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Haemorrhoidal disease is a common presenting anorectal condition. Although its treatment
dates several hundreds of years, there has been no consensus on an optimal treatment
modality. Advances in the understanding of the pathophysiology of haemorrhoids are aiding
clinicians in providing the most appropriate form of treatment. Once more sinister
pathologies have been excluded management strategies are tailored to the individual patient
depending on the severity of the disease. Clinical classification systems are particularlyuseful as a measure of severity. In many patients conservative measures may prove to be
highly effective, but persistence and progression of symptoms may necessitate more
interventional procedures. This article aims to define and classify haemorrhoids, and review
the efficacy of current treatment modalities including the latest techniues.
Introduction
The word !piles" is derived from the #atin word pila, meaning ball. It has traditionally been
the layman$s term for haemorrhoids, for which treatment dates bac% almost &''' years.
Although there are many well recognised precipitating factors associated with haemorrhoids(such as low fibre inta%e, prolonged straining and pregnancy) the precise aetiology remains
unclear, which is certainly reflected in the number of treatment options available. This review
aims to define haemorrhoidal disease both anatomically and clinically and further explain
how this affects subseuent management strategies. The efficacy of the most popular
modalities of treatment is reviewed and a novel surgical techniue is introduced.
Anatomy and Pathophysiology
The concept of anal cushions being the precursors of haemorrhoids was first introduced in
*+- and described in the classical , and ** o$cloc% positions (*). These cushions lie
predominantly above the dentate line and are separated from the sphincter complex by the
submucosal layer / a combination of blood vessels, muscular and connective tissue0 related
to which is the inferior haemorrhoidal plexus which can become engorged at the anal verge.
This is important in distinguishing prolapsing internal haemorrhoids which are lined by an
insensate covering and whose nec% arises above the dentate line, from external haemorrhoids
which arise below this line. The importance of anal cushions lies in part in the maintenance
of faecal continence0 vascular filling is thought to be responsible for approximately 1'2 of
resting anal pressure (1), and the cushions are able to provide a conformable plug to maintain
complete closure of the anal canal. Theories of the aetiology of haemorrhoids are thought by
some to be related to their vascularity and underlying supportive structure. #ocal changes in
pressure are thought to cause venous dilatation in the anal cushions and (along with avalveless venous system) lead to their engorgement, seen in the increased prevalence of
haemorrhoids in pregnancy. The alternative connective tissue theory suggests that the
underlying support provided by the collagenous fibres of the submucosa degenerates over
time and ultimately leads to a caudal displacement of the anal cushions (), perhaps
explaining the phenomenon of haemorrhoidal prolapse.
Figure 1 - Anatomy of the Anal Canal (4)
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Classification
Improved understanding of local anatomy has led to helpful clinical classifications for
haemorrhoids. The product of underlying pathophysiological and anatomic changes, theyallow examination findings to be standardi3ed, and therefore allow the most appropriate form
of treatment to be offered. One such classification is the 4oligher classification, which
describes & clinical entities (-). 4rade I describes a normal appearance externally with
haemorrhoids which bleed but do not prolapse whereas in grade II the haemorrhoids may
prolapse but reduce spontaneously. 4rade III and I5 describe prolapsing haemorrhoids which
reuire manual digital reduction or remain prolapsed permanently, repectively / figure 1.
However, with the increased availability of endoscopy, haemorrhoids are being able to be
visuali3ed during colonoscopic or sigmoidoscopic examination with a retroflexed scope /
figure . This has led to the development of endoscopic classification systems which again
address and closely correlate to the patient$s symptoms (6).
Although this classification is limited by the assumption of bleeding and prolapse being the
only symptoms attributed by haemorrhoids, it still has an important place in the management
of the condition when used in con7unction with the wider clinical picture.
