Anindya K Zahra
dr. Chakti Ari Swastika
dr. Erwin Nugraha
dr. Fabiola
dr. Vera Dewanto
dr. Garnisa Arsyi Aotearoa
Lapisan kulit
Efloresensi
Kelainan kulit yang dapat dilihat dengan mata telanjang
(secara obyektif)
Primer Sekunder Khusus
Makula – Patch Skuama Burrow
Papula – Plaque Eksoriasi Komedo
Nodul Likenifikasi Milia
Urtikaria Krusta Delle
Vesikel – bullae Fisura Purpura
Pustula Erosi Teleangiektasis
Kista Ulkus Hiperkeratosis
Fistula
Fibrosis
Gangren
Skar (atropik,
hipertropik, keloid)
Deksripsi UKK:
UKK primer, UKK sekunder, warna, batas, bentuk, ukuran, jumlah susunan,
distribusi
Perubahan warna kulit
Makula <1 cm
Patch >1 cm
Penonjolan kulit
Papula <1 cm Plaque >1 cm
Nodul
peninggian kulit batas jelas dengan ukuran >0,5 cm terdapat di
dermis dan subkutis
Urticaria & Angioedema
Plaque edematosa (wheals) hasil dari degranulasi sel mast dan
hiperpermeabilitas mikrovaskular dermis. Gatal.
Urticaria Angioedema
Vesikel <1 cm
Bula >1 cm
Kista
Penonjolan kulit berisi nanah
Pustula
Skuama Ekskoriasi
pengelupasan stratum korneum kerusakan kulit sampai ujung
epidermis stratum papilaris sehingga kulit
tampak merah disertai bintik-bintik
perdarahan
Jenis-jenis skuama:
• pitiriasiformis (halus)
• psoriasiformis (berlapis-lapis)
• iktiosiformis (seperti ikan) Ditemukan pada:
• kutikular (tipis) • dermatitis kontak
• lamellar (berlapis) • ektima
• membranosa atau eksfoliativa (lembaran-
lembaran)
• keratorik (terdiri epidermis)
Krusta tumpukan cairan yang mengering / kerak /
keropeng di atas permukaan kulit
Diskontinuitas jaringan
Fistula : hubungan
abnormal antara dua
tempat yang berepitel
Milia Comedo
White head Black head
Cervicitis GO Herpes
genitalis
Uretritis GO LGV
Cervicitis
NGO Ulkus Molle
(Chancroid)
Trikomoniasis
Condyloma
Acuminata
Ulkus Durum
Bakterial (Sifilis)
vaginosis
Uretritis NGO Ulkus*
Granuloma
Candidiasis Inguinale
vaginitis (Donovanosis)
Duh Tubuh Vagina
CERVICITIS → lihat duh tubuh uretra
• GO
• NON-GO
VAGINITIS
• TRIKOMONIASIS
• BAKTERIAL VAGINOSIS
• CANDIDIASIS VAGINITIS
A. Trikomoniasis
• Kausa: Trichomonas vaginalis
• Inkubasi: beberapa hari-4 minggu
• Klinis:
– Sekret homogen, banyak, purulen,
berbusa, warna kuning-hijau, bau
busuk
– Radang dan nyeri pada vulva &
vagina (+)
– pH vagina >4,5
– Cervix strawberry appearance
– Sediaan basah (larutan NaCl
fisiologis)
• flagelata (trichomonas) motil
B. Bakterial Vaginosis
• Kausa: Gardnerella vaginalis
(tersering)
• Inkubasi: Beberapa hari-4 minggu
• Klinis:
– Sekret homogen, putih keabuan,
tidak terlalu banyak, melekat pada
dinding vagina, tanda radang (-), bau
amis (esp setelah senggama)
– pH>4,5
– Sediaan basah (larutan KOH 10%)
ditemukan Clue Cells
• bakteri menempel pada dinding sel
– Whiff/amine test (+)
• Bau amis bila sekret ditetesi
larutan KOH
C. Candidiasis Vaginitis
• Kausa: Candida albicans
• Klinis
– Sekret putih bergumpal,
kadang kental kekuningan,
gatal, tidak bau/masam
– pH <4,5
– Vulva & vagina gatal, radang
(+), disertai edema atau fisura
– Sediaan basah (larutan KOH
10%) pseudohifa, ragi,
blastospora
Trichomoniasis
Bacterial Candidiasis
vaginosis vaginitis
Trichomonas Gardnerella
Candida albicans
vaginalis vaginalis
Kuning-hijau, Putih-kuning
Putih-abu
berbuih bergumpal
Whiff/amine test
Strawberry cervix Gatal, radang
(+)
Pedoman Nasional IMS, Kemenkes, 2015
*
*
*
STI –symptomatic approach
Duh Tubuh Duh Tubuh Bubo
Ulkus Kutil Kelamin
Uretra Vagina Inguinalis
Cervicitis GO Herpes
genitalis
Uretritis GO LGV
Cervicitis NGO
Ulkus Molle
(Chancroid)
Bacterial Condyloma
vaginosis Acuminata
Ulkus Durum
(Sifilis)
Trichomoniasis
Uretritis NGO Ulkus*
