Meiho University
Graduate Institute of Health Care

Thesis
KNOWLEDGE, ATTITUDE
AND SUNSCREEN USE BEHAVIOR AMONG
PATIENTS WITH MELASMA IN VIETNAM

Graduate student: Phạm Hoài Thu
Supervisor: Dr. Neoh Choo Aun


July 2015

美美美美美美
Meiho University
美美美美美美美
Graduate Institute of Health care

美美美美
Master Thesis


KNOWLEDGE, ATTITUDE
AND SUNSCREEN USE BEHAVIOR AMONG
PATIENTS WITH MELASMA IN VIETNAM

研研研研Phạm Hoài Thu
研研研研研Dr. Neoh Choo Aun

2015 美 06 美

KNOWLEDGE, ATTITUDE


AND SUNSCREEN USE BEHAVIOR AMONG
PATIENTS WITH MELASMA IN VIETNAM

Graduate student: XXXXXXXX

Supervisor: Dr. XXXXXXX

Meiho University

Graduate Institute of Healthcare

Thesis

A thesis submitted to the Graduate Institute of Health Care of


Meiho University

In partial fulfillment of the requirement for the degree of

Master of Health Care

July 2015


Abstract


Background: Melasma, a localized hyperpigmentation, affects millions of
people worldwide. The Dermatology Hospital in Ho Chi Minh city is the
biggest hospital specializing in treatment of dermatological conditions,
including melasma. After a course of laser therapy, patients were counseled to
use sunscreen to prevent the recurrence of melasma and revisit the hospital after
one-month use of sunscreen to check their conditions. Although no official data
about the rate of recurrence among affected patients, many recurrent cases have
been documented in practice. Such situation raises questions involving whether
or not patients used sunscreen after laser therapy, how they applied sunscreen in
their daily life and to what extent they are knowledgeable about melasma and
proper use of sunscreen to protect their body from recurrence of melasma.
Objective: The aim of the study was to find out the knowledge, attitude and
behavior related to sunscreen application among melasma patients who had
received laser therapy..
Methods: A cross-sectional hospitalized-based study is undertaken between
April and May 2015 in Ho Chi Minh city, Vietnam. A sample of 123 patients
with melasma was collected and took part in interviews with a structured
6


questionnaire. The significance of the results was assessed by t-test, ANOVA
test and Chi-Square test at p-value of 0.05 using SPSS version 16.
Results: There were 123 participants enrolled in the study; of which,
80.49% was female. There were 60.61% female patients had a history of
pregnancy. Most of participants in the study had the age from 20 to 49 years of
age (87.81%) and only 1.63% of participants aged over 60. There were 63.41%
patients had married, while 32.52% were unmarried. Kinh was the predominant
ethnic in this study (93.5%).
The total knowledge mean score of participants was relative low, yielding

1.96 ± 1.09 (0-4). The total attitude score among patients was relative high
(30.53 ± 4.16). The proportion of using sunscreen among participants was
78.05%. The analysis showed that gender and occupation had significant
associations with knowledge about sunscreen use among patients with melasma
(p< 0.05). Male had lower attitude score than female and this deference was
statistical significant (p< 0.001). Patients who were illiterate and finished
elementary school, high school, university gain the highest score compared to
other education groups (p=0.03). Between gender and sunscreen use had a
significant association (p< 0.001) in which female patients practiced sunscreen
use higher than male patients. elative with melasma and recurrence of melasma
7


were two factors those had statistical significant associations with behavior of
sunscreen use among patients (p=0.04 and p =0.005).
Conclusion: The study showed that patients with melasma had low
knowledge on sun exposure and sunscreen use. On the contrary, attitude and
behavior of sunscreen use were relative high. Gender play an important role in
determining knowledge, attitude and behavior of patients. Other factors
including sun-exposed occupation, educational, family history of melasma and
recurrence of melasma were also have influences on knowlegde, attitude and
behavior of participants. Thus, a education program on sunscreen use should be
implimented in the near future to improve knowledge, attitude and enhance
behavior of patients with melasma.
.

