Beauty is more than skin deep
Two dermatologists celebrated career achievements, delivering the AAD’s prestigious Kelly and Fox lectures.
Seemal R. Desai, MD, FAAD, and John J. Zone, MD, FAAD, don’t hold back. When global health problems arrived on their doorsteps, they each gladly picked up the pieces and began problem-solving. The experts delivered the A. Paul Kelly, MD, Research Award and Lectureship and the Everett C. Fox, MD, Memorial Lecture, respectively, in Friday’s session, N001 – Celebrating Excellence: A Duo of Distinguished Talks.
Deep-rooted beliefs
In Dr. Desai’s presentation, “Beyond Skin Deep: The Global Skin-Bleaching Epidemic, Colorism, and the Future of Pigmentary Care,” he examined the problematic trend of skin lightening. Dr. Desai is the founder and medical director of Innovative Dermatology and a clinical associate professor of dermatology at UT Southwestern Medical Center in Dallas.
“Receiving the A. Paul Kelly, MD, Research Award and Lectureship is especially meaningful to me because my career has focused on pigmentary disorders, skin of color, health equity, and improving awareness and education surrounding conditions that disproportionately affect underserved and diverse patient populations,” said Dr. Desai, who served as AAD president in 2024 to 2025. “To be recognized with an award that honors innovation, research, mentorship, and advocacy in this space is both deeply humbling and personally significant.”
According to Dr. Desai, the pursuit of lighter skin and practice of skin bleaching has a long, fraught history deeply rooted in European and imperial colonization and the slave trade, with darker-skinned and minority groups believing their skin color was tied to beauty and value. This has carried over through generations, but what has changed over time is the scale, with several converging factors exacerbating the issue.
Neal D. Bhatia, MD, FAAD, and Seemal R. Desai, MD, FAAD
The rise of e-commerce and disposable incomes have also made purchasing products with little regulation convenient and rampant, said Dr. Desai.
“The cultural roots were always there, what changed is the infrastructure that now feeds it,” he said.
Skin bleaching is especially engrained in South and Southeast Asia, the Caribbean, and sub-Saharan Africa, said Dr. Desai. In Nigeria alone, 77% of women report regular use of skin-lightening products, and many also use the products on their children. The global market for these products is currently valued over $20 billion and is estimated to nearly double ($37 billion) by 2032. Still, North America is not immune to the epidemic.
“With our multicultural patient populations in the U.S., these products are walking through our exam room doors every day, often unannounced,” Dr. Desai said. “Issues surrounding skin bleaching, fairness, and hyperpigmentation remain deeply intertwined in the cultural fabric of many societies, and dermatologists are uniquely positioned to address both dimensions.”
Facts and risks
Skin-lightening products regularly — and illegally — often contain toxic heavy metals, particularly mercury, because they’re inexpensive, readily available, and produce quick results. The U.S. Food and Drug Administration (FDA) conducts intense laboratory testing on global products and, in 2026, it found, for example, the Orbi 20 Whitening Cream marketed in Pakistan and purchased on eBay contained 27,762 ppm of mercury. Kojic acid and hydroquinone are other commonly found ingredients with severe side effects.
These ingredients interfere with melanin production, destroy melanocytes, and can cause permanent damage to the skin and beyond. The real systemic consequences are what make skin-bleaching a public health threat and demand urgent attention, said Dr. Desai.
“Patients use these products to lighten their skin for uncontrolled periods of time without physician supervision and can end up with irreversible, disfiguring darkening,” he said. “The real danger is not any single ingredient in isolation but the combination of unregulated agents, used chronically, without medical oversight, in pursuit of a cosmetic ideal that is itself rooted in colorism.”
The effects range from dermatologic (hyperpigmentation, exogenous ochronosis, skin atrophy, skin cancer) to biologic (edema, nephrotic syndrome, kidney and renal disease, hypertension) to neurologic (memory loss, anxiety, tremors, paresthesia). Fetuses and children are at increased risk for severe conditions like fetal mercury exposure and developmental neurotoxicity, Dr. Desai said.
The pursuit of awareness and education
Dr. Desai said dermatologists are responsible for asking questions and providing awareness. He draws on his South Asian background and meets patients with humility, empathy, and truth.
“Patients may not disclose use because of the stigma around these products, which makes nonjudgmental, specific questioning essential. When I identify toxicity, I stage the severity, assess for systemic involvement, and coordinate with nephrology, neurology, or toxicology, as needed,” he said. “Respectful education, not shame, is what drives lasting behavior change.”
