By: dr. R.

Helmy

Organ terbesar tubuh

Berat 16 -20% dari BB , luas permukaan 1,8-2 m2
Tubuh kehilangan air 1L per hari
Tebal 1-4 mm (variasi)dalam 1tubuh
Typically ,one square centimetre of skin contains:
3,000,000 cells of different types ,3 blood vessels
,10 hairs ,12 nerves ,15 sebaceous glands(minyak)
,199 sudiferous glands( keringat )
Terdiri dari bagian :Epidermis, dermis,hipodermis
KETEBALAN EPIDERMIS,
DERMIS,HIPODERMIS BERBEDA TIAP BAGIAN
EPI PLG TEBAL DITELAPAK KAKI, DERMIS
PLG TEBAL DI PUNGGUNG

Fungsi pertahanan
Pengaturan suhu tubuh
Fungsi persepsi
Fungsi absorbsi
Fungsi ekskresi
Keratinisasi
Pembentukan pigmen
Pembentukan vit D
Sweat production
Sebum production

A. Skin Featuring

str. Corneum/corneosit (hexagonal atau pentagonal)

Di dalam korneosit di stratum corneum inilah terdapat
NMF (Natural Moisturising Factor)
NMF terdiri dari amino acid, PCA (pyrolidone
Carboxyclic Acid), Laktat, Urea

skin surface lipid film (acid mantle) gabungan

produksi kelenjar minyak, keringat dan emulsifier
berupa minyak yang dihasilkan oleh celah sel
korneosit
untuk memperbaiki acid mantle ini diperlukan :
ceramide, omega 3, niacinamide dan lactic acid.

fine wrinkle

hair (hair folikel & valous hair/terminal hair)

B. Skin Layer
Epidermis
Corneum
Lucidum
Granulosum
Spinosum
Basale

Dermis
Hipodermis

C. Cellular Level / Skin Sel

Berdasarkan sel_sel hidup di:
a. epidermis

Sel keratosit (merupakan komponen utama

epidermis)
Dalam proliferasi dan diferensiasinya keratosit
melibatkan : Ca, phospor, retinol dan aktivasi
vitamin D
Diantara keratosit terdapat lipid bilayer yang terdiri
dari :
Ceramide (terdapat 22 jenis ceramide, namun pada dry

skin yang sering hilang adalah ceramide 3)

fatty acid
kolesterol
trigliserid

Melanosit (memiliki tentakel / dendrit)

Langerhans (menyerupai star cell)
Marker cell

b. dermis
Fibroblas (merupakann komponen utama dermis)
Endotel vaskular
Mast cell
histiosit

c. hipodermis

Adiposa
Fibroblas hipositik
Endotel vaskular

Lapisan

Epi

Dermis

Hipo

Fungsi

Proteksi

Penunjang

Isolator

Komponen
Utama
PH

Keratin

Colagen

Lemak

4,5 6,5

7,1 7,3

Tebal

0,3 mm

3,5 mm

Variatif

Kandungan
Air

10 25 %

60 70 %

Pembuluh
darah
Glands

>>

Keringat &
sebacceus

Epidermis = Warna Kulit

Dermis = Teksture Kulit
Hipodermis = Countur Kulit

Faktor-faktor yang menjaga agar tidak banyak

air yang keluar dari kulit adalah:
Lipid bilayer
NMF
Sebum
Thight membran junction
Aqua glisophorin AQP3

Adalah proses naiknya keratinosit dari stratum

basale ke stratum korneum
Disebut juga proses keratinisasi
Mengetahui periode kulit penting untuk
rentang waktu kita melakukan terapi
1 periode kurang lebih 28 hari pada usia 25
tahun dan bertambah 2-3 hari setiap 5 tahun

1. NMF
2. lipid bilayer
3. Acid mantle

1. NMF

NMF dapat menurun dikarenakan:

Mencuci muka dengan sabun atau detergen
Kadar air dalam udara kecil (low humidity).

pada humidity <10 % kering, hal ini menyebabkan

filagreen tdk menjadi NMF
(filagreen adalah protein di epidermis yang mencegah
keluarnya air)
Usia
Atopi (5 rhinitis alergi, asma,dermatitis atopi,
urtikaria, ptiriasis alba)
Exposure UV

