Dr. Lili Legiawati, Sp.

KK(K)

• Positions
– Head of Dept of Dermato-Venereology Cipto Mangunkusumo
General Hospital / Faculty of Medicine University of Indonesia
– Staff of Cosmetic Dermatology and Geriatric Dermatology
Division, Dept of Dermato-Venereology Cipto Mangunkusumo
General Hospital / Faculty of Medicine University of Indonesia
• Educations
– Medical doctor : Faculty of Medicine University of Indonesia
year 1995
– Dermato-Venereologist : Faculty of Medicine University of
Indonesia year 2004
– Consultant : Faculty of Medicine University of Indonesia year
2013
Dr. Lili Legiawati, Sp.KK(K)

● Organization
– Treasurer of Dermato-Venereology Collegium
– Accreditation Commision of Continuing Medical
Education (P2KB)
– Secretary of Geriatric Dermatology Study Group
– Member of Executive Board Cosmetic Dermatology
Study Group
Yes or No (Myths or facts) in
Cosmetic Dermatology
Lili Legiawati
Dermatovenereology dept.
Faculty of Medicine Universitas Indonesia / Cipto Mangunkusumo Hospital
 Definition Myths
• “A popular belief or tradition that
has grown up around something or
someone”

Definition Facts
• “Something that has actual
existence”
www.merriam-webster.com/dictionary
 Statistics of Outpatient Cosmetic Dermatology Clinic RSCM in
2017

Top 10 most cases found in Cosmetic Dermatology Clinic Cipto Mangunkusumo in 2017

NO DIAGNOSIS TOTAL NUMBER

1 Moderate Acne Vulgaris 163
2 Melasma 118
3 Mild Acne Vulgaris 91
4 Acne scar 72
5 Aging skin 42
6 Post Inflammation Hyperpigmentation 35
7 Severe Acne Vulgaris 29
8 Seborrheic Keratosis 21
9 Uneven skin color 21
10 Lentigo 17
Myths in Cosmetic dermatology

Myths in Acne

Myths in Skin care

Myths in Photoprotection

Myths in Skin aging

Myths in pigmentation
 Myths in Acne (1)

Myth 1: eating Myth 2 : diet is

chocolate not correlated
triggers acne with acne

Claudel J, Auffret N, Leccia M, Poli F, Dreno B. European Academy of Dermatology and Venereology. Acne and nutrition:
hypotheses, myths and facts. 2018;.
 Myths in Acne (1)

• Explanation :
– The relation between diet and acne
vulgaris remains controversies
– Studies shown high glycemic index diet
and dairy will induced hyperinsulinemia
leads to a inflammation cascade
– Studies stated that chocolate exacerbate
acne, but important to note that the
components of chocolate contain dairy
and sugar which play role in acne
Acne: The Role of Medical Nutrition Therapy
Burris J et al.
J of Acad Nutrition and Dietetics 2013 vol 113
 • Comparison of the potential
Glycemic of various foods to increase
blood glucose based on equal

index (GI) amounts of carbohydrates in

the food

• Potential of a food to
Glycemic • increase blood glucose
• (Glycemic index X
load carbohydrate
content/serving size)
•
Acne and diet
Bowers J
JAAD 2012; 66: 78-=4
Diet
Ta ble and
II. Exaacne . Bowe
mple s of low- a ndWP, et almic. foods
high-glyce JAAD 2010; 63:124-41
36

Food Glyce mic inde x∗Glyce mic load† (pe r 100-g s e rving)
Ca rrots , ra w 16 1.6
P e a nuts 14 1.7
Ora nge s , ra w 42 3.9
P lums , ra w 39 3.9
Apple s , ra w 38 4.8
P orridge ma de from rolle d oa ts 58 5.1
Chickpe a s , boile d 28 5.6
S pa ghe tti, white , boile d 42 11.0
White flour bre a d 70 32.7

Lis te d glyce mic inde x is whe n glucos e s uga r is us e d a s re fe re nce food.

Ada pte d from Fos te r-P owe ll e t a l.36 Glyce mic loa d is e s tima te d by multiplying glyce mic inde x by
gra ms of ca rbohydra te pe r 100-g s e rving a nd dividing by 100.
Acne: The Role of Medical Nutrition Therapy
Burris J et al.
J of Acad Nutrition and Dietetics 2013 vol 113
 Myths in Acne (2)

• Myth : acne is an infection and they are infectious to

others
• Explanation :
– Propionobacterium acnes is important in the
extension of the disease from simple comedones to
full blown inflammatory lesions, it is a secondary
phenomenon once the disease has been initiated.
– The relevant bacterium is an obligate anaerobe living
in the oxygen free environment of the pilosebaceous
apparatus and beyond any influence of surface
washing.