Figure 2 oligher Classification of !aemorrhoids"
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Figure # $etrofle%ed colonoscope sho&ing internal 'ie& of haemorrhoids
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he Clinical Picture
Haemorrhoids affect between &2 and 62 of the general population (), however this figure
is indicative only of symptomatic haemorrhoids and may well be an under8estimate. Hospital8
based proctoscopy studies have shown prevalence rates of up to 962 with the ma7ority of
patients being asymptomatic. (9) :ymptoms are widely variable, but haemorrhoids are
responsible for the ma7ority of cases of rectal bleeding. The most common symptoms after
bleeding include pain, mucous discharge and pruritus with or without associated
haemorrhoidal prolapse (+). The colour of the bleeding is attributed to the arterial oxygen
tension caused by arteriovenous communications within the anal cushions (*'), while pruritis
and associated discomfort is thought to be due to prolapse of the rectal mucosa leading to
deposition of mucus on the perianal s%in. The combination of type and severity of symptoms
in addition to examination findings, allows the most appropriate treatment modality to be
offered.
It is paramount not to attribute all cases of bright red rectal bleeding to haemorrhoids0Conditions from anal fissure to colorectal malignancy may all produce similar symptoms and
concurrent pathology must be excluded with investigation of the proximal colon, which in
most cases is performed by sigmoidoscopic or colonoscopic investigation. Also,
haemorrhoids are rarely responsible for anaemia (**).
he reatment adder
Classification systems, such as the one described above, allow standardisation of the
condition and can also monitor progression. Once a patient has been satisfactorily
investigated, the surgeon is in a position to offer the most appropriate treatment. As
haemorrhoids are essentially a benign condition, treatment is directed at alleviating symptoms
rather than to necessarily halt progression. ;ost surgeons have traditionally adopted a step8
wise approach in treatment depending on the severity of symptoms and clinical grading of the
haemorrhoids, with escalation if necessary. /
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Conser'ati'e +anagement
Conservative management is usually reserved for the minimum of symptoms and grade I orgrade II haemorrhoids. >y addressing some of the precipitating factors, they may well
prevent the need for further intervention. It essentially involves lifestyle modification and
dietary advice as well as medical treatment. :ome have suggested that constipation may be a
precipitating factor in the development and progression of haemorrhoids and the lower
incidence of the condition in populations with high dietary fibre inta%e may add weight to
this theory (*1), although this is never been proven definitively, and others have eually
proposed that haemorrhoids may actually lead to constipation (*). Adeuate fluid and fibre
inta%e may reduce straining effort during defaecation, along with laxatives, but may well also
prevent recurrence of haemorrhoids. A recent meta8analysis of fibre supplementation showed
that the ris% of bleeding was lower with an increased fibre inta%e, along with the rate of
recurrence (*&). #) and in7ection sclerotherapy, although cyrotherapy and
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photocoagulation are potential options.
Figure .on-conser'ati'e reatments
?># has been modified over the years from >laisdell$s original description (*6) which
advocated the application of a single band alone. Currently, surgeons may apply up to
bands at a time and can repeat this every 6 wee%s or so. The techniue involves the direct
visualisation of the haemorrhoidal pedicle through a proctoscope, with application of a band
around it using either forceps or a suction device. This results in ischaemic necrosis of the
haemorrhoidal tissue which subseuently auto8amputates. It is important to warn patients that
they may experience some bleeding after *'8*& days when the banded tissue sloughs off.
:uccess rates of between 6+2 and +&2 have been shown (*) with low complication rates,
although there have been potentially life8threatening complications reported. =ith higher
success rates than other office procedures, it is still deemed to be less efficient than
haemorrhoidectomy in the long term, albeit with less pain and fewer complications.(*9)
?ecent evidence suggests that in fact most patients complain of moderate or worse
discomfort after banding (*+).
In7ection sclerotherapy is a widely available techniue, the most common sclerosant being
-2 phenol in almond oil, and is particularly useful for bleeding piles. The sclerosant induces
an inflammatory reaction causing changes both in the haemorrhoidal mass and affecting the
underlying architecture. Haemorrhoids are again identified by proctoscopy and then in7ected
well above the dentate line. As long as the in7ections are appropriately directed there is no
pain experienced by the patient. Although this is a seemingly easy, reproducible procedure,there are as many reported problems with it as advantages. High failure rates accompanied by
misplaced in7ections have led many surgeons to abandon this office procedure.
