INFLAMASI PADA KULIT DAN KELAMIN (BUKAN KARENA INFEKSI) dr.

Imam Budi Putra, MHA, SpKK

DEPARTEMEN ILMU KESEHATAN KULIT DAN KELAMIN FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA RUMAH SAKIT H. ADAM MALIK MEDAN 1 2008

LICHEN PLANUS
LP : Akut atau kronis, inflamasi dermatosis pada kulit, selaput lendir dan genitalia. Gambaran , p g lesinya 4P (Papul, Purple, Polygonal, Pruritic).
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Onset : 30 60 tahun Perempuan > Laki-laki (Laki-laki = Perempuan) Etiologi : ? Hipotesis : Virus, berdasarkan :

Pada pemeriksaan hispatologis; pada epidermis menyerupai gambaran yang disebabkan oleh virus. Mikroskopik elektron : elemen elemen elemen-elemen virus.

Gambaran Klinis Lesi Pertama pada LP L iP t d Mulai ditungkai dan lengan Paling banyak : fleksor pergelangan tangan dan lengan bawah. bawah.
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Lesi Kulit Khas

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Papula, poligonal Papula poligonal, permukaan rata berkilat, pada puncaknya ditemukan cekungan cekungancekungan (Delle) Pada permukaan papula p p p dapat terlihat garis-garis anyaman berwarna putih yang disebut Wickem striae. (Tampak lebih jelas bila permukaan k li k kulit dibersihkan dengan minyak dan diamati y dengan kaca pembesar)

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Warna papula pada permukaan merah merah, kemudian cepat berubah menjadi ungu atau kemerahan. kemerahan
Dijumpai fenomena phenomena. phenomena isomorfik atau Koebner :

Lesi-lesi yang sudah menyembuh hiperpigmentasi atau hipopigmentasi (tanda khas). Lesi dikulit bertahan 1 2 tahun

Lesi di selaput lendir masih bertahan beberapa tahun sesudah lesi dikulit hilang.
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Lesi di selaput lendir Lesi-lesi d selaput l d memberi gejala kh Lesi-l di l lendir b l khas di mukosa mulut (buccal), lidah, bibir, faring dan seluruh saluran pencernaan. pencernaan.
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Lesi Genitalia Pada Pria : Penis ; papula anular atau striae putih
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Pada Wanita : Vagina dan vesika urinaria : gambar retikular serupa jala yang terdiri atas garis-garis garisputih atau striae abu-abu. abu-abu.
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Kuku Adanya kelainan 10% (Samman) 10% Kulit Kepala Papul folikuler
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alopesia sikatriks

Keluhan Subjektif :
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Sangat gatal (LP hipertrofik) Selaput l di : rasa t b k S l t lendir terbakar pada d d daerah h mulut Timbul erosi sakit

VARIASI GAMBARAN KLINIK

I. I

Variasi bentuk Bentuk Anuler

Pada 10% penderita LP Papula membentuk gambaran cincin Dapat juga terbentuk dari penyebaran ke pinggir, penyembuhan ditengah lesi LP khas Pada l P d glans penis i
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Bentuk Linier

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Jarang Papula papula berjejer dalam satu garis d l t i gambaran b zoster

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II. II. Variasi Lokalisasi

Selaput Lendir

Mukosa buccal, lidah, bibir, palatum, tonsil dan faring paling sering Dapat juga : Sal cerna (Lambung anus) Mukosa vagina, kandung kencing, laring, conjunctiva Efloresensi : Jaringan serat atau garis-garis putih atau garis garis abu-abu, berkelompok atau sendiri. Lesi selaput l d 2/3 k l lendir / kasus

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 Genitalia 25% kasus k terjadi t j di pada d genitalia laki-laki yang paling sering : glans penis Papula (khas) : Anular atau linier (Putih) Di vulva dan vagina sama seperti lesi pada selaput lendir. Kuku Timbul setelah beberapa minggu lesi di kulit Permukaan k k k P k kuku kasar d dan menipis, warna coklat penghancuran dan atrofi Tanda penting LP (walaupun di kulit belum ada)

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The image cannot be display ed. Your computer may not hav e enough memory to open the image, or the image may hav e been corrupted. Restart y our computer, and then open the file again. If the red x still appears, y ou may hav e to delete the image and then insert it again.

Kepala

Lesi berbentuk papula folikuler alopesia sikatriks dan liken pilaris.

