The relationship between anterior tooth loss and quality of life among elderly in Posbindu, Bojongnangka, Kelapa Dua Sub-District, Tangerang, Jakarta-Indonesia
Vol 7, No 3 (2018): (In Press For
December 2018)
Table of Contents
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Shahrbano Keyhaniyan Roya Khaksar Seyedeh Elham Norollahi Abbas Ghayoumi
Javinani Sahar Ghazanfari Ali Akbar Samadani
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The relationship between anterior tooth loss and quality of life among elderly in Posbindu,
Bojongnangka, Kelapa Dua Sub-District, Tangerang, Jakarta-Indonesia
Helwiah Umniyati Audiawati Surachmin Ghea Ambarsati
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Achievement of psychological comfort in 5-6-Year-Old children with scoliosis against the
background of daily medicinal-prophylactic clothes’ wearing for half a year
AA Bikbulatova Andreeva E G
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Peculiarities of abnormalities of locomotor apparatus of children at preschool age with
scoliosis of I-II degree living in Central Russia
A.A. Bikbulatova
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Orderly muscle activity in elimination of erythrocytes microrheological abnormalities in
rats with experimentally developed obesity
Yu. Vatnikov Zavalishina S.Yu Seleznev S.B Kulikov E.V Notina E.A Rystsova E.O
Petrov A.K Kochneva M.V Glagoleva T.I
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Gustina Putri Isma Aprita Lubis Imam Budi Putra
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Cwanestasia Zefanya Gracia Achsanuddin Hanafie Akhyar H Nasution
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Ni Nengah Ariati Arma Fetria A.A. Putra Purnamawati Ni Nyoman Suarni Ida Ayu Eka
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Bagus Komang Satriyasa
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Citra Lestari Hengky Marlie Fauzia Nilam Orienty
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Supomo Supomo
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Edi Handoko Mohammad Dwijo Murdiyo Hendro Soesanto
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Fifi Veronica Leo Lubis Arifin S Lulu L Fitri A Rizal Ambrosius P Hanna Gunawan Ronny
Lesmana Keri Lestari Dandan Unang Supratman
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Deli Mona Femy Witrihezly Azalea
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Andhika Yudistira
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Selfi Handayani Ari Handono Ramelan Kristanto Yuli Yarsa Dono Indarto Bambang
Purwanto Koosnadi Saputro Didik G Tamtomo
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Amanda Juwita Sendjaja Buenjim Mariano Hernando L Cruz Jr
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Associations between nutrition attitudes, socioeconomic status, and vitamin E intake on
blood pressure among elderly with hypertension in Klaten, Central Java-Indonesia
Triagung Yuliyana Kusnandar Kusnandar Diffa Hanim
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Impact of daily wearing of medioprophylactic clothes on the state of locomotor system of 56-year old children with scoliosis of I-II degree
AA Bikbulatova EG Andreeva
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Association between Matrix Metalloproteinase-2 with Bone Destruction Degree in Patients
with Atticoantral Chronic Suppurative Otitis Media at Haji Adam Malik Central General
Hospital, Medan, Indonesia
Richa Syafni Putri Wulandari Harry A Asroel Askaroellah Aboet Fotarisman Zaluchu
Sutoyo Eliandy
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Melasma characteristic in hormonal contraceptive acceptors at Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan-Indonesia
Ilen Mahdalena Nelva K Jusuf Imam B Putra
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Current clinical status of hydrotherapy; an evidence based retrospective six-years (20122017) systemic review
Sameera Mohammed Almassmoum Eman Ahmed Balahmar Shoroug Taye Almutairi
Goot Albuainain Rizwan Ahmad Atta Abbas Naqvi
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Farida Briani Sobri Odetta Natatilova Halim
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Nyoman Golden
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ORIGINAL ARTICLE
Bali Medical Journal (Bali Med J) 2018, Volume 7, Number 3: 645-649
P-ISSN.2089-1180, E-ISSN.2302-2914
Published by DiscoverSys
Melasma characteristic in hormonal contraceptive
acceptors at Kelurahan Mangga Kecamatan Medan
Tuntungan, Medan-Indonesia
CrossMark
Mahdalena,1 Nelva K Jusuf,2 Imam B Putra2
ABSTRACT
Background: Melasma is one of the most common skin problems in
dermatology. Areas often exposed to ultraviolet, especially the face
as a predilection of its disorder. The etiology of melasma remains
unknown. There are several risk factors considered to play a role in
the pathogenesis of melasma, one of them is the hormone, especially
those contained in hormonal contraceptives.