There are certain contraindications for banding and in7ecting piles such as patients being on
formal anticoagulant medication and coagulopathies, but there are no guidelines discouraging
the use of a combination of procedures under these circumstances. One large study has shown
that by using a combination of sclerotherapy, rubber band ligation and infrared coagulation
over a period of 1 months on average, satisfaction rates of around +'2 were achieved with
less than *'2 reuiring surgical intervention. (1')
Cyrotherapy appears to have fallen out of favour. =ith the use of a specialised probe, thehaemorrhoidal mass is ablated, and can be repeated over time. @otential problems include
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ulceration and discharge as a conseuence of impaired healing following application of the
cyro8probe. (1*)
@hotocoagulation reuires the use of specific infrared optical euipment. The procedure is
similar to sclerotherapy in that direct visualisation of the haemorrhoid with a procotscope is
reuired. Once the coagulator device is primed, the base of the haemorrhoidal tissue istargeted and necrosis ensues. The subseuent healing of the mucosa leads to shrin%age of the
piles and ulcer formation. It has been most commonly used for internal haemorrhoids and has
been shown to be a superior techniue to sclerotherapy with fewer complications (11).
*urgical ,ptions
/%cision !aemorrhoidectomy
Haemorrhoidectomy has remained the centre of all the surgical procedures for symptomatic
haemorrhoids of high grade or those failing office procedures. Although the exact details ofthe operation and its variants are beyond the scope of this review, haemorrhoidectomy has
been shown to be the most effective treatment for haemorrhoids (1). Originally described by
=hitehead in the late part of the *+th century, its modification, the ;illigan8;organ
operation (1&) was later reserved for prolapsing haemorrhoids of grade III and I5. This
involves excision of the internal and external components of each haemorrhoid, leaving the
s%in open in a 8leaf clover pattern and allowing healing to occur by secondary intention.
Over the years newer, more efficient surgical procedures have been developed with the
operation being performed with either an open (as described above) or closed techniue
where the haemorrhoid component is excised and the wounds closed primarily (1-). The
theory behind the closed or oulder) haemorrhoidectomy are also varieties of operation
which have the common theme of excising haemorrhoidal tissue, the latter using a specialised
surgical instrument to minimise tissue trauma and confer faster wound healing. At present the
#iga:ureT; haemorrhoidectomy has been shown to more efficacious than conventional
haemorrhoidectomy (1).
Bnfortunately, complication rates have traditionally been higher in surgery than office
procedures with post8operative pain being the most common, though this is not necessarilythe case with newer techniues (19). A number of trials have attributed this to be the main
factor preventing patients from an early return to normal life, and have suggested time8frames
of between 1 and & wee%s before patients return to wor% (1+8*). Other complications include
urinary retention, sepsis, incontinence and anal stenosis (1, ).
Figure 0 Photograph of +illigan-+organ !aemorrhoidectomy (#4)
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*tapled Anope%y
This procedure has recently gained a reputation for being the 4old8standard for prolapsed
haemorrhoids (grade III and I5) with encouraging results regarding postoperative recovery
and comparable complication to traditional haemorrhoidectomy (-).
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3oppler-uided !aemorrhoidal Artery igation (3-
!A)
The newest treatment modality which is gaining considerable popularity is oppler8guided
haemorrhoidal artery ligation. Although essentially a surgical procedure, it is far lesstraumatic than traditional surgical options and does not involve the excision of haemorrhoidal
tissue and their associated complications. This techniue was first described more than
decade ago and involves the use of a specialised proctoscope coupled with a oppler probe
(&-). It can be performed with or without general anaesthesia depending on the patient and
clinical circumstances. It has been performed on grades II8I5, but is thought to be most
useful for grades II and III. The procedure wor%s on the principle that arterial flow through
local arteriovenous anastamoses maintains the haemorrhoidal mass. #igating these vessels
ultimately leads to haemorrhoid shrin%age with conseuent reduction and cessation of
bleeding.