8


Acknowledgement


First and foremost, I would like to send from bottom of my heart my thanks
to my supervisor, Dr. Neoh Choo Aun., for all encouragement, support and
feedback you gave to me. Secondly, I would like acknowledge the endeless and
precious supports from other Meiho professors, who always facilitate me
complete this thesis.
I also would like to thank a lot to valuable supports by The Director Board
of Demartology Hospital during my studying and my thesis implimentation. For
all patients who had participants in this study I send my special thanks to all of
you for accepting me to use your information

9


Contents

Page

Appendix 1: The questionnaire
Appendix 2: The informed consent
Appendix 3: the Ethical Committee of certification

10


List of tables

Page

11



List of figure

Page

12


Chapter 1: Introduction

1.1. Statement of this research
Melasma, a localized hyperpigmentation, affects millions of people
worldwide. Although there are no global data about the prevalence of melasma,
studies showed a wide variation in prevalence among countries worldwide. A
study in Brazil where high sun exposure is common showed that the prevalence
of melasma ranged from 5.9% to 9.1% in the different regions of the country
(Sociedade Brasileira de Dermatologia SBD, 2006). Other studies in Nepal and
Saudi Arabia reported melasma is one of the most frequent pigmentary
dermatosis (Alakloby, 2005; Walker, Shah, Hubbard, Pradhan, & Ghimire,
2008). In United States, Halder et al (1983) confirmed melasma is a frequent
post-inflammatory hyperpigmentation among black population.
Melasma has a significant impact on appearance, causing psychosocial and
emotional distress, and reducing the quality of life of the affected patients.
Studies indicated that patients with melasma experienced many distresses such
as frustration, dissatisfaction, low self-esteem, and embarrassment in their daily
life (Cestari, Hexsel, Viegas, Azulay, Hassun, Almeida, & et al, 2006; Purim &
13



Avelar, 2012). In addition, there are high expenditures related to medical
treatments and procedures whose results do not always meet the expectations of
patients (Handel, Miot, & Miot, 2014).
There are various treatment modalities of melasma have been established
for years including sunscreen products (Grimes, 2007; Pathak, Fitzpatrick, &
Kraus, 1986; Scheinfeld, 2007), hydroquinone (Abramovits, Gover, & Gupta,
2005; Grimes, 1995; Gupta, Gover, Nouri, & et al, 2006; Lynde, Kraft, &
Lynde, 2006; Victor, Gelber, & Rao, 2004), azelaic acid (Baliña & Graupe,
1991; Kakita & Lowe, 1998; Lowe, Rizk, Grimes, & et al, 1998; Sarkar, Bhalla,
& Kanwar, 2002) and other chemical therapies (Nerya, Musa, Khatib, & et al,
2004; Nerya, Vaya, Musa, & et al, 2003). However, with its recurrent and
refractory nature, the possibility of recurrence of melasma makes it become a
difficult-to-treated pigmentary dermatosis. Laser therapy is currently applied in
melasma treatment as a potential therapy since evidence showed its
effectiveness in decline of melasma recurrence (Jang, Lee, Kim, & Kim, 2011 ;
Kroon, Wind, Beek, van der Veen, Nieuweboer-Krobotová, Bos, &
Wolkerstorfer, 2011 ; Wattanakrai, Mornchan, & Eimpunth, 2010). To optimal
the effectiveness of laser therapy, the combination of proper chemical treatment
and laser procedure is a recommended strategy for treatment of melasma
14