Aim: To know the characteristic of melasma related hormonal
contraceptive acceptors in Kelurahan Mangga Kecamatan Medan
Tuntungan, Medan.
Methods: This was a cross-sectional descriptive study which involved 83
subjects with hormonal contraceptive acceptors in Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan. Diagnosis of melasma was made
based on history, clinical features and by Wood’s lamp examination. The
data obtained is processed and presented in tabulation form.
Results: In this study, the proportion of melasma in hormonal
contraceptive acceptors was 17 subjects (20.5%). The proportion
of melasma in oral contraceptive acceptors was 6 subjects (26.1%),
injection of 7 subjects (19.4%), implant 4 subjects (16.7%). Based
on the hormonal contraceptive content, the proportion of melasma
contains estrogen and progesterone was 11 subjects (23.4%) and
progesterone alone 6 subjects (16.7%). Based on duration of hormonal
contraceptive use melasma was found during 6-12 months in
2 subjects (11.7%), 13-24 months in 1 subjects (5,9%), 24-36 months
in 4 subject (23,5%), >36 months in 10 subject (58,8%). Based on the
type of clinical pattern that is centrofacial type in 9 subjects (52,9%),
malar in 8 subjects (47,1%). Based on Wood’s lamp is epidermal type in
16 subjects (94.1%), dermal type in 1 subject (5,9%).
Conclusions: In hormonal contraceptive acceptors was obtained
proportion of melasma 20,5% with oral contraception by 26.1%, 19.4%
injection and 16.7% implant. Proportion of melasma contains estrogen
and progesterone was 23.4%. Duration of hormonal contraceptive use,
melasma was found at most more than 36 months in 58,8%. The most
commonly found clinical pattern that is centrofacial type in 52,9% and
based on Wood’s lamp is epidermal type in 94.1%.
1
Pre graduate of Dermatology and
Venereology Faculty of Medicine
Universitas Sumatera Utara,
Indonesia
2
Department of Dermatology and
Venereology Faculty of Medicine
Universitas Sumatera Utara,
Indonesia
*
Correspondence to:
ilen.mahdalena@gmail.com
Mahdalena:
ilen.mahdalena@gmail.com
Nelva Karmila Jusuf:
nelva_jusuf@yahoo.com
Imam Budi Putra:
imam_65@yahoo.com
Department of Dermatology and
Venereology, General Hospital of
Sumatera Utara University, Doktor
Mansyur No. 66, Medan, 20154
Received: 2017-12-25
Accepted: 2018-6-25
Published: 2018-8-1
Keywords: melasma, hormonal contraceptive acceptors
Cite This Article: Mahdalena, Jusuf, N.K., Putra, I.B. 2018. Melasma characteristic in hormonal contraceptive acceptors at Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan-Indonesia. Bali Medical Journal 7(3): 645-649. DOI:10.15562/bmj.v7i3.1000
INTRODUCTION
Melasma is one of the most common problems in
dermatology.1 The predilection site for this disorder is the area that is often exposed to Ultraviolet
(UV), especially the face. Melasma has a disturbing effect on appearance, leading to a decrease
in confidence, especially the deterioration of the
quality of life.2,3 Etiology of melasma is certainly
unknown. There are several risk factors that are
considered to play a role in the pathogenesis of
melasma, including UV exposure, hormones,
drugs, genetics, races and cosmetics ingredients.4 Hormones play a role in the pathogenesis
of melasma, estrogen, and progesterone have
an impact in melasma development, because
melasma is common in pregnancy, hormonal
contraceptive use, estrogen therapy in prostate
cancer patients and conjugate estrogen use in
women after menopause.5 In facts, melasma is
Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj
an undesirable skin effect on contraceptive use
hormonal.6 This can be seen in histopathologic
examinations that show increased expression of
estrogen receptors on melasma-treated skin.7
Hormonal contraceptives are methods or
contraceptives containing a combination of
synthetic estrogens and progesterone or synthetic