Figure Cast of haemorrhoid &ith arterial supply displayed (40)
Bsing the proctoscope to identify terminal branches of the superior rectal artery and
haemorrhoidal artery, the vessels are subseuently ligated by placing haemostatic sutures
(
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An even newer techniue which aims to act on grade I5 haemorrhoids with rectal mucosaprolapse is the 48HA# recto8anal repair (?A?). It uses the same method as 48HA# but
additionally applies a vertical running suture which retracts the prolapsed mucosa. There are
no large series$ published on this treatment, however it could be potentially a rival to stapled
anopexy.
he Future
The resurgence in the treatment of haemorrhoids has led to the introduction of more efficient
variants of traditional techniues and novel surgical procedures all aimed to increase efficacy,
reduce complications and promote better healing and higher satisfaction. =ith greater
understanding of the anatomy and pathophysiology of the condition, it may be possible to
limit treatment to a few interventions relating directly to an appropriate classification system.
It is highly improbable that there will be one all8encompassing optimal treatment modality
for haemorrhoids, as the condition represents a spectrum of severity. However, the important
message is that whichever treatment is used, it must be safe and efficient.
?D, @enninc%x
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and in vitro study in man. Int E Colorectal is. *+9+F &0 **98*11.
/ Haas @A, 4. Dvaluation of anaemia caused by hemorrhoidal bleeding. is
Colon ?ectum. *++&F 0 *''68.
*1 / >ur%itt @. 5aricose veins, deep vein thrombosis and haemorrhoidsF Dpidemiology and
suggested aetiology. >;E. *+1Fii0 --68-6*.
* / Eohanson Elaisdell @C. Office ligation of internal haemorrhoids. American E. of :urg. *+-9F +60
&'*8&'&.
* / >at #, ;el3er D, Goler ;, re3nic% . Complications of rubber band ligation of
symptomatic internal haemorrhoids. iseases of Colon and ?ectum. *++F 60 1981+'.
*9 / :hanmugam 5, Thaha ;A, ?abindranath G:, Campbell G#, :teele ?EC, #oudon ;A.
?ubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane
atabase of :ystematic ?eviews 1''-. Issue *, Art oF C''-'&.
*+ / =atson
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operative treatment of haemorrhoids. #ancetF *+0 10 ***+8**1&.
1- / occasanta @, Capretti @4, 5enturi ;, Cioffi B, e :imone ;, :alamina 4, Contessini8
Avesani D, @eracchia A. ?andomised controlled trial between stapled circumferential
mucosectomy and conventional circular hemorrhoidectomy in advanced hemorrhoids with
external mucosal prolapse. Am E :urg. 1''*F *910 6&869.
1 / :enagore A, ;a3ier =@, #uchtefeld ;A, ;acGeigan E;, =engert T. Treatment of
advanced hemorrhoidal diseaseF a prospective, randomised comnparison of cold scalpel vs.
contact dFLA4 laser. is Colon ?ectum. *++F 60 *'&18*'&+.
/ evien C5, @u7ol E@. Total circular hemorrhoidectomy. Int :urg. *+9+F &0 *-&8.
& / Appearance immediately after pile removal. Eeremy #ivingstone$s :urgical @age, 1''.
JOnlineK Available at www.livingstone.demon.co.u%Mimg1+.7pg. Accessed 'M'*M1''
- / :utherland #;, >urchard AG, ;atsuda G, :weeney E#, >o%ey D#, Childs @A. A
systematic review of stapled hemorrhoidectomy. Arch :urg 1''1F *0 *+-8*&'6.
6 / #ongo A. Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal
prolapse with a circular stapling deviceF a new procedure. @roceedings of the 6th =orld
Congress of Dndoscopic :urgery, Eune , *++9. ;undo33i Dditore, *++9.
/ g G8H, Ho G8:, Ooi >:, Tang C#, Du G=. Dxperience of ** stapled
haemorrhoidectomy operations. >r E of :urg. 1''6F +0 11681'.