Some countries have passed regulations or bans. In 2023, the Nigeria National Agency for Food and Drug Administration and Control even declared a state of emergency. However, the gaps between instruction and enforcement — policy and practice — are far and frequent, especially in places where the problem is most prevalent: “A public health emergency hiding in plain sight,” said Dr. Desai.
Pigmentary care will improve once therapies and education reflect the full diversity of the global population.
“The future is more targeted, more personalized, and more inclusive, and I am genuinely optimistic,” Dr. Desai said.
Dr. Desai left attendees with final food for thought, which he said is straightforward, attainable, and overdue.
“First, ask the question the right way. The history you do not take is the diagnosis you will miss. Second, think systemically. We are often the physicians who make the connection or do not. Third, lead with humility, not judgment. Our patients are responding to real social pressures that did not originate with them. Meet them where they are, redirect them to safe options, and take that advocacy beyond the exam room into policy, into the community, and into how we train the next generation.”
Eager investigation
There’s a proverbial saying, “Curiosity killed the cat.” But in Dr. Zone’s experience, curiosity sparked a pursuit of knowledge that still has not been extinguished. Dr. Zone, who is a professor of dermatology and the Bertram H. and Janet Marshall Schaap Presidential Endowed Chair at University of Utah Health in Salt Lake City, delivered the presentation, “Gluten: A Story of Relentless Intellectual Curiosity.”
Neal D. Bhatia, MD, FAAD, and John J. Zone, MD, FAAD
As a young resident, Dr. Zone’s mentors (Drs. Dick Dobson and Tom Provost) encouraged him to spend time in the lab and explore the science of medicine as well as the practice of it. He took this to heart and has spent the last several decades honing his passion for unraveling a rare skin disease: dermatitis herpetiformis.
Dermatitis herpetiformis (DH) is a cutaneous manifestation of celiac disease, an intestinal disease caused by gluten. Though celiac disease was described in the late 19th century, its cause was not correctly identified until 1940 when, during World War II, the Netherlands was cut off from grains and experienced the Dutch Famine. At that time, Dr. Willem Dicke realized that critically ill children had been cured by the coincidental elimination of grains — specifically, gluten — from their diet.
This observation led to discovery and innovation about the role of gluten in chronic intestinal disease and its cutaneous manifestation, DH.
“The story of gluten is really about this relentless intellectual curiosity and innovation that has occurred over the last 80 years to give us an understanding of how gluten affects our body and affects our skin,” he said.
Dr. Zone has conducted his investigation by practicing keen observation, constant collaboration with his colleagues, and intense interest in learning everything he can about the chronic condition.
“Every day, physicians see a lot of patients, and many times, there are mysteries,” Dr. Zone said. “If you want to be an innovator, if you want to have intellectual curiosity, you have to constantly pick out those unusual things and then discuss them with others. Brainstorming is an incredibly fun part of science.”
The pursuit of innovation
One of Dr. Zone’s biggest scientific breakthroughs occurred while investigating how granular immunoglobulin A (IgA) antibodies reach the papillary dermis. Through experimentation with animal models, he was able to reproduce the process and validate the deposition of the antibody and its binding to transglutaminase 3 (TG3) in the skin.
Virtually all patients with DH also have celiac disease, both of which can be mild to severe. Dr. Zone said DH is more likely to occur in individuals whose intestinal condition goes untreated for an extended period.
“Because of the chronic inflammation in the intestine, 15% of people with celiac disease will get dermatitis herpetiformis by producing the IgA antibody to transglutamine 3,” Dr. Zone said.
Once DH is diagnosed with skin biopsy, it is extremely treatable with the anti-inflammatory drug dapsone to quell short-term symptoms and a life-long gluten-free diet to prevent recurrence. Dr. Zone’s group also discovered that iodide activates TG3 and, by this mechanism, worsens DH for some patients. In the future, Dr. Zone said he hopes to determine exactly how dapsone interacts with IgA antibodies to improve the condition.
Whether it’s dermatitis herpetiformis or any other dermatologic disease, Dr. Zone echoed the essential requirements of innovation: “Number one, be observant. Look for things that don’t fit. Number two, learn to discuss those things with your colleagues. Like, isn’t it weird that such and such happened? And then once you identify one of those things, if you want to be an innovator, be relentless and resilient. Those are the things I learned most from my career.”