2. Lipid Bilayer
Usia
Seasonal effect
Atopi
Genetik
Diet (berkaitan dengan ketersediaan omega 3)
Glucocorticoid (stres hormon menghambat
terbentuknya lipid bilayer)

3. Acid mantle
Lipid lowering drugs (contoh golongan -statin)
dehidrasi
scrub berlebihan
exfoliate agent
electricity home device
sabun
low estrogen (menopause, haid)
UV & x-radiation
usia (elderly dan neonatus)
stres
kulit tipe 1 fitzpatrick
Testosteron
increased bacteria

Barier disruption diperbolehkan pada acute

inflamasi karena akan merangsang
pembentukan kolagen yg kemudian
merangsang skin rejuvenation

Klien feel oily tidak berarti true oily skin bila

kita temukan :
o
o

anisotropik yg tdk nyata

Wood lamp berwarna ungu

Udara panas sebum meningkatfeel oily

Bila klien kita feel oily, dapat kita berikan
additional treatment misalnya scrub atau
masker 3hr sekali.

1. Oxidatif Stress

2. Lipid Peroksidase

Yg mengatasi vit larut lemak

3. Mitokondria damage

Yang mengatasi vitamin larut air vit C

Glutation dan SOD

4. Cellular senescence

Ada tentakel (tentakel berfx utk mentransfer

melanin dr lapisan bawah ke atas)
Tiap 10 desmosome, 1 melanosit
Menghasilkan melanin

Absorbsi UV
Photoproteksi (menyerap free radikal)
Menangkap radikal bebas
Mencegah peroksidase lipid
Mencegah oksidatif stres
Mencegah fotoaging
Mencegah fotokarsinogenesis
Membantu sintesis vitamin D

FREE RADICALS
ROS (Reactive Oxygen Species)
Oxidatife stress, lipid peroxidase,mitocondrial
damage,cellullar scenescene.
Antioksidan

Enzim : SOD, glutation, peroxidase, catalase

Scavengers : tocopherol, ascorbic acid, lipoic
acid, uric acid
Quencher : Beta caroten, melanin, xantin,
Chelator

UVR may cause :

-Free radicals
-Vitamin C oxidisation
-Incactivate vitamin A receptors
-Peroxidation of lipids in cell membranes can demage cell membranes by
disruption fluidity and permeability . Lipid peroxidation can also adversely affect
the function of membrane bound proteins such as enzyme and receptors.
-Langerhan cell dendrite shortening and cell migration
-Melanogenesis (formation of pigment granules eumelanin and pheomelanin)
-Keratinocyte proliferation (to pick up melanosomes)
-Increase collagenase / elastase enzymes of MMP family
-Venous / lymphatic capillary demage due to loss structural support of loose
connective tissue (areolar)
-Impair cellular replication trought DNA demage
-Cellular senescense
-Vitamin D synthesis

Other skin conditions caused by UVR :

-Loss of resiliency and adhesion / recoil of
elastin fibrils
- loss of structural integrity and skin
density of collagen fibrils
- loss of of strengh of superficial fascia
septa
- hyper-pigmentasi skin conditions
- vascular skin conditions
- reduced immune system
- excess immune system

Pituitary gland (MSH)

Keratinosit
Fibroblast
Endokrin
Hormonal (estrogen, tiroid, insulin)
Inflamasi (ada prostaglandin terbentuk
pigmen tampak luka menghitam)
Chemical
Heavy metal (merkuri di kosmetik)
Tetrasiklin
Antimalaria, amiodarone dll

Aktivasi dan sintesis enzim tirosinase

Peroksidase

Tirosin +(tirosinase) dopa

+(peroksidase)produksi melanin

Transfer ke keratinosit

Melanin:

Eumelanin (true melanin coklat , pada org Asia)

Pheomelanin (merah/ kuning cerah, pd org Eropa)
Bila tirosin terbentuk tidak sempurna, yang akan
terbentuk adalah pheomelanin

Hemoglobin
Karotenoid
Blood circulation
Melanin
Kolagen

Dermal epidermal junction

Berisi kolagen (jar.ikat) dan cairan intersel
(matrix)
Suatu bahan harus melewati DEJ sblm ke endotel
vaskular (DEJ mrpkn filter pada nano
kosmetik)
<500 nano dapat menembus DEJ sehingga akan
berpengaruh ke sistemik
Bila DEJ rusak, melanin dapat terperangkap yg
menyebabkan pigmentasi sulit untuk kita
hilangkan.