progesterone similar to natural hormones in a
woman's body. Hormonal contraceptives are indicated to prevent pregnancy and present in pill,
injections, and implants.8 Hormonal contraceptives
have several side effects which are melasma.8 A
study by Ortonne et al. regarding the role of UV
and hormone enhancement in development of
melasma among 324 patients, reported that 42%
melasma patients were associated with pregnancy
history, and 25% of 171 peoples due to hormonal
contraceptives acceptors.9
645
ORIGINAL ARTICLE
Table 4.1
Distribution of melasma in hormonal contraceptive acceptors
Hormonal Contraseptive Acceptors
Contraceptive Types
Melasma
Without melasma
17 (20.5%)
66 (69.5%)
Oral contraception
6
(26.1%)
17
(73.9%)
Injection
7
(19.4%)
29
(80.6%)
Implant
4
(16.7%)
20
(83.3%)
Estrogen & progesterone
11
(23.4%)
36
(76.6%)
Progesterone
6
(16.7%)
30
(83.3%)
Contraceptive Composition
Table 4.2
Distribution of melasma based on the duration of use
Contraceptive types
Duration of usage(month)
36
5
(29.4%)
3
(17.7%)
2
(11.8%)
Table 4.3
Distribution of melasma by clinical pattern type and Wood’s lamp
n
Clinical Pattern Type
%
52.9
Centrofacial
9
Malar
8
47.1
0
0
Epidermal
16
94.1%
Dermal
1
5.9%
Mixed
0
0
Unclear
0
0
Mandibular
Wood’s Lamp
METHOD
This is descriptive observational research with
cross sectional approach. The sample is a group of
hormonal contraceptive acceptors in Kelurahan
Mangga Kecamatan Medan Tuntungan, Medan,
Indonesia involving 83 subjects were taken by
using consecutive sampling method. The inclusion
criteria are the hormonal contraception acceptors
who are willing to participate in this study and
sign the informed consent. Subject with a family
history of melasma, thyroid disorders and history
using drugs that are phototoxic and photoallergic
were excluded. On the subjects of data recording,
anamnesis, and clinical examination. Samples with
melasma will be examined using Wood’s lamp to
646
(0.0%)
Implant
see melasma type. Data analysis was done descriptively and result presented in table form.
RESULTS
Eighty-three subjects of hormonal contraceptive
acceptors have been observed in Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan.
Based on table 4.1, the proportion of melasma
in hormonal contraceptive acceptors was found in
17 subjects (20.5%) and 66 subjects (79.5%) without melasma. Based on hormonal contraceptive
types, the distribution of melasma most common
in oral contraceptives (26.1%), followed by injection (19.4%) and implants (16.7%). Hormonal
contraceptives contain estrogen and progesterone
Published by DiscoverSys | Bali Med J 2018; 7(3): 645-649 | doi: 10.15562/bmj.v7i3.1000
ORIGINAL ARTICLE
more frequently caused to melasma (23.4%) than
progesterone only (16.7%).
In Table 4.2 based on duration of hormonal
contraceptive use we found the onset of melasma
rise in 10 (58.9%) subjects which use more than
36 months, 6 subjects (23.6%) use 25-36 months,
1 subject (5.9%) use 13-24 months, 2 subjects
(11.8%) use 6-12 months. We did not find the risk
of melasma when hormonal contraceptive used
below 6 months.
From 17 patients hormonal contraceptive acceptors with melasma, we found centrofacial type in 9
subjects (52.9%), which was the most common type,
followed by the malar type in 8 subjects (47.1%) and
mandibular type was not found. The most common
melasma type by Wood’s lamp examination is
epidermal type in 16 subjects (94.1%), dermal type
in 1 subject (5.9%). (Table 4.3).
DISCUSSION
Melasma can be found all over the world, especially people who live in tropical areas that always
exposed to the UV. This hyperpigmentation disorder can affect all races and often occurs in people
with Hispanic and Asian races which have skin type
Fitzpatrick III-V.1
In this study, the proportion of melasma in
hormonal contraceptives acceptors found in
17 subjects (20.5%) as can be seen in table 4.1.
