquinone is a substance that can have a place in the treatment of dark spots when used under a physician’s supervision and for periods the physician sets. The problem arises with unsupervised, long-term use at high concentrations. According to a warning from the U.S. Food and Drug Administration (FDA), skin rashes, facial swelling and discolouration that may not reverse have been reported with non-prescription hydroquinone skin lighteners.

This lasting discolouration is called exogenous ochronosis (ochronosis of external origin). It appears where the cream was applied, mostly on the face, as blue-black or grey-blue patches in a net-like or lace-like pattern. In a systematic review (a compilation of published case reports) including 126 patients with hydroquinone-associated ochronosis, ochronosis was reported most often in middle-aged women and in people with darker skin; the median duration of use was 5 years. In most cases, high-concentration products or products of unknown concentration had been used; cases developing after a few months of use are rare.

The hardest aspect of ochronosis for people is this: the person using the product often interprets it as their dark spot getting worse and uses more cream. In ochronosis, however, using more cream makes the problem bigger. The authors of the same review state that treatment is often disappointing. So if you notice a blue-grey darkening where the cream was applied, it is important to stop the cream and see a dermatologist.

Hydroquinone is generally not recommended during pregnancy and breastfeeding; for details, see our article “Medical Aesthetics in Pregnancy and Breastfeeding”.

Symptoms from mercury creams: how is poisoning recognised?

When mercury is applied to the skin again and again as a cream or soap, it can enter the bloodstream. The symptoms often start insidiously; they can develop over months and years and can be confused with other illnesses. The main effects reported by the WHO and the FDA are these:

• Kidneys: kidney damage; nephrotic syndrome, in which the loss of protein in the urine increases, has been reported. The FDA also draws attention to the possibility of rapidly developing kidney failure.
• Nervous system: trembling, numbness or tingling in the hands and feet or around the mouth, headache, tiredness, forgetfulness, irritability, shyness, changes in vision or hearing.
• Mood: anxiety, depression; in severe cases, loss of contact with reality (psychosis).
• Skin: rash, discolouration and scarring; reduced resistance of the skin to bacterial and fungal infections.

In the cases reported by the WHO, stopping the cream was the basic step in bringing down the mercury levels in the blood and urine over time; the decrease can take months. Kidney findings were also reported to have regressed in most of the women who stopped the cream. However, the FDA states that these products can cause serious health problems that may be lasting. So if you think you have used a mercury cream, see a physician even if you have no complaints. The physician decides which tests are needed and on the treatment.

People living in the same home can also be affected

The risk of mercury cream is not limited to the person using it. According to the FDA, family members can be affected through mercury vapour released from the product and through towels or cloths contaminated with mercury. The FDA also states that children and pregnant women are at greater risk from these products and should not be exposed to them.

• You may have held your baby or child or touched their face after applying the cream.
• Towels, pillowcases and cloths that the cream has touched may also have been used by others.
• You may have shared the cream with a relative or given it to them as a gift.

If one of these situations applies to you, tell your physician about this too. The physician decides which members of the household need to be assessed.

Cortisone 'whitening' creams

Creams containing cortisone (corticosteroids) are medicines used in some skin diseases on a physician’s recommendation and for set periods. When they are applied to the face for months without a physician’s supervision to lighten dark spots or 'whiten the skin', their side effects become pronounced. The known side effects of these creams are:

• Thinning of the skin (atrophy); the skin becomes paper-thin and bruises and tears easily.
• Stretch marks (striae), especially in skin folds such as the armpits and groin.
• Fine red blood vessels becoming visible (telangiectasia).
• A spot-like rash around the mouth and nose (perioral dermatitis) and redness (steroid rosacea).
• Skin infections appearing, getting worse or being masked; increased hair growth.
• A flare-up of redness and burning when the cream is stopped (withdrawal symptoms).

When applied to large areas and for a long time, cortisone can also affect the body’s own hormone balance. If you have been using a cortisone cream for a long time, talk to a physician instead of stopping the cream on your own; the physician makes the plan for stopping it.

How can a risky product be recognised?