Vit C (Magnesium Ascorbyl Phosphate)

Vit A (beta karoten, retinol, retinyl palmitate)
Asam amino essensial (proline, glisine, lysine)
Cooper peptides
Mg dan Ca
Bioflavonoid
Growth factor (eGF-epidermal growth factor
dan TGF3 (sitokin)
Hormon estrogen like (soy extract)

Zinc dan Fe (kofaktor sintesis kolagen)

Essensial fatty acid (omega 3)
Hyaluronic acid
Glucosamine
DMAE (dimetilamine etanol)antioksidan
SOD

Coagulation phase (contoh cauter)

2. Inflamation (peeling)
3. Lag phase di hari 3-5 (fibroblast mensintesis
kolagen, 50% kolagen terbuat)
4. Fibroplastic phase (hr 5-4 minggu)
5. Maturative phase (4 mg-2 tahun)
Catatan:
Acute skin inflamation dibutuhkan utk skin
rejuve/skin health (2 minggu)
1.

Inflammatory & lag phase 1-5

Days
Wound Healing

Nutrition
Suplemment
Omega 3
Vitamin A & E
Colostrum
Vit. C
Calcium

Topical Applied
Anti Oxidant
Alpha Lipoic
Vit A, C & E
Omega 3
Gluthatione
Resveratrol

Clinical
Interventio
n
Lymph Drainage
Photo
Modulation

Fibroplastic phase
5 14 Days
Wound healing

Nutrition
Supplement

Omega 3
Vit. A & E
Colostrum
Vit. C
Calcium
Minerals
Iron
Zinc
Copper
Amino acids

Topical Applied
Anti Oxidant
Growth Factors
Sun protection

Alpha lipoic
Vit. A, C & E
Omega 3
Gluthatione
Resveratrol
Colostrum
Copper peptides

Broad spectrum
Sun protection
290 400 nm

Clinic
Intervention

Lymph
drainage
Photo
modulation

Maturative phase
14 28 days 2 years
Wound healing

Nutrition
Supplement

Omega 3
Vit. A & E
Colostrum
Vit. C
Calcium
Minerals
Iron
Zinc
Copper
Amino acids

Topical Applied
Anti Oxidant
Growth Factors
Sun protection

Alpha lipoic
Vit. A, C & E
Omega 3
Gluthatione
Resveratrol
Colostrum
Copper peptides

Broad spectrum
Sun protection
290 400 nm

Clinic
Intervention

Lymph
drainage
Photo
modulation

Penetration
Ionthoporesis
Sonophoresis

Sistemic factor (Diabetes Melitus)

Drugs
Steroid
Antineoplastic agents
Penicilamin
NSAID
Vit A oral
Trace mineral
Cooper
Mg

1.

Apikal

2.
3.

Pembuluh darah
Limfatik (membuang zat-zat yang tidak terbuang dr
vena)
nerve

Mantle layer (tidak ada di eyelid, nailbed, bridge

of nose n penis)
Deeper layer
tergantung dari jenis kelamin dan area anatomis
selulit
di area muka bisa atrofi
meningkat di area yang dipengaruhi hormon

Tiroid
Paratiroid
Estrogen
Testosteron
Insulin
Growth hormon
Androgen

Glogau
Fitzpatrick
Bowmann

1.
2.
3.
4.
5.

Parameter kita mengasses aging sesuai umur

Kerut (statis dan dinamis)
Skin discoloration
Keratosis seboroik
Telangiectasis
Scar

Tipe I
Tipe II
Tipe III
Tipe IV

: no
: mild
: moderate
: severe

(<35 thn)
(40 thn)
(50 thn)
(60-70 thn)

1.

2.
3.
4.

5.
6.

Berdasarkan reaksi terhadap sang eksposure

dan berdasarkan genetik
Terbakar tapi tidak pernah tanning (hitam)
(blue n green eyes, blonde europe)
Selalu terbakar, kadang hitam
Kadang terbakar tp selalu hitam
Tidak pernah terbakar, selalu hitam
Lebih hitam
Hitam

1.
2.

3.
4.