Suhartono’s study characteristics of melasma in
hormonal contraceptive acceptors in 125 subjects,
the result 57 subjects (31.3%) rise melasma due
to the use of hormonal contraceptives.10 Ortonne
et al. found a smaller value than this study, in 324
subjects with melasma obtained 171 subjects (53%)
used hormonal contraceptives at some stage, and
25% of the 171 peoples claimed that the onset of
melasma occurred after hormonal contraceptives
use.9 Furthermore, in a study by Ikino et al. in Brazil
found that the risk factors for melasma result from
hormonal contraceptives use are smaller than this
study, of where 51 subjects with melasma, 5 subjects
(9.80%) associated with hormonal contraceptive.3
Table 4.1 represents from 83 subjects whom
application hormonal contraceptives, only 23
subjects used oral contraceptives, this result less
than injection and implant, but the incidence of
melasma the higher compared with injection and
implants which is 26.1 %. The results of this study
consistent with Suhartono’s study in Semarang
which also shows that oral contraceptives acceptors
less than injection or implants, but the incidence
of melasma due to the oral contraceptives is higher
compared with other hormonal contraceptives
(35.5%).10 Guinot et al. in Tunisia found that oral
Published by DiscoverSys | Bali Med J 2018; 7(3): 645-649 | doi: 10.15562/bmj.v7i3.1000
contraceptives were reported as an aggravating
factor in 38% of melasma.11 Handel et al. showed
a lower number, from 207 subjects found at 10%
of melasma due to oral contraceptives.2 The incidence of melasma due to hormonal contraceptives,
especially oral contraceptives was also found lower
results in Tamage et al. and Achar et al. studies, with
16.2% and 18.4%, respectively.12,13
Hormonal contraceptives contain estrogen
and progesterone is more frequently leads to
melasma than progesterone alone in 11 subjects
(23.4%). Estrogen and progesterone play a role
in the development of melasma, which hormonal
contraceptives use caused estrogen and progesterone imbalance. Estrogen increases vascularization
of the skin and suppresses the activity of sebaceous glands. Estrogen also increases pigment cell
activities.14 Progesterone increase the spread of
melanin in cells and the expression of PR proteins
in skin hyperpigmentation due to melasma.15,16
Wiedemann et al. concluded that progesterone
derivatives in oral contraceptives might reduce the
risk of melasma based on the finding that progesterone reduces proliferation without a significant
effect on tyrosinase activity, in contrast to the effects
of estrogen stimulation on melanocyte cultures.17
This probably causes a lower incidence of melasma
due to hormonal contraceptives containing progesterone alone.
Table 4.2 shows the onset of melasma based on
the duration of hormonal contraception is the most
more than 36 months of 10 subjects (58.9%). A study
by Ortonne et al. found that the onset of melasma
after hormonal contraceptives use was 25%, but
it was not explained how long the time was.9
Suhartono’s study found that melasma occurred after
oral contraceptive use, injection and implant more
than 20 months.10 Guinot et al. showed a significant
association between severity of melasma and duration of oral contraceptive use; melasma often occur
between 1 to 3 years after its use.11
Centrofacial type is the most common clinical
pattern seen in hormonal contraceptive acceptors
in 9 subjects (52.9%) (table 4.3). Centrofacial is the
most common type, which is 63% covering forehead area, nose, medial cheeks, below the nose and
chin.2 This study is similar to Krupashankar et al.
that found 45% on centrofacial and 39% on malar.18
Guinot et al. also found centrofacial type frequently
encountered in the study, which was 76%, malar
23%, and mandibular 1%.11 This result is different
from Jagannathan et al. that shows the distribution
of melasma in 80 women obtained that malar 65%,
centrofacial 26.25%, and mandibular 8.75%.19 The
result same as Pawar et al., of 120 patients with
melasma, all subjects (100%) showed melasma
647
ORIGINAL ARTICLE
distribution at malar area, with 76 subjects (63,33%)
on forehead and 16 (13,33%) on chin.20 The most
common melasma type by Wood’s lamp examination is epidermal type 94.1%. This study is in similar with Jagannathan et al. that found epidermal
type 48.75%, dermal 20%, mixed 28.75% and 2.5%
unclear.20 Reddy et al. also show that epidermal
type is 47%, dermal 34% and mix 20%.21 Wood’s
lamp with 320-450nm wavelength can be used to
determine into the melanin on the skin. On Wood’s
lamp examination, epidermal types of melasma
will appear more clearly than light.22
Estrogens have a significant effect on many
different cell types in skin physiology, including keratinocytes, fibroblasts, and melanocytes.