9 / ;ehigan >E, ;onson E?, Hartley ED. :tapling procedure for haemorrhoids versus
;illigan8;organ haemorrhoidectomyF randomised controlled trial. #ancet. 1'''F --0 918
9-.
+ / ?owsell ;, >ello ;, Hemingway ;. Circumferential mucosectomy (stapledhaemorrhoidectomy) versus conventional haemorrhoidectomyF randomised controlled trial.
#ancet. 1'''F --0 +89*.
&' / Ho LH, Cheong =G, Tsang C, et al. :tapled hemorrhoidectomy / cost and
effectiveness. ?andomised controlled trial including incontinence scoring, anorectal
manometry, and endoanal ultrasound assessments at up to months. is Colon ?ectum.
1'''F &0 *6668*6-.
&* / Dsser :, Ghubchandani I, ?a%hmanine ;. :tapled hemorrhoidectomy with local
anaesthesia can be performed safely and cost8efficiently. is Colon ?ectum. 1''&F &0 **6&8
**6+.
&1 / ?ipetti 5, Caricato ;, Arullani A. ?ectal perforation, retropneumoperitoneum, and
pneumomediastinum after stapling procedure for prolapsed hemorrhoidsF report of a case andsubseuent considerations. is Colon ?ectum. 1''1F &-0 1698'.
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& / ;aw A, Du G=, :eow8Choen , :hetty , #indsey I, ;ortensen E, =arren >ritish Haemorrhoid Centre 1''. Cast of a haemorrhoid. JOnlineK Available at
www.halocentre.comMwhatishalo.html. Accessed 'M'*M'
& /
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Mandi di bak mandi dengan air hangat,biasanya dapat mengurangi rasa sakit
di perianal.0al ini mungkin karena air hangat dapat merelaksasai meksnisme
spinkter dan spasme.1ebuah literatur menyebutkan, kompres es dapat
menguragi nyeri akibat thrombosis akut.1ebagian besar pasien melihat adanya
perbaikan atau resolusi komplit dari gejala-gejala yang mereka alam, dengan
tindakan konservasi! di atas. Pengobatan diarahkan hanya pada gejala dan
bukan penampakan hemoroid.
"ika pasien mengeluhkan nyeri hebat, kemugkinan ia menderita hemoroid
ekternal akibat thrombosis.2ni biasanya membaik dalam 3-)* hari, tetapi jika
tetap terasa sakit da luar periode tersebut, bisa di lakukan eksisi untuk
menghilangkan thrombus. Penggunaan dressing penekan, bisa menjadi pilihan
pengobatan.
Pengobatan Farmakologis
Pengobatan !armakologis non spesi!ik meliputi laksati!, analgesik,
antiin!lamasi dan obat-obatan topikal#mengandung anatesi local dan
steroid$.1ementara obat-obatan spesi!ik untuk hemoroid #agen phlebotropik$
yang ada saat ini adalah !lavonoid, mencakup micronised diosmin dan
hesperidin dan hidrosomin. Obat-obatan ini secara signi!ikan menurunkan gejala
dan mencegah terjadinya rekurensi.%ahkan sebuah studi menemukan,
pemberian diosmin dan hesperidin sama e!ekti! dengan rubber band ligation,
dengan e!ek samping yang lebih kecil.
Laksatif
4aksati! dalam bentuk serat dapat membantu menguragi gejala hemoroid,
terutama perdarahan. 1ebuah tinjauan dilakukan P.&lonso dan ka(an-ka(an
terhadap tujuan hasil penelitan melibatkan 35 pasien, yang secara acak dibrri
serat atu non serat.Meta analisa ini menunjukan, laktasi! dalam pengobatan
hemoroid simtomatik.
Diosmin-Hesperidin
Keduanya biasa di!omulasi sebagai micronized purified flavonoid fraction
#MP66$ unik, yang mengandumg 7*8 diosmin dan )*8 hesperidin. 0esperidindiektrak dan genus citrusdengan spesies Rutaceae aurantieae,suatu tipe jeruk
kecil yang biasa ditemukan di daratan 1panyol, &!rika tara dan
9hina,sementara diosmin yang merupakan senya(a !lavonoid diperoleh melalui
proses sintesa, mulai dari bahan baku.