Untuk mengasses kulit sensitif:

Parameter:
Jerawat (pimples and comedo)
Rosasea (merah bila ada pemicu, cth: makan
sambal)
Flush (hot, itchy, wlpun tdk merah)
DKI

A : Asimetris
B : Border
C : Colour
D : Diameter (>6 mm)
E : Enlargement (vertikal n horizontal)

Body dismorfik disorder

Ada pada 1-3 % populasi estetik
Cth:
Klien merasa gemuk
Klien merasa banyak jerawat
Klien merasa hitam
Klien merasa pesek

Ciri kepribadian:
Narsistik
Window shopping dokter
Kapasitas psikiatrik tdk usah ditangani

1.Kulit Berminyak
Lemak bekerja berlebihan sehingga terlihat
Mengkilat,Tebal,Tonus kuat,Pori besar dan biasanya
Berjerawat.
2.Kulit Normal
Tidak berminyak dan tidak kering sehingga terlihat
segar dan bagus,pori nyaris tidak terlihat
3.Kulit Kering
Kelenjar lemak kurang aktif,kulit kusam,tipis
,bersisik,halus,lebih cepat timbul keriput.
4.Kulit Kombinasi
Normal berminyak di bagian tengah wajah dan normal
kering di bagian lainnya,biasanya usia di atas 35 th
keatas

LIPID DRY

OILY

Secretion

Secretions

Matt , showing minimal oil over

majority of the face and neck.
Viewed with black light there
will be no or minimal indication
of yellow/orange pin points of
sebum over the

Sebasceous scretations will be

excessiv trought T zone , neck ,
decollete and between
shoulder blades. Slick to touch
. Viewed with black light,
yellow or orange pin points of
sebum will be

Texture
Surface may be rouht and flaky ,
with open or closed comedones
around the nose wing.
Premature ageing and wringkles.
When viewed with black light
there will be with flacky patches
in odd areas like the
zygomatic/cheeks

Colour
Skin appears blotchy and
dull in appearance.
Igmentation and diffused
redness ,easily aggressed
or sensitised when placed
under duress

DIFFUSED
REDNESS
Colour
Permanent high colour or
blotchy with flushing tendecy.
Nose, chin, cheeks are the first
areas to be affected. If chin has
permanent diffused redness it
is an exellent diagnostic clue

Texture
Texture

Scarring may be evident ,

and be slightly thickned
with open pores. Open &
closed comedones , may
have pustules
Colour
Sallow , tired with a
sheen. May have
underlying diffused
redness due to over
treatment with harsh skin
care

Looks fine textured and may

mark and scars easily. Ages
quickly and can be congested
and blemished.

Colour
Often minimal, but may
be oily. Could have an
impaired acid mantle and
be easily aggressed.

Hot water
Air conditioning
Pollutan
Friction from clothing
Frequent air travel
Other chemical

Clinical protocol for lipid dry

skin
1. Use cleanser & toner for dry
skin
2. Maintain acid mantle at all
times
3. Use cream or oil based masks
4. Do not use drying alcohol or
clay based masks
5. Do not use harsh abrasive
exfoliants
6. Extream care with chemical
peels
7. Moderate use of vapor zone
8. Massage with essential fatty
acids or high emolient slip cream
9. Complate treatment with an
occulusive cream
10.
Minimal
use of
Clients
protocol
forexfoliation
lipid dry skin
modalities
1.
Use cleanser & toner for dry
2.
3.

4.
5.
6.
7.
8.

skin
do not use drying alcohol or
clay based masks
do not harsh abrasive
exfoliants
use creams designed for lipid
dry skins to maintain acid
mantle
minimal sun exposure with
sun protection at all times
avoid artifical atmospheres
take essential fatty acids 03 &
06
take vitamin supplements for
epidermis

Clinical protocol for oily skin

1.
Use cleanser & toner for
oily skin
2.
if acneic use cleanser &
toner without fragrance of
colour.
3.
maintain acid mantle at all
times
4.
only use masks for oily
skin on oily areas
5.
Do not use harsh abrasive
exfoliants
6.
Moderate use vapor zone
machine
7.
Moderate use of vapor
zone machine
Clients protocol for oily skin
Use cleanser & toner for oily
skin, if acneic use cleanser &
toner without fragrence or
colour
2.
maintain acid mantle at all
times
3.
only use masks for oily skin
on oily areas
4.
do not use harsh abrasive
exfoliants
5.
do not wear skin drying
agents when in the sun
6.
minimal sun exposure with
sun
1.