It is not always possible to identify a risky product by a single sign; products containing mercury and cortisone may not state this on the label. Even so, if even one of the signs below is present, do not use the product:

• There is no ingredient list (product ingredients), or it cannot be read.
• There is no information at all on the packaging in the language of the country where it is sold (in Turkey: Turkish); the label is only in a foreign language.
• Terms such as 'mercury', 'Hg', 'mercurous chloride', 'calomel', 'mercuric', 'mercurio', 'mercuric iodide', 'ammoniated mercury', 'cinnabaris' or 'hydrargyri oxydum rubrum' appear on the label or in the ingredients.
• The packaging carries a warning such as 'do not allow contact with silver, gold, rubber, aluminium and jewellery'; the WHO states that such warnings may point to mercury.
• The ingredients say 'hydroquinone', but the product is sold as a cosmetic, without a prescription and without a physician’s recommendation.
• The product is sold only online, through social media accounts or via messaging apps; it is said to have been 'specially brought from abroad'.
• There are unrealistic promises such as 'snow-white in a few days' or 'permanent whiteness'; the product is sold in a jar without a label.

In Turkey, cosmetic products are notified by the responsible company to the database of the Turkish Medicines and Medical Devices Agency (Türkiye İlaç ve Tıbbi Cihaz Kurumu, TİTCK) before being placed on the market. TİTCK states that registration in the Product Tracking System (Ürün Takip Sistemi, ÜTS) does not mean a licence, permit or approval granted by the Agency. In other words, a product appearing as registered is not proof that its contents are safe; products containing banned substances can in any case be sold through unregistered channels. For the general warning signs of counterfeit products and treatments of unknown origin, see our article “Counterfeit Products and Unlicensed Treatments”.

The legal situation by country

The table below summarises what the official regulations on cosmetic products say. Medicines prescribed by a physician are a matter for medicines legislation, not cosmetics legislation, and are not included in this table.

The situation is similar at international level. According to the WHO, countries that are parties to the Minamata Convention should, after 2020, have banned the manufacture, import and export of cosmetics with a mercury content above 1 part per million (1 ppm), including skin lightening soaps and creams (apart from registered exemptions). However, the WHO emphasises that even in countries with bans, these products continue to be sold online and through other channels.

What should you do if you have used one?

1. If you have one of the emergency symptoms in the table, call 112 without waiting.
2. Stop using the cream immediately. Wash your hands and the skin the cream has touched thoroughly.
3. Do not throw away the packaging, the box or any purchase record. Put the product in a tightly sealed bag or a leak-proof container and keep it out of the reach of children. Take a photo of the label and the ingredient list.
4. See a physician even if you have no complaints. Describe the product, how long you have used it and on which parts of the body, whether you are pregnant or breastfeeding, and the people you live with.
5. If you have been using a cortisone cream for a long time, make the plan for stopping it with your physician.
6. If you later need to dispose of the product, do not throw the closed container away carelessly; find out the local waste rules.
7. If you have had an unwanted effect from the product, according to TİTCK this can be reported first to the company and then, with a physician’s report, to the Agency through the ÜTS Mobil app using an e-Devlet (Turkish e-government) login.

The safe route for dark spots: treatment planned with a physician

Most dark spots are harmless, but each has a different cause and treatment. Treatment of dark spots should be planned with a physician, taking into account the type of spot, your skin type, whether you are pregnant or breastfeeding and the medicines you take. The FDA also recommends discussing treatment options for problems such as age spots and sun spots with a physician instead of using non-prescription skin lighteners. Even a dark spot cream recommended by your physician should not be used for longer than recommended.

Whatever treatment is chosen, the basic step is daily sun protection; for this, see our article “Sunscreen Guide”. Which dark spots laser and light treatments work on, and why caution is needed with melasma, is explained in our article “Pigment Lasers”.

Limits of the evidence: much of the information on ochronosis and mercury poisoning is based on case reports, case series and field investigations by health authorities. It is not known in what proportion of people using these products problems develop; because the contents and concentrations of the products vary greatly, no personal risk can be given to you. This page is for general information and does not replace an examination.