Original article

Pattern of pigmentation disorder in Cosmetic Clinic H. Adam Malik General Hospital, Medan, 2012 - 2015

Nelva K. Jusuf

Department of Dermatology and Venereology, Faculty of Medicine,University of Sumatera Utara H. Adam Malik General Hospital Medan, Indonesia

E-mail: [email protected]

Abstract

Background: Abnormalities of pigmentation is a cosmetic problem which affects the overall appearance of an individual. Pigmentation disorder are caused by the increase (hypermelanosis) or the decrease (hypomelanosis) amount of . Objective: To determine the pattern of pigmentation disorder in Cosmetic Dermatology Clinic H. Adam Malik General Hospital Medan in 2012-2015. Methods: A retrospective study using subject’s medical records from the Cosmetic Dermatology Clinic H. Adam Malik General Hospital Medan in 2012 – 2015, presented descriptively. Results: In 2012 – 2015 the number of patients who visited the Cosmetic Dermatology Clinic were respectively 210, 228, 211, 142. Hypermelanosis were found respectively in 24.76%, 16.20%, 12.79%, 5.63%. Whereas hypomelanosis were found 18.10%, 9.21%, 8.53%, 8.45%. During 2012 – 2015 was the most common disorder found among hypermelanosis group, followed by post inflammatory . Meanwhile was the only diagnosis in hypomelanosis group. Each year most of the pigmentation disorder patients came from the age group 38-48 years old except in 2015. Women were more affected than men. Conclusion: In 2012-2014, the largest proportion of pigmentation disorder were hypermelanosis, mostly melasma. In 2015, it was hypomelanosis with vitiligo as the diagnosis.

Keywords: pigmentation disorder, cosmetic division, retrospective

Introduction , post inflammatory , etc.3 Pigmentation disorder may be classified to hypermelanosis and hypomelanosis.1 Pigmentation disorders, especially the ones on the Hypermelanosis is a condition where face, may affect patients both emotionally and hyperproduction of melanin is found. psychologically. These disorders mainly affect Hypermelanosis is found in melasma, , women, influence self-confidence, which may ephelides, skin discoloration due to metal, post- worsen quality of life. In a research conducted by inflammatory hyperpigmentation (PIH), ochronosis, Hamdani and Jusuf in 21 Posyandu (Center for etc. Melasma is the most common form of pre-post-natal healthcare and information for hyperpigmentation.1 Based on the data that were woman and children < 5 years old) in Medan collected from January to December 2009 in H. Labuhan by using Dermatology Life Quality Index Adam Malik General Hospital Medan, out of 5,369 (DLQI), it was found that the life quality of those patients who came to the Dermatovenerology who have pigmentation disorder on the face were Outpatient Clinic H. Adam Malik General Hospital greatly affected (54,0%), moderate level were Medan, 22 (0.41%) were diagnosed with 21.0%, very important level were 15.0%, small melasma.2 Hypomelanosis, on the other hand, is effect were 6.0% and no effect level were 3.0%. due to decreased amount of melanin production in Based on the age group, the quality of life were the skin. This pigmentation disorder were vitiligo, greatly affected at the age 31-40 and 40-51 (17 subjects). Based on the duration off suffering the

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most is >1 year with very important effect were The result from the medical record shows that in 51.0%. Hyperpigmentation affect as many as 2012, there were 210 patients who came to 54.2% of all the type of facial pigmentation.4 Nair Cosmetic Dermatology Clinic, with 52 of them and Jusuf conducted a research to married women (24,76%) had hypermelanosis while who had melasma in Posyandu Kelurahan Tanjung hypomelanosis only 38 patients (18,10%). The Rejo, Medan city, it was found that these women diagnosis of hypermelanosis consist of melasma had middle rate quality of life (69,3%).5 41 patients (78,85%) and PIH 11 patients (21,15%). While the diagnosis of hypomelanosis The general objective of this research is to know was only vitiligo in 38 patients (100%) . The most the pattern of pigmentation disorder in Cosmetic patients (41,11%) were found from the age group Dermatology Clinic H. Adam Malik General 38-48 years old. It was found in 20 men (22,2%) Hospital Medan 2012-2015. Meanwhile, the and 70 women (77,8 %) (table 1). specific objective is to analyze the proportion of patients with pigmentation disorder based on the In 2013, there were 228 patients who came to type, age, and gender. Cosmetic Dermatology Clinic, with 37 of them (16,20%) had hypermelanosis while only 21 Methods patients had hypomelanoses (9,21%). The diagnosis of hypermelanosis consists of melasma This is a retrospective study using medical records 31 patients (83,78%), PIH 5 patients (13,52%) and from the Cosmetic Dermatology Clinic H. Adam ochronosis 1 patient (2,70%). While the diagnosis Malik General Hospital Medan in 2012 – 2015, of hypomelanosis was only vitiligo in 21 patients presented descriptively. Inclusion criteria were (100%). Most patients (50%) were found from the medical records with complete information. The age group 38-48 years old. It was found in 7 men use of medical records have been approved by the (12%) and 51 women (88%) (table 2). H.Adam Malik General Hospital. Table 2. Distribution of pigmentation disorder Results in Cosmetic Dermatology Clinic H. Adam Malik Hospital 2013.