1.
2.
3.

4.
5.
6.
7.
8.

9.

Clinical protocol for diffused

redness
Use cleanser & toner with no
fragrance or colour
avoid extremes of hot & cold
& over vaso-dilation of
capillaries
maintain acid mantle at all
times
use non drying masks
do not use harsh abrasive
exfoliants
extreme care with chemical
peels (if at all)
use cool spray or lucas
massage with essential fatty
acids
complate treatment with an
occlusive cream

Clients protocols for diffused redness

1.
Use cleanser & toner with no
fragrance or colour
2.
avoid extremes of hot & cold &
over vasodilation of capillaries
3.
no AHAs for home care
4.
avoid hot spicy foods
5.
do not use harsh abrasive
exfoliants
6.
Avoid alcohol or coffe
7.
Minimal sun exposure with sun
protection at all times
8.
avoid artificial atmospheres

normal

berminyak

kering

kombinasi

pori

kecil /
medium

besar

Kecil ketat

T-zone
besar, pipi
pori
kecil/sdng

kelembapan

bagus

Sangat
tinggi

Tidak bagus T-zone sngt

tinggi, klt
kering tdk
bgs

Teksture
kulit

halus

Kasar / tebal Kasar / tipis

kulit tampak
berpetak2
kecil &
berserpih

kelainan

Komedo,
pustule,
papul, milia

Bmnyk
tampak
tebal, krng
nampak
tipis

Sensitive,
T-zone
penuan dini, pustule
bintik-bintik papule, krng
milia &
pmblh kplr
rusak

Hal yang perlu di Anamnesa :

Jenis Kulit, Tipe Kulit
Tonus & Turgor
Pori Pori
Lipatan & Garis Kulit
Kelainan Kelainan kulit
Bentuk wajah
Penentuan Tindakan
Bahan kosmetik yang dipakai
Cara perawatan atau Pengobatan

Tonus : Dg mencubit Kulit pipi

Turgor : Dg Menekan Kulit pipi di bawah tulang pipi

Pori Pori

Tergantung dari jenis kulit

Lipatan garis Kulit

Kerutan biasa: Antara alis,sekitar mata,lipatan hidung dan

bibir
Kerutan usia : pada kening,leher,mulut

Magnifying lamp (lampu dan kaca pembesar)

merupakan alat yang penting bagi therapist
saat menganalisa kulit, memberikan
kemapuan untuk melakukan pemeriksaan
hingga hal yang kecil.
Dengan magnifying lamp ini akan
memperjelas jenis keadaan dan problem kulit.

Penggunaan alat ini akan meyakinkan klien

ketika dilakukan pengamatan pada kulitnya.
Karena dengan pemeriksaan yang intensif ia
akan merasa lebih yakin akan menerima
perawatan yang tepat sesuai dengan problem
dan kondisi kulitnya.

Magnifying lamp sangat membantu ketika

melakukan extraction ( extrasi ) black head,
white head dan membersihkan jerawat.
Menggunakan magnifying lamp akan
memberikan kesan yang professional pada
salon / klinik perawatan dan bertanggung
jawab.

Ketika hendak mengarahkan magnifying lamp

pada wajah klien, sebelumnya lindungi mata
klien dengan eye pads ( kapas lembab penutup
mata ), baru nyalakan lampu, jangan
menyalakan lampu di atas wajah klien.
Nyalakan dahulu baru diarahkan ke wajah
klien.

Sama dengan magnifying lamp tetapi lebih

sederhana.
Lampu sebagai penerangan di pasang external
(tersendiri).

Woods lamp ini diciptakan oleh Robert Williams,

seorang dokter Amerika.
Alat yang digunakan pada medical professional (
dunia kedokteran ) untuk membantu
mendiaknosa kondisi kulit, misalnya ringworm.
Woods lamp ini juga digunakan aesthetician
untuk membantu menganalisa kulit.

Alat ini bekerja dengan prinsip, bahwa

perbedaan kondisi kulit akan tampak dengan
warna yang berbeda di bawah sinar UV dari
lampu ini.
Lampu wood ini bekerja lebih baik ditempat
yang gelap.
Dengan analisa ini, maka theraphist dapat
menganalisa keadaan kulit.