Goodman G. Acne - Natural history, facts and myths. Australian Family Physician. 2006;35(8).
 Myths in Acne (3)

• Myth : certain hairstyles or haircut predispose acne

• Explanation :
– Infrequent or irregular hair shampoo does not
exacerbate acne, nor leaving the hair long or greasy
or wearing the hair over the face likewise.
– One case report : overbrushing hair may exacerbate
acne, this is suggested to be a type of mechanical
acne
– Although wearing headband, head cap, or other
hair accessories can induce acne mechanica by a
combination of friction, occlusion, sweating, and
heat.
Goodman G. Acne - Natural history, facts and myths. Australian Family Physician. 2006;35(8).
Brans R. Mechanical Causes of Occupational Skin Disease. Kanerva’s Occupational Dermatology. 2018;:1-12.
 Myths in Acne (4)

• Myths : acne is puberty disease and does not

need therapy
• Explanation :
– Acne is a chronic disease, often starts at
puberty and lasts long time after puberty
– Acne requires long term therapy, and will not
be cured just by consuming or applying
antibiotic
– If left untreated, acne will exacerbate into
sequale and also affecting psychosocial
Goodman G. Acne - Natural history, facts and myths. Australian Family Physician. 2006;35(8).
 Myths in Acne (5)

• Myth : cosmetic does not cause acne

• Explanation :
– There is clear evidence showing that various
cosmetic ingredients elicit comedones in both
animal and human studies
– It was believed that cosmetic usage could be
used to explained 95% of the cases of adult
women presenting with a mild acneiform
condition and Kligman coined the term ‘acne
cosmetica’ to describe this persistent low-grade
acne in adults
Goodman G. Acne - Natural history, facts and myths. Australian Family Physician. 2006;35(8).
 Myths in Acne (6)

• Myth : acne does not affect psychosocial

• Explanation :
– Acne has a large impact on appearance  self-
esteem, self-consciousness, and everyday functions.
– Associated with depression and suicidal thoughts,
social dysfunction and reduced employment
opportunities
– Acne psychological impact perceived sexual
attractiveness, relationships with family and friends,
judgments of others, stigmatization, stress, and fear
of scarring or disease persistence.
Dreno B, Bagatin E, Blume-Peytavi U, Rocha M, Gollnick H. Female type of adult acne: Physiological and psychological considerations and
management. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2018;16(10):1185-1194.
 Myths in Sunscreen (1)

• Myth :
Sunscreen with high SPF is the only protection needed
from sun exposure
• Explanation :
– Sunscreen alone is not giving sun protection entirely
– Most of sunscreen photodegraded after exposed
from sun ray
– Sunscreen would not lasts after 2 hours of sun
exposure
– Using sun screen is not as effective as wearing sun
protected clothing and avoiding exposing to sun at
Kullavanijaya & Lim (JAAD11.00 – 16.00
2005) McCullough & Kelly (Ann N.Y. Acad Sci 2006) Ainbinder & Touitou (Textbook of Aging 2010)
Hornung RL (Ped Derm 2011) Sambandan & Ratner (JAAD 2011)
 Myths in Sunscreen (2)

• Myth :
The higher the SPF the better
• Explanation :
– Current study shows that applying sunscreen
with SPF 50 protect UV ray up to 98%
– However, applying more than SPF 50 sunscreen
has only slightly more protective to UV ray only
up to 99%

Ramos-e-silva M, Celem LR, Ramos-e-Silva S, Fucci-da-costa AP. Anti aging cosmetics: facts and controversies in Clinics in
dermatology. 31 (2013) 750-58.
 Myths in Sunscreen (3)
• Myth : applying sunscreen with SPF 15 and SPF 30 will result in SPF
45
• Explanation :
– The highest SPF that is used is the SPF provided. Which in this
case is SPF 30.
– Applying the correct amount of sunscreen is better than
applying high SPF sunscreen with incorrect amount
• Correct amount of applying sunscreen (Tea Spoon Rule)