Table 1. Distribution of pigmentation disorder in Cosmetic Dermatology Clinic H. Adam Malik n (%) Hospital 2012. Pigmentation disorders Hypermelanosis 37 16,20 Hypomelanosis 21 9,21 n (%) Not pigmentation disorder 170 74,59 Pigmentation disorders Total 228 100 Hypermelanosis 52 24,76 Diagnosis of hypermelanosis Hypomelanosis 38 18,10 Melasma 31 83,78 Not pigmentation disorder 120 57,14 Post-inflammatory 5 13,52 Total 210 100 hyperpigmentation Diagnosis of hypermelanosis Ochronosis 1 2,70 Melasma 41 78,85 Total 37 100 Post-inflammatory 11 21,15 Diagnosis of hypomelanosis hyperpigmentation Vitiligo 21 100 Total 52 100 Total 21 100 Diagnosis of hypomelanosis Age group (years old) of pigmentation disorder Vitiligo 38 100 patients Total 38 100 5-15 2 3,44 Age group (years old) of pigmentation disorder 16-26 8 13,79 patients 27-37 6 10,34 5-15 0 0 38-48 29 50,00 16-26 17 18,89 49-59 11 18,96 27-37 12 13,33 > 60 2 3,44 38-48 37 41,11 Total 58 100 49-59 17 18,89 Gender of pigmentation disorder patients > 60 7 7,78 Men 7 12 Total 90 100 Women 51 88 Gender of pigmentation disorder patients Total 58 100 Men 20 22,2 Women 70 77,8 Total 90 100

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In 2014, there were 211 patients who came to the Discussion Cosmetic Dermatology Clinic, with 27 of them (12.79%) had hypermelanosis while only 18 Pigmentation disorder can be classified to patients had hypomelanoses (8.53%). The hypermelanosis and hypomelanosis group. From diagnosis of hypermelanosis consist of melasma 2012 - 2014 in Cosmetic Dermatology Clinic 18 patients (66,67%), PIH 8 patients (29,63%) and ephelides 1 patient (3,70%). While the diagnosis of Table 4. Distribution of pigmentation disorder hypomelanosis was only vitiligo 18 patients in Cosmetic Dermatology Clinic H. Adam Malik (100%). Most patients (28,89%) were found from Hospital 2015. the age group 38-48 years old. It was found in 10 men (24.4%) and 35 women (75.6%) (table 3). n (%) Pigmentation disorders Table 3. Distribution of pigmentation disorder Hypermelanosis 8 5,63 in Cosmetic Dermatology Clinic H. Adam Malik Hypomelanosis 12 8,45 Hospital 2014. Not pigmentation 122 85,92 disorder n (%) Total 142 100 Diagnosis of hypermelanosis Pigmentation disorders Melasma 7 87,50 Hypermelanosis 27 12,79 Post-inflammatory 1 12,50 Hypomelanosis 18 8,53 hyperpigmentation Not pigmentation 166 78,68 Total 8 100 disorder Diagnosis of hypomelanosis Total 211 100 Diagnosis of hypermelanosis Vitiligo 12 100 Total 12 100 Melasma 18 66,67 Age group (years old) of pigmentation Post-inflammatory 8 29,63 disorder patients hyperpigmentation 5-15 1 5,00 Ephelides 1 3,70 16-26 9 45,00 Total 27 100 Diagnosis of hypomelanosis 27-37 4 20,00 38-48 2 10,00 Vitiligo 18 100 Total 18 100 49-59 3 15,00 Age group (years old) of pigmentation > 60 1 5,00 Total 20 100% disorder patients Gender of pigmentation disorder patients 5-15 2 4,44 Men 4 20 16-26 9 20,00 Women 16 80 27-37 10 22,23 Total 20 100 38-48 13 28,89 49-59 9 20,00 > 60 2 4,44 Total 45 100 H. Adam Malik General Hospital Medan, the largest Gender of pigmentation disorder patients proportion of pigmentation disorder was Men 10 24,4 hypermelanosis, with melasma as the most Women 35 75,6 common diagnosis. This situation corresponds with Total 45 100 Hamdani and Jusuf research in 2016, who found that there were more pigmentation disorder on the face due to hypermelanosis (65%) compared to In 2015, there were 142 patients who came to hypomelanosis (35%) in 21 Posyandu in Medan Cosmetic Dermatology Clinic, with 8 of them Labuhan. 4 (5,63%) had hypermelanosis while only 12 patients had hypomelanosis (8,45%). The diagnosis of Melasma is a cosmetic problem which can affect hypermelanosis consist of melasma 7 patients women’s appearances, social life, and also (87,50%) and PIH 1 patients (12,50%). While the emotional status.6 This is a chronic disorder and diagnosis of hypomelanosis was only vitiligo in 12 may cause frustration to both the patient and the patients (100%) with. Most patients (45%) were doctor, as the disorder is very difficult to treat.7 Nair found from the age group 16-26 years old. It was and Jusuf in 2015 found that women with melasma found in 4 men (20%) and 16 women (80%) (table had middle rate quality of life, measured with 4). MelasQol.5