Progesterone increases the spread of melanin in
cells. Although the pathogenesis of melasma has
not been fully understood. But melasma considerably has some risk factors influential in addition
to hormones contained in hormonal contraceptives such as genetic, races, UV exposure, thyroid
dysfunction, drugs and cosmetics ingredients.1,4,6,9
The limitations of this study are the number of
samples are still small and the area of research that
is only in one kelurahan (district). It is necessary to
conduct further multicenter research with a large
sample size in order to describe the proportion
of melasma in hormonal contraceptive users in
Indonesia
CONFLICT OF INTEREST
The authors declared that they have no conflicts of
interest
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
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CONCLUSION
The proportion of melasma in hormonal contraceptive acceptors is 20,5%. Where the highest result rise
the melasma in a subject who used oral contraceptive, hormonal contraceptives contain estrogen and
progesterone and duration more than 36 months.
The type of melasma is centrofacial type and epidermal type. In the future, multicenter research needs to
be done with a large sample size in order to be able
to describe the proportion of melasma in hormonal
contraceptives acceptors in Indonesia, as well as to
explore the use of hormonal contraceptives (oral,
injection and implants) with melasma.
12.
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ACKNOWLEDGMENT
None declared
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ORIGINAL ARTICLE
Bali Medical Journal (Bali Med J) 2018, Volume 7, Number 3: 645-649
P-ISSN.2089-1180, E-ISSN.2302-2914
Published by DiscoverSys
Melasma characteristic in hormonal contraceptive
acceptors at Kelurahan Mangga Kecamatan Medan
Tuntungan, Medan-Indonesia
CrossMark
Mahdalena,1 Nelva K Jusuf,2 Imam B Putra2
ABSTRACT
Background: Melasma is one of the most common skin problems in
dermatology. Areas often exposed to ultraviolet, especially the face
as a predilection of its disorder. The etiology of melasma remains
unknown. There are several risk factors considered to play a role in
the pathogenesis of melasma, one of them is the hormone, especially
those contained in hormonal contraceptives.
Aim: To know the characteristic of melasma related hormonal
contraceptive acceptors in Kelurahan Mangga Kecamatan Medan
Tuntungan, Medan.
Methods: This was a cross-sectional descriptive study which involved 83
subjects with hormonal contraceptive acceptors in Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan. Diagnosis of melasma was made
based on history, clinical features and by Wood’s lamp examination. The
data obtained is processed and presented in tabulation form.
Results: In this study, the proportion of melasma in hormonal
contraceptive acceptors was 17 subjects (20.5%). The proportion
of melasma in oral contraceptive acceptors was 6 subjects (26.1%),
injection of 7 subjects (19.4%), implant 4 subjects (16.7%). Based
on the hormonal contraceptive content, the proportion of melasma
contains estrogen and progesterone was 11 subjects (23.4%) and
progesterone alone 6 subjects (16.7%). Based on duration of hormonal
contraceptive use melasma was found during 6-12 months in
2 subjects (11.7%), 13-24 months in 1 subjects (5,9%), 24-36 months
in 4 subject (23,5%), >36 months in 10 subject (58,8%). Based on the
type of clinical pattern that is centrofacial type in 9 subjects (52,9%),
malar in 8 subjects (47,1%). Based on Wood’s lamp is epidermal type in
16 subjects (94.1%), dermal type in 1 subject (5,9%).