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III. III. Variasi Morfologi Hipertrofik

Lesi plak verukosa berwarna merah coklat dan ungu cruris anterior
Folikuler

Papula-papula Papula papula seperti duri pada kulit selaput kulit, lendir dan kulit kepala trias liken plano p pilaris
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 Vesikulo - Bulosa

Bentuk vesikobulosa >> Timbul pada tempat bekas atau sedang terdapat LP Bentuk bula <<, tegang Pada kulit normal atau pada bekas lesi LP dan selaput lendir mulut
Erosif dan Ulseratif

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Erosif
Atrofi

ulcus : selaput lendir

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Jarang g Bersama bentuk yang lain

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 Degenerasi Maligna Pada bentuk hipertrofik p karsinoma epiderma Oleh karena iritasi menahun, pengobatan oleh arsen sinar X arsen, X. Aktinik

trauma,

Papul kecoklatan (menyerupai granuloma anulare) Pada usia muda, di daerah tropis, sub tropis Gejala ringan atau tanpa gejala
Eritematos Papul lunak, eritem tanpa gatal Kadang-kadang tidak ada hubungan dengan g g g g LP yang sesungguhnya, tapi pada gambaran histopatologis khas LP.

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PEMERIKSAAN LABORATORIUM
Pemeriksaan d h tid k banyak menunjang P ik darah tidak b k j Jumlah leukosit dan limposit menurun

PEMERIKSAAN HISTOPATOLOGI
Epidermis : hiperkeratosis, akantosis tidak teratur, p p , , penebalan stratum granulosum, degenerasi mencair membrana basalis, hilangnya stratum basalis, degenerasi keratinosit (Colloid Civatte bodies) (Colloid, Dermis : Sel infiltrat padat, menyerupai pita yang terdiri dari sel limfosit dan histiosit. histiosit. Bentuk Bula : pemisahan antara epidermis dan dermis Bentuk Atrofi : Epidermis menipis. menipis.
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Bentuk folikuler : Sel-sel infiltrat di sekitar Selfolikel rambut menghancurkan folikel rambut Lesi di selaput lendir : Tidak hiperkeratosis atau hipergranulomatosis. hipergranulomatosis. Pada lesi yang lama : bagian atas dermis : melano fag >> Gambaran khas LP : pita lebar lurus yang terdiri dari fibrin dan fibrinogen pada epidermal dermal juntion Pemeriksaan immunofluorescence langsung : Deposit fibrin di junctional dan IgM, sedikit IgA, IgG dan C3 di Colloid Bodies
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DIAGNOSIS
Diagnosis ditegakkan berdasarkan : gambaran klinis LP atau variannya yang khas, ditunjang y y g j g dengan pemeriksaan histopatologi BahanBahan-bahan yang dapat menimbulkan erupsi y g p p seperti ini adalah : emas, streptomisin, tetrasiklin, arsen, merkuri, yodida, quinakrin, dan klorokuin. klorokuin. Lichen planus liken eruption tidak dapat dibedakan secara klinis dan histopatologis, dari liken planus. planus.

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DIAGNOSIS BANDING
Kulit 1. Psoriasis 2. Granuloma anulare 3. Nevus unius lateralis 4. Liken striatus Mukosa 1. Leukoplakia 2. Kandidosis oral 3. Lupuseritematosis 4. Sifilis II
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Genitalia 1. Psoriasis 1 P i i 2. Dermatitis seboroika 3. 3 Skabies 4. Herpes genitalis Bentuk Hipertrofik 1. Neuro Dermatitis 2. 2 Liken amiloidosis 3. Sarkoma kaposi Bentuk Folikuler 1. Liken spinulosis 2. 2 Liken nitidus
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Bentuk Atrofi (Kepala Muka) (Kepala,

1. 2. 2 3.

Lupus eritematosus Folikulitis Skleroderma

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PENGOBATAN
Topical Glucocorticoids occlusive pada lesi Intralesi triamcinolone 3 mg/ml lesi mukosa mulut dan bibir Cyclosporine dan tacrolimus solution mouthwash ( l LP) th h (oral Asam vitamin A (Asam retinoat 0,05%) S t Systemik ik Cyclosporine 5 mg/kg BB per hari kasus yang resisten dan general. Glucocorticoids : oral prednisone dosis inisial 70 mg tapering 5 mg Systemic retinoid (Acitretius) 1 mg/kg per hari (oral LP, hipertropi LP)
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 PUVA Photochemoterapy General LP atau k G l t kasus yang resisten d i t dengan obat b t topikal
M Mycophenolate mofetil, H h l t f til Heparin (E i (Enoxaparin) i )

Immunomodulator, Azathiophrine

PROGNOSIS
Beberapa dapat sembuh sendiri Dapat sembuh 1 2 tahun berlanjut 5 10 tahun Tergantung bentuk dan luasnya Kambuh 10 20% dari kasus 20% Pengobatan yang cepat dan tepat dapat g y g p p p memberikan penyembuhan
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(Lichen Sclerosus et atrophicus)