(Arora, Sarkar, Garg, & Arya, 2012 ).
1.2. Significance of this research
The Dermatology Hospital in Ho Chi Minh city is the biggest hospital
specializing in treatment of dermatological conditions, including melasma. It is
estimated that about 1,200 patients with pigmentation disorders visited the
hospital in 2013, of those 34% experienced melasma (Dermatology Hospital,
2013). Currently, laser treatment with subsequent sunscreen has been applied
for three years and become a standard procedure in melasma treatment in the

hospital. After a course of laser therapy, patients were counseled to use
sunscreen to prevent the recurrence of melasma and revisit the hospital after
one-month use of sunscreen to check their conditions. Although no official data
about the rate of recurrence among affected patients, many recurrent cases have
been documented in practice. Such situation raises questions involving whether
or not patients used sunscreen after laser therapy, how they applied sunscreen in
their daily life and to what extent they are knowledgeable about melasma and
proper use of sunscreen to protect their body from recurrence of melasma.
Surprisingly, there are not any studies explore this issue in the hospital setting.
To answer all of these questions, I conduct this study.

15


1.3. Aim of this research
The main aim of this study to find out the awareness and behavior related to
sunscreen application among melasma patients who had received laser therapy.
The specific objectives of this study therefore include:
1. Identify knowledge, attitude and behavior regarding sunscreen use among

melasma patients.
2. Identify the relationships between demographic, knowledge and attitudes
and sunscreen use behavior among melasma patients.
1.4. Research questions
What is the knowledge, attitude and behavior of sunscreen use among
patients visiting Demartology Hospital? What are factors that have impacts on
knowledge, attitude and behavior of patients with melasma?
1.5. Chapter summary
Melasma, a localized hyperpigmentation, affects millions of people
worldwide. Melasma has a significant impact on appearance, causing

psychosocial and emotional distress, and reducing the quality of life of the
affected patients. The Dermatology Hospital in Ho Chi Minh city is the biggest
hospital specializing in treatment of dermatological conditions, including
melasma. After a course of laser therapy, patients were counseled to use
16


sunscreen to prevent the recurrence of melasma and revisit the hospital after
one-month use of sunscreen to check their conditions. Although no official data
about the rate of recurrence among affected patients, many recurrent cases have
been documented in practice. Surprisingly, there are not any studies explore this
issue in the hospital setting. To answer all of these questions, this study is
conducted.

17


Chapter 2: Literature Review

2.1. Introduction
In this chapter, definition of melasma was decribed firstly. The second part
introduced epidemiology of melasma including prevalence and risk factors of
melasma worldwide. Management of melasma was the third part mentioned in
this chapter. The final part focused on knowledge, attitude and behavior of
sunscreen use and factors that influence those interested variables.
2.2. Definition of melasma
Melasma is a human melanogenesis dysfunction that results in localized,
chronic acquired hypermelanosis of the skin. It occurs symmetrically on
sunexposed areas of the body, and affects especially women in menacme (Miot,
Miot, Silva, & Marques, 2009).

The word melasma originates from the Greek root “melas”, which means
black, and refers to its brownish clinical presentation. The designations: “mask
of pregnancy”, liver spots, uterine chloasma, chloasma gravidarum, and
chloasma virginum do not fully characterize the disease, nor are semantically
appropriate, although the term “chloasma” (derived from the Latin chlóos and
18


the Greek cloazein: greenish) is still used in the medical literature (Bolanca,
Bolanca, Kuna, Vuković, Tuckar, Herman, & et al, 2008; Miot, et al., 2009).
2.3. Epidemiology of melasma
2.3.1. Prevalence and incidence of melasma
Although there are no data about the global prevalence of melasma, studies
showed a wide variation in prevalence among countries worldwide. A study
from Brazil showed that melasma accounted from 5.9% to 9.1% of
melanodermias in the different regions of the country (Sociedade Brasileira de
Dermatologia SBD, 2006). Another study conducted in Nepal with 546
dermatological patients evidenced melasma as the fourth most frequent
diagnosis and the first most commonly reported pigmentary dermatosis (Walker,
et al., 2008). In addition, a retrospective study conducted in Saudi Arabia, which
analyzed data from 1076 dermatology patients, also described melasma as the
fourth most common dermatosis (Alakloby, 2005). Another study conducted
with 2,000 dermatological patients of black origin in Washington, DC, revealed
that the third most commonly-cited skin disorders were pigmentary problems
other than vitiligo. Of these patients, the majority had a diagnosis of
postinflammatory hyperpigmentation, followed in frequency by melasma
(Halder, et al., 1983) .
19