Conclusions: In hormonal contraceptive acceptors was obtained
proportion of melasma 20,5% with oral contraception by 26.1%, 19.4%
injection and 16.7% implant. Proportion of melasma contains estrogen
and progesterone was 23.4%. Duration of hormonal contraceptive use,
melasma was found at most more than 36 months in 58,8%. The most
commonly found clinical pattern that is centrofacial type in 52,9% and
based on Wood’s lamp is epidermal type in 94.1%.
1
Pre graduate of Dermatology and
Venereology Faculty of Medicine
Universitas Sumatera Utara,
Indonesia
2
Department of Dermatology and
Venereology Faculty of Medicine
Universitas Sumatera Utara,
Indonesia
*
Correspondence to:
ilen.mahdalena@gmail.com
Mahdalena:
ilen.mahdalena@gmail.com
Nelva Karmila Jusuf:
nelva_jusuf@yahoo.com
Imam Budi Putra:
imam_65@yahoo.com
Department of Dermatology and
Venereology, General Hospital of
Sumatera Utara University, Doktor
Mansyur No. 66, Medan, 20154
Received: 2017-12-25
Accepted: 2018-6-25
Published: 2018-8-1
Keywords: melasma, hormonal contraceptive acceptors
Cite This Article: Mahdalena, Jusuf, N.K., Putra, I.B. 2018. Melasma characteristic in hormonal contraceptive acceptors at Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan-Indonesia. Bali Medical Journal 7(3): 645-649. DOI:10.15562/bmj.v7i3.1000
INTRODUCTION
Melasma is one of the most common problems in
dermatology.1 The predilection site for this disorder is the area that is often exposed to Ultraviolet
(UV), especially the face. Melasma has a disturbing effect on appearance, leading to a decrease
in confidence, especially the deterioration of the
quality of life.2,3 Etiology of melasma is certainly
unknown. There are several risk factors that are
considered to play a role in the pathogenesis of
melasma, including UV exposure, hormones,
drugs, genetics, races and cosmetics ingredients.4 Hormones play a role in the pathogenesis
of melasma, estrogen, and progesterone have
an impact in melasma development, because
melasma is common in pregnancy, hormonal
contraceptive use, estrogen therapy in prostate
cancer patients and conjugate estrogen use in
women after menopause.5 In facts, melasma is
Open access: www.balimedicaljournal.org and ojs.unud.ac.id/index.php/bmj
an undesirable skin effect on contraceptive use
hormonal.6 This can be seen in histopathologic
examinations that show increased expression of
estrogen receptors on melasma-treated skin.7
Hormonal contraceptives are methods or
contraceptives containing a combination of
synthetic estrogens and progesterone or synthetic
progesterone similar to natural hormones in a
woman's body. Hormonal contraceptives are indicated to prevent pregnancy and present in pill,
injections, and implants.8 Hormonal contraceptives
have several side effects which are melasma.8 A
study by Ortonne et al. regarding the role of UV
and hormone enhancement in development of
melasma among 324 patients, reported that 42%
melasma patients were associated with pregnancy
history, and 25% of 171 peoples due to hormonal
contraceptives acceptors.9
645
ORIGINAL ARTICLE
Table 4.1
Distribution of melasma in hormonal contraceptive acceptors
Hormonal Contraseptive Acceptors
Contraceptive Types
Melasma
Without melasma
17 (20.5%)
66 (69.5%)
Oral contraception
6
(26.1%)
17
(73.9%)
Injection
7
(19.4%)
29
(80.6%)
Implant
4
(16.7%)
20
(83.3%)
Estrogen & progesterone
11
(23.4%)
36
(76.6%)
Progesterone
6
(16.7%)
30
(83.3%)
Contraceptive Composition
Table 4.2
Distribution of melasma based on the duration of use
Contraceptive types
Duration of usage(month)
36
5
(29.4%)
3
(17.7%)
2
(11.8%)
Table 4.3
Distribution of melasma by clinical pattern type and Wood’s lamp
n
Clinical Pattern Type
%
52.9
Centrofacial
9
Malar
8
47.1
0
0
Epidermal
16
94.1%
Dermal
1
5.9%
Mixed
0
0
Unclear
0
0
Mandibular
Wood’s Lamp
METHOD
This is descriptive observational research with
cross sectional approach. The sample is a group of
hormonal contraceptive acceptors in Kelurahan
Mangga Kecamatan Medan Tuntungan, Medan,
Indonesia involving 83 subjects were taken by
using consecutive sampling method. The inclusion
criteria are the hormonal contraception acceptors
who are willing to participate in this study and
sign the informed consent. Subject with a family
history of melasma, thyroid disorders and history
using drugs that are phototoxic and photoallergic
were excluded. On the subjects of data recording,
anamnesis, and clinical examination. Samples with
melasma will be examined using Wood’s lamp to
646
(0.0%)
Implant
see melasma type. Data analysis was done descriptively and result presented in table form.