Perhatikan : Woods lamp jangan sampai

terlalu panas, hindari kontak langsung pada
sinar ketika lampu dinyalakan baik dengan
mata klien maupun aesthetician.
Bila diperlukan : Gunakan penutup mata pada
klien.

Ada yang portable

Bisa di hubungkan dengan TV atau Komputer.
Prinsip : pemampakan di perbesaran
Baik untuk mensugesti klien.
Di praktekkan.

Microcomedones become non-inflamed skin

blemishes called comedones--either a
whitehead or a blackhead:

A blackhead occurs when the pore opens to the surface, and the
sebum, which contains the skin pigment melanin, oxidizes and
turns a brown/black color. It is not dirt and can not be washed
away. Blackheads can last for a long time because the contents
very slowly drain to the surface.

A papule occurs when there is a break in the follicular wall. White

blood cells rush in and the pore becomes inflamed.

A pustule forms several days later when white blood cells make
their way to the surface of the skin. This is what people usually
refer to as a "zit" or a "pimple".

Nodule
When a follicle breaks along the bottom, total collapse can
occur, causing a large, inflamed bump that can be sore to the
touch
Development: A nodule occurs when the follicle wall
ruptures deep within the dermis. Contaminated debris from
the follicle empties into the dermis and infects adjoining
follicles. A nodule is a severe form of an acne lesion.
Cyst
Sometimes a severe inflammatory reaction can result in very
large pus filled lesions.
Development: Like nodules, cysts begin as a deep break in
the follicle wall. A membrane develops around the infection
in the dermis. As a cyst works its way to the surface, it
damages healthy skin tissue, destroying the follicle. The
likelihood of scarring is very high.

Histologically, milia are retention cyst of

pilocebaseous follicle, usually seen in term
infants and scattered in nose, chin and
forehead. They exfoliate and disappear within
first few weeks of life. No treatment is
required.

Syringomas are harmless sweat duct tumors,

typically found clustered on eyelids, under the
eyes and zygomatic, although they may also be
found in other areas of the body. They are skincolored or yellowish firm rounded bumps, 1-3
mm in diameter, and are often confused with
xanthelasma.

They start to appear in adolescence and are

more common in women than men. Always
remember to ask if there is any other member
of the family with this disorder because it has
been shown to have a genetic link.
These really can be a bother in high humidity.

Gula murni akan membuat proses glikasi yang

mendegradasi kolagen
AGE (advanced Glicasi End Product) free
radical membuat inflamasi
gambaran pillow like app pd kelopak mata

Orange juice 600

Tea
2025
Coffee
2200
Clasic coke 8500
Diet coke 9500

Age unit /250ml

1 . Cereal
2. Pastry
3. Cake
4. Duck skin

193,400
426,740
838,400
6,259,000

Dietary consideration
minimize intake of food high in AGE such as
meat, cheese, egg yolk
Decreased cooking temperature
broilling and frying can lead to increased
amount of AGEs

Carnosine 2000 mg
Lipoic acid 400-600 mg
Chromium 300 microgram
Vit E 400 IU

Under the microscope, Xanthelasma can be seen to be

composed of lipid-laden macrophages (histiocytes)
which have engulfed low density lipoproteins (LDLs)
by endocytosis, these cells then become known as
foam cells. It has been suggested that increased
plasma lipid peroxidation (derived from the oxidized
low-density lipoprotein LDLs) may lead to
accumulation of cholesterol in macrophages and
formation of foam cells

This LDL lipid material is stored within the cytoplasm

(intracellular), and has accumulated in an area like
capillaries.
How do these lipids arrive in the dermis? It appears
that the LDLs had crossed the endothelial cell barrier of
the capillary and became oxidized by ROS (reactive
oxygen species of radical) it was after that event the
macrophages came into play.

Hiperpigmentasi melanotik, penyebab:

kehamilan, pil antihamil, kosmetika
obat-obatan, genetik, defisiensi gizi
metabolik, endokrin, makanan, UV
infeksi, peradangan kulit, keganasan
disfungsi hati

O= normal skin colour without evidence of

hiperpigmentation
1=barely visible hiperpigmentation
2=mild hiperpigmentation
3=moderate hiperpigmentation
4=severe hyperpigmentation

Malar
Mandibular
Centrofacial

Bercak ukuran 0,5-1 cm

Warna coklat kehitaman, berbatas tegas
Daerah terpajan/tidak
Dewasa usia lanjut

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PRAKTEK