The incidence of melasma is not precisely known. Changes occurred in
recent decades due to the increase in sun exposure time spent by the population
during leisure and daily activities were not substantiated in studies (Souza,
Fischer, & Souza, 2004).
2.3.2. Risk factors for melasma
It is believed that melasma occurs in all ethnic and population groups;
however, epidemiological studies have reported higher prevalence among more
pigmented phenotypes. Melasma is common among Hispanic-Americans and
Brazilians who live in inter-tropical areas, where there is greater exposure to
ultraviolet radiation (UVR) (Perez, Luke, & Rossi, 2011; Sheth & Pandya,
2011; S. C. Taylor, 2003). Among a Latino population resident in USA,
prevalence of melasma was 8.8%, and 4.0% of respondents reported past
occurrence of melasma (Werlinger, Guevara, González, Rincón, Caetano, Haley,
& et al, 2007).
A clear female predominance was observed in the reports of the disease. An
Indian study found a less significant prevalence (6:1), whereas in Brazil and
Singapore, there was also a clear female predominance: 39:1 and 21:1,
respectively (Achar & Rathi, 2011; Goh & Dlova, 1999; Hexsel, Lacerda,
Cavalcante, Machado Filho, Kalil, Ayres, & et al, 2013). In another study
20


conducted in India, an even greater discrepancy between men and women was
identified: among 120 patients with melasma, 25.8% were men (Sarkar, Jain, &
Puri, 2003).
Melasma occurs more frequently in pregnancy period. A population-based
survey of 855 Iranian women reported among 39.5% respondents with
melasma, 9.5% were pregnant women (Edalatkhah, Amani, & Rezaifar, 2004).
A cross-sectional study in Southern Brazil identified melasma in 10.7% of 224
pregnant women (Hexsel, Rodrigues, Dal'Forno, Zechmeister-Prado, & Lima,

2009). In about 40-50% of the female patients the disease is triggered by
pregnancy or by the use of oral contraceptive. 8% to 34% of women taking
COC (combined hormonal oral contraceptive) develop melasma, which was
also reported after hormone replacement therapy (Wu, Lambert, Lotti,
Hercogová, Sintim-Damoa, & Schwartz, 2012).
Intensity of sun expose may have an impact on the risk of development of
melasma. A study in India showed that the prevalence of melasma among paddy
field workers reached up 41% (Shenoi, Davis, Rao, Rao, & Nair, 2005).
Scheinfeld et al (2007) also concluded that intensity of sun expose plays an
important role in the development of the disease.
Since melasma results from a local change in pigmentation, it preferably
21


affects more strongly melanized phenotypes, and is mainly present in
intermediate skin types III-V (Fitzpatrick classification). In a sample of 302
Brazilian patients, 34.4% had skin type III, 38.4% had skin type IV and 15.6%
had skin type V (Tamega Ade, Miot, Bonfietti, Gige, Marques, & Miot, 2013).
In Tunisia, a survey of 188 women showed that 14% had skin type III, 45% had
skin type IV and 40% had skin type V (Guinot, Cheffai, Latreille, Dhaoui,
Youssef, Jaber, & et al, 2010). It is theorized that individuals with skin type I
fail to produce additional pigmentation, and individuals with skin type VI
already produce it at maximum efficiency; thus, skin types I and VI characterize
phenotypes of stable pigmentation.
2.4. Management of melasma
Melasma has been described as refractory to treatment because there is no
cure and the condition tends to recur in susceptible individuals. The standard
medical management of melasma includes broad-spectrum sunscreens typically
used for prevention and various depigmenting agents, such as hydroquinone
(HQ), tretinoin, azaleic acid, topical corticosteroids, kojic acid, and chemical

peels (Grimes, 1995; Lynde, et al., 2006; Prignano, Ortonne, Buggiani, & et al,
2007).
2.4.1. Sunscreen application
22