RESULTS
Eighty-three subjects of hormonal contraceptive
acceptors have been observed in Kelurahan Mangga
Kecamatan Medan Tuntungan, Medan.
Based on table 4.1, the proportion of melasma
in hormonal contraceptive acceptors was found in
17 subjects (20.5%) and 66 subjects (79.5%) without melasma. Based on hormonal contraceptive
types, the distribution of melasma most common
in oral contraceptives (26.1%), followed by injection (19.4%) and implants (16.7%). Hormonal
contraceptives contain estrogen and progesterone
Published by DiscoverSys | Bali Med J 2018; 7(3): 645-649 | doi: 10.15562/bmj.v7i3.1000
ORIGINAL ARTICLE
more frequently caused to melasma (23.4%) than
progesterone only (16.7%).
In Table 4.2 based on duration of hormonal
contraceptive use we found the onset of melasma
rise in 10 (58.9%) subjects which use more than
36 months, 6 subjects (23.6%) use 25-36 months,
1 subject (5.9%) use 13-24 months, 2 subjects
(11.8%) use 6-12 months. We did not find the risk
of melasma when hormonal contraceptive used
below 6 months.
From 17 patients hormonal contraceptive acceptors with melasma, we found centrofacial type in 9
subjects (52.9%), which was the most common type,
followed by the malar type in 8 subjects (47.1%) and
mandibular type was not found. The most common
melasma type by Wood’s lamp examination is
epidermal type in 16 subjects (94.1%), dermal type
in 1 subject (5.9%). (Table 4.3).
DISCUSSION
Melasma can be found all over the world, especially people who live in tropical areas that always
exposed to the UV. This hyperpigmentation disorder can affect all races and often occurs in people
with Hispanic and Asian races which have skin type
Fitzpatrick III-V.1
In this study, the proportion of melasma in
hormonal contraceptives acceptors found in
17 subjects (20.5%) as can be seen in table 4.1.
Suhartono’s study characteristics of melasma in
hormonal contraceptive acceptors in 125 subjects,
the result 57 subjects (31.3%) rise melasma due
to the use of hormonal contraceptives.10 Ortonne
et al. found a smaller value than this study, in 324
subjects with melasma obtained 171 subjects (53%)
used hormonal contraceptives at some stage, and
25% of the 171 peoples claimed that the onset of
melasma occurred after hormonal contraceptives
use.9 Furthermore, in a study by Ikino et al. in Brazil
found that the risk factors for melasma result from
hormonal contraceptives use are smaller than this
study, of where 51 subjects with melasma, 5 subjects
(9.80%) associated with hormonal contraceptive.3
Table 4.1 represents from 83 subjects whom
application hormonal contraceptives, only 23
subjects used oral contraceptives, this result less
than injection and implant, but the incidence of
melasma the higher compared with injection and
implants which is 26.1 %. The results of this study
consistent with Suhartono’s study in Semarang
which also shows that oral contraceptives acceptors
less than injection or implants, but the incidence
of melasma due to the oral contraceptives is higher
compared with other hormonal contraceptives
(35.5%).10 Guinot et al. in Tunisia found that oral
Published by DiscoverSys | Bali Med J 2018; 7(3): 645-649 | doi: 10.15562/bmj.v7i3.1000
contraceptives were reported as an aggravating
factor in 38% of melasma.11 Handel et al. showed
a lower number, from 207 subjects found at 10%
of melasma due to oral contraceptives.2 The incidence of melasma due to hormonal contraceptives,
especially oral contraceptives was also found lower
results in Tamage et al. and Achar et al. studies, with
16.2% and 18.4%, respectively.12,13
Hormonal contraceptives contain estrogen
and progesterone is more frequently leads to
melasma than progesterone alone in 11 subjects
(23.4%). Estrogen and progesterone play a role
in the development of melasma, which hormonal
contraceptives use caused estrogen and progesterone imbalance. Estrogen increases vascularization
of the skin and suppresses the activity of sebaceous glands. Estrogen also increases pigment cell
activities.14 Progesterone increase the spread of
melanin in cells and the expression of PR proteins
in skin hyperpigmentation due to melasma.15,16
Wiedemann et al. concluded that progesterone
derivatives in oral contraceptives might reduce the
risk of melasma based on the finding that progesterone reduces proliferation without a significant
effect on tyrosinase activity, in contrast to the effects
of estrogen stimulation on melanocyte cultures.17
This probably causes a lower incidence of melasma
due to hormonal contraceptives containing progesterone alone.