Use more than half a teaspoon Use more than a teaspoon

each on : each on :
• head & neck area • Anterior torso
• right arm • Posterior torso
• left arm • Right leg
• Left leg
Kullavanijaya & Lim (JAAD 2005) McCullough & Kelly (Ann N.Y. Acad Sci 2006) Ainbinder & Touitou (Textbook of Aging 2010)
Hornung RL (Ped Derm 2011) Sambandan & Ratner (JAAD 2011)
 Myths in Sunscreen (4)

• Myth :
Using make up with SPF has the same effect as
using sunscreen, hence no need for using
sunscreen
• Explanation :
Many SPF labelled in the marketed makeup or
foundation products not stating the SPF type
(non photostable, not containing UVA blockers)
and applying the product is inadequate to reach
the SPF effect that is desired
Kullavanijaya & Lim (JAAD 2005) McCullough & Kelly (Ann N.Y. Acad Sci 2006) Ainbinder & Touitou (Textbook of Aging 2010)
Hornung RL (Ped Derm 2011) Sambandan & Ratner (JAAD 2011)
 Myths in Sunscreen (5)

• Myth : applying sunscreen can cause lack of

vitamin D
• Explanation
– In small amount (few minutes every day) sun
exposure indeed needed to produce vitamin D
in skin
– Studies shown that long-term usage of
sunscreen has little to no effect of vitamin D
level in their body, nor inducing secondary
osteoporosis
Kullavanijaya & Lim (JAAD 2005) McCullough & Kelly (Ann N.Y. Acad Sci 2006) Ainbinder & Touitou (Textbook of Aging 2010)
Hornung RL (Ped Derm 2011) Sambandan & Ratner (JAAD 2011)
 Myths in Sunscreen (6)

• Myth : sun exposure in cloudy weather and rainy

season are not dangerous
• Explanation :
– Clouds are not full protective from sun x ray, upto
80% of sun ray can penetrate through clouds
– UVA also radiates all year and able to penetrate
through glass and cloud
– So, applying sunscreen is mandatory in all season
and weather

Kullavanijaya & Lim (JAAD 2005) McCullough & Kelly (Ann N.Y. Acad Sci 2006) Ainbinder & Touitou (Textbook of Aging 2010)
Hornung RL (Ped Derm 2011) Sambandan & Ratner (JAAD 2011)
 Myths in Sunscreen (7)

• Myth : applying sunscreen only requires one time

daily and no need to reapply
• Explanation :
– Sunscreen application only lasts for 2-3 hours
– The correct time to apply sunscreen :

15-30 minutes Reapplying it 15-

Reapply every 2-
before expose to 30 minutes after
3 hours
sun exposed to sun

Ichihashi et al. JAAM 2009

 Sunscreen Recommendation

• Must begin in early age

• Avoiding sun exposure especially at time of 10.00 –
16.00
• Find shaded area
• Avoid tanning and tanning bed
• Wear sun protective clothing
• Wear sunscreen when having activity outside

Kullavanijaya & Lim (JAAD 2005) McCullough & Kelly (Ann N.Y. Acad Sci 2006) Ainbinder & Touitou (Textbook of Aging 2010) Hornung RL (Ped Derm
2011) Sambandan & Ratner (JAAD 2011)
 Myths in Skin Care (2)

• Myth : Cleansing face frequently prevents acne

• Explanation :
– Patients perceive that open comedones or
blackheads are full of dirt although the black
colour caused by oxidation of fats
– Excessive sebum production that does occur in
most acne patients is perceived as dirty, although
these surface lipids have little to do with acne
production
– While it is true that pores do get functionally
blocked, this is at a depth well beyond washing
techniques
Goodman G. Acne - Natural history, facts and myths. Australian Family Physician. 2006;35(8).
 Myths in Skin Care (3)

• Myth : all skin types can wear the same category

of cleanser
• Explanation :
– Skin cleanser must not disrupt skin barrier also
preserve the skin’s lipid and moisturizers that
supply barrier repair ingredients to the stratum
corneum
– Never use antiseptic soap
– The choice of cleanser greatly affect the
success of entire skin care regime
Fitzpatrick J, Morelli J. Dermatology secrets plus. 2016.
Rubin J, Neligan P. Plastic surgery volume 2 : Aesthetic Surgery. 1st ed. 2011.
 Myths in Pigmentation (1)

• Myth : darker-complexion individuals are not likely to

develop disorders of hyperpigmentation
• Explanation :
– Melasma, common pigmentation disorder, has two
predisposing factors : sun exposure and sex hormones
– Darker-complexion individuals tend to have
hyperpigmentation post cosmeuceutical procedure
– It tends to affect darker-complexioned who lives in
areas of intense sun exposure and who have Fitzpatrick
skin types IV and V

Fitzpatrick J, Morelli J. Dermatology secrets plus. 2016.