Kelainan kulit Anogenital, chronis, atrophic Etio : ? DNA : Borrelia Spp (Jerman, Jepang) PNA : Sporochetes (USA) p ( ) Perempuan >> 10x dari laki-laki 10x lakiDewasa >> (A k 1 13 t h ) D (Anak tahun)

LICHEN SCLEROSUS

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Gambaran Klinis :
Papul berwarna putih ivory atau putih porceline Permukaan meninggi atau gg datar, verocous Papul dapat berkonfluen membentuk plaque Pada lesi yang sudah lama depressed Dilatasi pilosebaceous atau kelenjar keringat (Keratin plugs / delle) Gambaran karakteristik : Bula, erosi, purpura, tellangiectasia. tellangiectasia.
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Pada vulva; plaque hyperkeratotic vulva; erosi maserasi vulva atropi khususnya clitoris dan labia minora ukuran introitus vagina berkurang (mengecil) Terjadi fusi labia minora dan mayora
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Pada laki-laki yang tidak sirkumsisi di daerah lakipreputium/frenulum papulpapul-papul konfluen warna putih ivory sclerotic Glans : putih ivory atau putih porceline, purpura hemoragic g
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Lesi pada vulva menjadi sensitif ketika berjalan : pruritus, pruritus sakit (erosi) dysuria dyspareunia (erosi), dysuria,
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Pada laki-laki lakiphimosis

rekuren

balanitis, balanitis

Acquired
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Pada perempuan yang lebih muda dapat terjadi resolusi Pada perempuan yang lebih tua p p y g Pada laki-laki lakiVulva dan V l d penis i phimosis squamous cell carcinoma ll i atropi vulva p

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Histopatologi : infiltrasi lymphocytic atropic epidermis lymphocytic, dermis. dermis. Sebahagian epidermis edematous, sub epidermal zone tidak terstruktur Adanya serabut k l d b kolagen yang h homogen pada d papiladermis
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Pengobatan : Tidak ada pilihan terapi khusus Topikal : - Poten glucocorticoids (Clobetasol Propionate) 6 8 minggu - Monitor tanda-tanda tandaglucocorticoid induced atrophy - Pimekrolimus atau takrolimus - Topical androgen << (Hypertrophy clitoris) (H t h lit i )
Systemik y

: - Hydrochloroquine : 125 150 y q mg/hari untuk beberapa minggu bulan (monitor efek samping pada mata) Pada laki-laki : sirkumsisi laki31

GRANULOMA ANNULARE
GA : Self limited, asymtomatic, chronis pada dermis de mis (lokal : tidak ada tanda-tanda kelainan tandasecara internal diseases) papulpapul-papul annulare Pada dorsum manus, kaki, siku, dan lutut kadangkadang-kadang bisa generalisata. generalisata. Pada anak dan dewasa muda Perempuan : laki-laki = 2 : 1 lakiEtiologi : ? Immunologios : Mediated necrotizing inflammation pada pembuluh darah
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Gambaran Klinis : Papul d P l dan plaques (1 l 5 cm), annular, arciform plaques dan penekanan di tengah Seperti warna kulit kulit, violaceous, erytematous Subcutaneous GA (jarang) : tidak sakit, seperti warna kulit kulit, soliter atau multiple nodulus, deep dermal atau subcutaneous. subcutaneous.

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Distribusi : Lesi tunggal : Dorsum manus

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Lesi multiple : Ekstremitas dan punggung atau generalisata

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Lesi subcutaneous : dekat sendi, telapak tangan dan telapak kaki

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Variasi Klinis : Lesi perforasi GA dengan nekrobiosis dengan lipoidica GA f fascia, tendon d sclerosis l GA generalisata bersamaan dengan DM Differential Diagnosis : Lesi Papula dan plaques p p q Lichen planus Papular sarcoid Necrobiosis lipoidica Lymphocytic infiltrate of Jessner
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 Subcutaneous Nodules

Reumatoid Noduls Atau yang mempunyai kemiripan pada pemeriksaan patologi dari GA rheumatic nodul GA, atau rhematoid nodul
Lesi Anular

Tinea (T. corporis), E th Ti (T. i ) Erythema migrans i (cutaneous larva migrans), sarkoid, lichen p planus. planus.

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Pemeriksaan Laboratorium : Histopatologi : Focal chronic inflamasi dan histiocytic infiltrasi pada superfisial dan mid dermis dengan necrobiosis dari connective tissue yang dikelilingi oleh dinding pallisade histiocytes dan multi nucleated giant cells. l t d i t cells. ll
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Pengobatan : Topical glucocorticoid Cryospray PUVA photochemoteraphy GA generalisata occlusif Injeksi Intralesi triamsinolon : 3 mg/ml

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TERIMA KASIH
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