Because solar radiation, particularly UVA and UVB, is known to increase
the risk of developing melasma or exacerbating existing disease, sunscreen
products are essential for both prevention and management of melasma
(Grimes, 2007; Pathak, et al., 1986; Scheinfeld, 2007). A broad-spectrum agent,
containing both zinc and titanium (which have peaks of absorption in the UVA
and UVB ranges, respectively), is recommended. The sunscreen should also
have a sun protection factor (SPF) higher than 45. Patients with melasma or
those who are at risk for melasma should be advised to use sunscreen daily,
particularly under conditions of exposure (Grimes, 2007; Lynde, et al., 2006;
Scheinfeld, 2007).
Data from a number of recent trials indicate that corrective use of sunscreen
may also play a role in the management of melasma by improving the patient’s
quality of life and self-image while he or she is undergoing what may be a
protracted course of treatment. Boehncke et al (2002) conducted a pilot study in
which 20 female patients with a range of facial dermatoses (eg, acne, rosacea,
vitiligo) were instructed by a cosmetician in the use of a corrective cosmetic.
The mean index score of quality of life (reduced score indicates improved
quality of life) decreased from 9.2 at baseline to 5.5 at the end of 2 weeks of
makeup use. A similar outcome was observed in a study of 73 women with
23


severe facial pigmentary disorders (eg, melasma, acne, hypopigmentation,
rosacea) (Balkrishnan, McMichael, Hu, & et al, 2005). These patients received

an application of a corrective cosmetic at the initial visit, along with a supply of
the product and instructions on its use. Assessments were conducted at baseline
and at 2-week, 4-week, and 3-month follow-up visits on 63 patients using the
Skindex-16, an evaluative instrument measuring self-reported burden of disease.
At the 3-month end point, there was a 30% improvement in mean Skindex-16
score (P < .001). The corrective cosmetic was well tolerated.
2.4.2. Hydroquinone
Hydroquinone

(1,4-dihydroxybenzene)

is

a

hydroxyphenol;

its

pharmacodynamic action in the context of melasma appears to involve
disruption of melanin synthesis. By inhibiting the action of the tyrosinase
enzyme, HQ prevents the enzymatic oxidation of tyrosine to dopa and, thus, the
subsequent conversion of dopa to melanin. Other proposed effects of HQ in
melasma involve interference with DNA and RNA synthesis, local degradation
of melanosomes, and destruction of proliferating melanocytes (Abramovits, et
al., 2005; Grimes, 1995; Gupta, et al., 2006; Lynde, et al., 2006; Victor, et al.,
2004).
Therapy with HQ at various concentrations (2%, 4%, and 5%) has been
24



described as the gold standard for melasma therapy. Multiple clinical studies
have evaluated the efficacy and safety of HQ (Eespinal-Perez, Moncada, &
Castanedo-cazares, 2004; Glenn, Grimes, Pitt, & et al, 1993; Sanchez, Pathak,
Sato, & et al, 1981). However, side effects can be a concern with HQ, especially
at higher concentrations and particularly because dermatologists may prescribe
higher, extemporaneously compounded concentrations of the agent. Side effects
associated

with

HQ

include

erythema,

dermatitis,

nail

bleaching,

postinflammatory hyperpigmentation, hypopigmentation of normal skin, and
ochronosis, which has been associated with prolonged use of high
concentrations of HQ (Findlay, Morrison, & Simson, 1975; Grimes, 1995;
Jordaan & Van Niekerk, 1991).
2.4.3. Alternative treatments for melasma
Azelaic Acid
Azelaic acid (AzA) is a naturally occurring nontoxic C9 dicarboxylic acid

that has demonstrated substantial biologic activity and pharmacodynamic
properties. Beneficial results have been shown in a range of hyperpigmentation
disorders, including melasma and lentigo maligna, primarily through AzA’s
antiproliferative effects on hyperactive melanocytes and its inhibition of
tyrosinase activity (Glenn, et al., 1993; Grimes, 2007; Gupta, et al., 2006). The
25