Rubin J, Neligan P. Plastic surgery volume 2 : Aesthetic Surgery. 1st ed. 2011.
 Post-inflammatory hyperpigmentation
• Acquired increase in pigmentation secondary to an
inflammatory process
Inflamma Hyperpigmen
tion tation

Direct stimulation Indirect stimulation:

of melanocytes: • Damage skin or by-products
inflammatory from inflammatory cells 
ROS, such as SO and NO 
mediators, IL-1a,
stimulates melanocyte
endothelin-1, and/or • Damage to epidermal cells 
stem cell factor release of endocrine inducers
of pigmentation, such as α-
melanocyte-stimulating
Ho, et al. A Retrospective Analysis of the Management of Acne Post-
Inflammatory Hyperpigmentation Using Topical Treatment, Laser hormone
Treatment, or Combination Topical and Laser Treatments in Oriental
Patients. Lasers Surg Med. 2011; 43:1-7
 • Caused by:
– ↑ production + abnormal distribution of
melanin
– Hemosiderin deposition secondary to
hemorrhage.
• All skin types  more common and severe in dark
skin type, Fitzpatrick type IV-VI (African, American,
Hispanik , Asian)  very significant psychological
impact

Chang MW. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. Elsevier Mosby; 2009:333–
389.
Davis EC, Callender VD. Postinflammatory hyperpigmentation a review of the epidemiology, clinical features, and treatment options in
 • Type:
–Epidermal: light brown – dark brownDetermine
–Dermal: bluish grey – brownish grey therapy
• Benign 
– Majority will improve spontaneously
 take months-years to resolve
– Some cases can be permanent

Chang MW. Disorders of hyperpigmentation. In: Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. 2nd ed. Elsevier Mosby; 2009:333–
 Myths in Pigmentation (3)

• Myth : wearing skin-lightening treatment

will permanently removes skin
pigmentation
• Explanation:
– All skin lightening treatment will take 12-
16 weeks for results and that sun
exposure will immediately cause
recurrence of the condition

Fitzpatrick J, Morelli J. Dermatology secrets plus. 2016.

Rubin J, Neligan P. Plastic surgery volume 2 : Aesthetic Surgery. 1st ed. 2011.
 Myths in Pigmentation (4)

• Myth : applying skin lightening products long

term is safe
• Explanation:
– Applying skin lightening products in a long
term causes many side effects including
exogenous ochronosis
– Older study shown this effect appear only in
high concentration of hydroquinone, but
latest study found low concentration of
hydroquinon already has this effect
– Another long term effects found in animal
study are nephrotoxicity and carcinogenicity

Kooyers T, Westerhof W. Toxicology and health risks of hydroquinone in skin lightening formulations. Journal of the European
Academy of Dermatology and Venereology. 2005;0(0):060606032107074.
 Myths in skin aging (1)

• Myth : only genetic and age play a role in the

formation of wrinkle
• Explanation :
– Skin aging includes intrinsic and extrinsic factors
– Intrinsic factor : aging or chronological age
– Extrinsic factor : environmental and behavioral
factors.
• sun exposure
• smoking
• dietary nutrients
• body mass index
• menopausal status
6. Fitzpatrick J, Morelli J. Dermatology secrets plus. 2016.
 Myths in Skin Aging (2)

• Myth : specific skin care products can not

rejuvenate skin or make the skin younger
• Explanation :
– There are therapies that make the skin appear
less wrinkled and thus appear younger
– Topical applications : tretinoin cream and α-
hydroxy acids both have been shown in studies
to thicken skin and make wrinkles less
noticeable

Fitzpatrick J, Morelli J. Dermatology secrets plus. 2016.