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The etiology of melasma has yet to be dermal, or the compound type that may happen understood. The factors that have a role in after a trauma, allergy reaction, inflammation etiopathogenesis of melasma are endocrinologic, lesions, dermatitis caused by sunlight exposure, or genetic predisposition, UV radiation, and others cosmetic procedures (chemical peeling etc). It may such as certain cosmetic ingredients and happen to all gender, race and age, although medicines that are photosensitive. Out of the many mostly happen to those with dark skin.12 In this predisposing factors of melasma, UV exposure is research from the year 2012-2015, the PIH were the most prominent.1,7 found respectively 21,15%, 13,52%, 29,63%, and 12,50%. In this research, from the year 2012 to 2014 most of the patients with pigmentation disorder were Ephelides or are a small hyperpigmented from the 38-48 years old age group. In 2015, macules on the face, with the size restricted to 2- Hamdani and Jusuf found that those with 4mm. It mostly happens to individuals with fair skin, pigmentation on the face were from the age group red or blonde hair, who are mostly Caucasians or 31-40 years old and 41-50 years old.4 These is the Chinese, and usually inherited genetically.12 In this reproductive age for women, which is often research, ephelides were only found in 1 case in associated to the development of melasma. Nair 2014. In RS Dr. Sardjito Yogyakarta ephelides was and Jusuf in 2014 found that those who had found among 31 employees and 30 of them melasma were from the age group 31-40 year old.5 (96,8%) were female.13

UV exposure has been known to worsen In this research, from the year 2012-2015, melasma. In fact, melasma has been reported to hypomelanosis were found respectively 16,10%, be seen less in winter, as there is less sunlight 9,21%, 8,53%, and 8,45% with vitiligo being the exposure as well. Furthermore, melasma is most one and only diagnosis for hypomelanosis. In the commonly found in women who use hormonal research by Hamdani and Jusuf, it was found that contraception. The usage of cosmetics that contain hypomelanosis greatly affect the quality of life photosensitizer, oilum bergamot, and perfume (64,2%).4 Vitiligo is a skin disorder were also reported to cause the development of that can be recognized by the white spots that were melasma.1,7,8 caused by the destruction of . Vitiligo is chronic and may affect patients cosmetically so Ochronosis refers to the brownish-yellow or ochre- that they may have low self-esteem and may affect colored accumulation of pigment found in the patients’ life quality.14,15 In Indonesia, the research connective tissue of patients with the disease.1 for this disorder is still very limited. In Dr. M. Djamil Exogenous ochronosis (EO) manifests as General Hospital Padang from 2001-2016, asymptomatic hyperpigmentation in photo-expose incidents of vitiligo were reported to be at 0,46%.16 region.9 It occurs over sites of chemical contact, Most were sporadic, but about 16-46% of the like the osseous surfaces of the zygomatic areas of patients have family histories and inheritance the face, side and back of the neck as well as the patterns that correspond with polygenic trait.17 extensor aspects of extremities, usually in a symmetrical pattern. The lesions are grey brown or Vitiligo may affect anyone at all age.17 However, blue-black macules and usually with hyperchromic, most cases of vitiligo occur before the age of 20 pinpoint, caviar-like papules.9 EO can be years old and 70-80% occur before the age of 30 secondary to the topical application of years old.18 This matter corresponds with Rizal’s hydroquinone, resorcinol, or oral administration of research, in which it was stated that vitiligo mostly antimalarials or mercury.10 EO is a disorder that affect those from the age group 21-30 years old.16 rarely happen but may be very cosmetically Men and women both may be affected with disturbing and may cause psychological vitiligo.17,18 The etiology of vitiligo is still not known disturbance in patients, especially dark skinned yet. There are some genetic, autoimmune, and patients, also found in Hispanics, Caucasians, and biochemistry hypotheses for vitiligo.17,19,20 The Asians including Indonesians.11 The most common presence of genetic susceptibility may trigger a cause of EO is hydroquinone. EO is also found process of autoimmune and with the increment of simultaneously with melasma, due to the oxidative stress may cause the destruction hydroquinone that is used to treat melasma.11 In of melanocyte which resulted in the emersion of this research, ochronosis were only found in one depigmentation lesions.21 patients in 2013. Overall in this study between 2012-2015 Post-inflammatory hyperpigmentation (PIH) is a hyperpigmentation disorders were found melanotic hypermelanosis, containing epidermal,

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