Melalui mikronisasi, kedua bahan akti! tersebut mengalami proses
penggilingan dengan teknologi tinggi. 1ebuahjet of air at supersonic velocities
mampu mengurangi ukuran partikel standar dari 3:m, hingga kurang dari
;:m.&kibatnya, penyerapan keduanya jadi lebih cepat dan lebih baik, sehingga
bisa meningkatkan bioavailabilitas. 2mplikasinya tentu mengarah pada e!ikasi
klinis yang lebih cepat dan superior.
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Kedua senya(a tersebut memiliki mekanisme kerja yang unik. 4ayaknya
noradrenalin, obat ini mengakibatkan kontraksi vena,menurunkan ekstravasasi
dari kapiler dan menghambat reaksi in!lamasi terhadap prostaglandin terhadap
prostaglandin #P
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%anyak obat bebas yang bisa di gunakan untuk mengobati hemoroid. 2ni
biasanya obat yang sama yang digunakan untuk mengatasi gejala anal, seperti
gatal atau tidak nyaman. %eberapa penelitian menunjukkan, obat-obatan ini
tidak berdampak pada hemoroid, hanya menurunkan gejala hemoroid.
Produk-produk yang digunakan untuk pengobatan hemeroid tersedia dalambentuk ointments, creams, gels, suppositories, !oams dan pads.1aat digunakan
pada anal canal, produk-produk ini dimasukkan dengan jari atau suatu pipa.
1ebelum dimasukkan, pipa harus diberi pelumas.
Protektan
Proktetan mencegah iritasi daerah perianal dengan membentuk barier !isik
pada kulit, yang mencegah kontak kulit yang teriritasi dengan cairan atau
kotoran yang berpotensi memperburuk kondisi.%arier tersebut menurunkan
iritasi, rasa gatal, sakit dan rasa terbakar.
Protektan meliputi@
&luminium
9ococa buter
inc oide atau calamine #yang mengandung Ainc oide$ dalam konsentrasi
sampai ;+8
Astrigents
&strigents menyebabkan koagulasi protein dalam sel kulit perianal ataulapisan kanal anal. 0al ini menyebabkan kulit kering, yang pada akhirnya
membantu mengurangi rasa terbakar, gatal dan sakit.
&strigents meliputi@
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9alamine +-;+8
>inc oide +-;+8
Witch haAel )*-+*8
Antiseptik
&ntiseptik menghambat perkembangan bakteri dan organisme lain. %elum jelas,
apakah antiseptik lebih e!ekti! dari sabun dan air.
9ontoh antiseptic meliputi@
%oric acid
0ydrastis
Phenol
%enAalkonium chloride
9etylpyridinium chloride
%enAenthorium choloride
Resorcinol
Keratolitis
Keratolitik adalah kimia yang menyababkan lapisan terluar kulit atau jaringan
lain mengelupas.&lasan digunakan obat ini, agar obat-obatan yang digunakan
pada anus dan daerah perianal dapat masuk ke jaringan yang lebih dalam. 'ua
agen keratolitik yang disetujui 6'& adalah@
&lumunium chlorhydroy allantoinate *,;-;,*8
Resoncinol )-8
Anlgesik
Produk-produk analgesik, seperti produk anatesi, menguragi rasa sakit, gatal
dan terbakar dengan menekan reseptor dari sara! rasa sakit.
9ontoh analgesik@
Menthol *,) B ),*8 #lebih besar dari ),*8 tidak dianjurkan$
9amphor *,) B 8 #lebih besar dari 8 tidak dianjurkan$
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"uniper tar ) B +8
Kortikosteroid
Kortikosteroid menentukan in!lamasi dan mengurangi rasa gatal. "ika
digunakan berkepanjangan , bisa menyebabkan kerusakan permanen pada kulit.