 Myths in Skin Care (4)

• Myth : skin aging can not be prevented by

consistent skin regimen
• Explanation :
– The prevention (and treatment) of cutaneous
aging should begin with a consistent skin
regimen that include daily SPF, antioxidants,
and retinoids
– Retinoid has been proven to prevent age and
improve wrinkles by promoting collagen

Ramos-e-silva M, Celem LR, Ramos-e-Silva S, Fucci-da-costa AP. Anti aging cosmetics: facts and controversies in Clinics in
dermatology. 31 (2013) 750-58.
 Myths in Skin Aging (3)

• Myth : applying moisturizer is not affecting skin

aging
• Explanation :
– Aged skin often feels dry to the touch
– Moisturizers are the mainstay of daily
maintenance of normal skin and treatment for
dry skin
– Moisturizers help heal a damaged epidermal
barrier and make the skin feel smoother, a
property known as emollient.
Hashizume H. Skin Aging and Dry Skin. The Journal of Dermatology. 2004;31(8):603-609.
Photoaging Treatments Categorized by Prevention Strategy
Primary Secondary Tertiary

Photoprotection

Retinoic Acid

Antioxidants

Estrogens

Growth factors/ cytokines

Chemical Peels
Microdermabrasion/
Microbiation

Laser

Botulinum Toxins

Soft Tissue Augmentation

Ramos-e-silva M, Celem LR, Ramos-e-Silva S, Fucci-da-costa AP. Anti aging cosmetics: facts and controversies in Clinics in dermatology. 31 (2013) 750-58.
 Evidence of antiaging therapies
Type of Intervention Drug/Process Type of Evidence

Retinoids Tretinoin A2
Tretinoin A1
Tezarotene, tretinoin A1
Tazarotene A1
Anti-oxidants Vitamin C A2
Oral supplement (antioxidants, B
glucosamine, amino acids, and
minerals)
Oral antioxidant suplement A2
(vitamin E, vitamin C. Carotenoid,
selenium, and proanthocyanidin)

Coenzyme Q10 C
α-Lipoic acid A2

Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook D, Cook RJ. JAMA 1995;274:1880-4)
 Hormonal Estrogen, systemic A2
Estrogen, topical D2
Estrogen, topical D2
Growth factors and cytokines __ D2

New compounds FROP-3 D2

Date palm kernel extract A2
Chemical peels Glycolic acid (50%) peel B
Resurfacing techniques Microdermabrasion D2
Microcoblation D2
Laser systems Erbium:YAG laser D2
1450 nm diode laser C
(nonablative)

Guyatt GH, Sackett DL, Sinclair JC, Hayward R, Cook D, Cook RJ. JAMA 1995;274:1880-4)
 Myths in skin aging (4)

• Myth : applying antioxidant will protect skin from

free radical
• Explanation :
– Antioxidant protect the skin from free radical
damage due to oxidant stress generated by
sunlight and pollutant
– Many antioxidants have proved effective when
taken orally or topically

Fitzpatrick J, Morelli J. Dermatology secrets plus. 2016.

 ROS and photoaging

Chen L, Hu JY, Wang SQ. J. Am Acad Dermatol. Nov 2012;67(5):1013-23

Zusmann J, Ahdout J, Kim J.Vitamin and photoaging. Do scientific data support their use?J Am Acad Dermatol 2010;63:
507-25
 Evidence based study vitamin pada fotoaging
Intervention Formulation Evidence in Evidence
support against
Vitamin A Topical 0.025% Tretinoin cream A2
0.05% Tretinoin cream A2
0.05% Tretinoin cream D2
0.1% Tretinoin cream A2
0.1% Isotretinoin cream A1
0.05% Isotretinoin cream A1
0.01, 0.025, 0.05 Tazarotene A1
cream
0.05% Tretinoin cream A1
0.1% Tazarotene cream A1
0.4% Retinol lotion A2
Retinyl N-formyl aspartamate A2
cream
Retinyl propionate cream A2
0.05% Retinaldehyde cream A2

Oral Oral isotretinoin 10-20mg D2

Oral isotretinoin 10 mg D1
Oral isotretinoin 20 mg D1

43
A1,Randomized, controlled, double-blind trial, N > 100; A2, randomized, controlled, double-blind trial, N <100; CRS, Cimicifuga
racemosa extract; D1, observational study, > 1 treatment group, double-blind; D2, observational study, no blinding.
 Evidence based study vitamin pada fotoaging
Vitamin C Topical ascorbic acid A2
serum A2
Topical ascorbic acid 5% A2
cream A2
Topical ascorbic acid
10% cream
Topical cream
containing TGF-β(1), l-
ascorbic acid, and CRS

Vitamin E No studies to date

Vitamin B3 Topical 5% niacinamide A2
Topical 4% niacinamide A2
Topical 2% niacinamide A2
Vitamin D No studies to date
Vitamin K Topical gel containing 2% D1
phytonadione, 0.1%
retinol, 0.1% ascorbic
acid, and α-tocopherol
44
Thank you