Table 4.2 shows the onset of melasma based on
the duration of hormonal contraception is the most
more than 36 months of 10 subjects (58.9%). A study
by Ortonne et al. found that the onset of melasma
after hormonal contraceptives use was 25%, but
it was not explained how long the time was.9
Suhartono’s study found that melasma occurred after
oral contraceptive use, injection and implant more
than 20 months.10 Guinot et al. showed a significant
association between severity of melasma and duration of oral contraceptive use; melasma often occur
between 1 to 3 years after its use.11
Centrofacial type is the most common clinical
pattern seen in hormonal contraceptive acceptors
in 9 subjects (52.9%) (table 4.3). Centrofacial is the
most common type, which is 63% covering forehead area, nose, medial cheeks, below the nose and
chin.2 This study is similar to Krupashankar et al.
that found 45% on centrofacial and 39% on malar.18
Guinot et al. also found centrofacial type frequently
encountered in the study, which was 76%, malar
23%, and mandibular 1%.11 This result is different
from Jagannathan et al. that shows the distribution
of melasma in 80 women obtained that malar 65%,
centrofacial 26.25%, and mandibular 8.75%.19 The
result same as Pawar et al., of 120 patients with
melasma, all subjects (100%) showed melasma
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ORIGINAL ARTICLE
distribution at malar area, with 76 subjects (63,33%)
on forehead and 16 (13,33%) on chin.20 The most
common melasma type by Wood’s lamp examination is epidermal type 94.1%. This study is in similar with Jagannathan et al. that found epidermal
type 48.75%, dermal 20%, mixed 28.75% and 2.5%
unclear.20 Reddy et al. also show that epidermal
type is 47%, dermal 34% and mix 20%.21 Wood’s
lamp with 320-450nm wavelength can be used to
determine into the melanin on the skin. On Wood’s
lamp examination, epidermal types of melasma
will appear more clearly than light.22
Estrogens have a significant effect on many
different cell types in skin physiology, including keratinocytes, fibroblasts, and melanocytes.
Progesterone increases the spread of melanin in
cells. Although the pathogenesis of melasma has
not been fully understood. But melasma considerably has some risk factors influential in addition
to hormones contained in hormonal contraceptives such as genetic, races, UV exposure, thyroid
dysfunction, drugs and cosmetics ingredients.1,4,6,9
The limitations of this study are the number of
samples are still small and the area of research that
is only in one kelurahan (district). It is necessary to
conduct further multicenter research with a large
sample size in order to describe the proportion
of melasma in hormonal contraceptive users in
Indonesia
CONFLICT OF INTEREST
The authors declared that they have no conflicts of
interest
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CONCLUSION
The proportion of melasma in hormonal contraceptive acceptors is 20,5%. Where the highest result rise
the melasma in a subject who used oral contraceptive, hormonal contraceptives contain estrogen and
progesterone and duration more than 36 months.
The type of melasma is centrofacial type and epidermal type. In the future, multicenter research needs to
be done with a large sample size in order to be able
to describe the proportion of melasma in hormonal
contraceptives acceptors in Indonesia, as well as to
explore the use of hormonal contraceptives (oral,
injection and implants) with melasma.
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ACKNOWLEDGMENT
None declared
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