Granuloma
Candidiasis Inguinale
(Donovanosis)
Herpes Genitalis
CLUE:
• HSV2
• Vesikel/ ulkus dangkal kecil
bergerombol, nyeri
• Dengan/tanpa riwayat rekurensi
Granuloma
Inguinale
(Donovanosis)
Azitromisin 1 g/minggu
ATAU
Azitromisin 500 mg/hari
selama 3 minggu
hingga lesi sembuh total
Doksisiklin 2x100 mg
ATAU
Ciprofloksasin 2x750 mg
ATAU
Eritromisin 4x500 mg
ATAU
Trimetoprim-
Sulfametoksasol 160/800
mg 1 kali/hari
STI –symptomatic approach
Duh Tubuh Duh Tubuh Bubo
Ulkus Kutil Kelamin
Uretra Vagina Inguinalis
BUBO BUBO
INGUINAL INGUINAL
(+) (-)
ULKUS Chancroid/ Granuloma
(+) Chancre/ Inguinal/
Herpes Donovanosis
Genital
ULKUS LGV -
(-)
STI –symptomatic approach
Duh Tubuh Duh Tubuh Bubo
Ulkus Kutil Kelamin
Uretra Vagina Inguinalis
Cervicitis GO
Ulkus Durum
(Sifilis)
Uretritis GO LGV
Cervicitis NGO
Trichomoniasis
Uretritis NGO Ulkus*
Herpes
genitalis
Candidiasis
GENITAL
HPV WARTS
Warts(Condyloma Accuminata)
on the Thigh
• Kausa: HPV
• Massa seperti bunga kol
(cauliflower like mass)
• Tes acetowhite
Tx:
Asiklovir 5x200 mg
Valasiklovir 2 x 500 mg
VZV –Varicella (Chicken Pox)
Lesi polimorfik (makula, papula,
vesikel, krusta)
Lesi muncul dari wajah badan
ekstremitas
Terapi: - Asiklovir 5x800
- Valasiklovir 3x1000
Hutchinson’s sign
precedes the development
of ophthalmic herpes
zooster
Ramsay Hunt Syndrome
VZV Infection of the head and neck that
involves the facial nerve, often the CN VII,
but might also CN VIII, IX, V, VI
Ganglion
geniculatum
Might be observed:
(CN VII)
• VZV auricularis
• VZV in any zoster zones of the head
and neck (herpes auricularis, herpes
facialis, herpes occipitocollaris) with
facial palsy
• VZV in any of the zoster zones with
facial palsy and auditory symptoms
(tinnitus, deafness, vertigo,
nystagmus, ataxia)
• Steady burning/aching
pain or paroxysmal
jabbing pain of nerve
• Lasting > 1 month
following healing of rash
• More common in women,
estimated incidences:
• 75% at age 70 years
• 50% at age 60 years
Sinonim:
Impetigo Bockhart Nyeri (+)
Predileksi: Predileksi: Predileksi: tempat banyak friksi (eg: aksila, bokong)
tungkai bawah bibir atas, dagu
Furuncle & Carbuncle
Furuncle Carbuncle
This lesion represents multiple confluent
furuncles draining pus from multiple openings
Furunculosis
Terapi Pioderma
• Lokal
– Banyak pus/krusta: kompress dengan PK 1/5000, rivanol 3x sehari
@1jam selama keadaan akut
– Tidak tertutup pus/krusta: krim mupirosin 2% atau asam fusidat 2%
2x sehari selama 7-10 hari
• Sistemik (5-7 hari)
– Kloksasilin atau dikloksasilin
• 4x250-500 mg (dewasa); 50 mg/kg/hari dalam 4 dosis (anak)
– Amoxiclav
• 3x250-500 mg (dewasa); 25 mg/kg/hari dalam 3 dosis (anak)
– Eritromisin
• 4x250-500mg (dewasa); 20-50 mg/kg/hari dalam 4 dosis
• Insisi dan drainase
– Khusus karbunkel yang menjadi abses
Skin and soft tissue infection
CLUE:
• Superfisial Batas
TEGAS , merah terang
• GABHS
• Wajah, tungkai
Treatment:
• (See treatment slide)
• Cold compress
• Elevation and rest
Selulitis
CLUE:
• Deeper (subkutan)
Batas TIDAK TEGAS
• Keterlibatan deep
lymphatic vessels (+)
• S. aureus/GABHS
• Tungkai
Treatment:
• (See treatment slide)
• Cold compress
• Elevation and rest
Phlegmon
• Selulitis dengan supurasi (undrainable)
• Acute diffuse purulent inflammation of the adipose
tissue, may continue to muscles and tendons
Treatment:
• (See treatment slide)
• Cold compress
• Elevation and rest
Treatment
Skin and soft tissue infection
Erythrasma
CLUE:
• Corynebacterium
minutissimum
• Flexural areas
• Macules/patch with
fine scales and
sharply defined
borders
• Wood’s lamp: CORAL
RED (bacteria produce
fluorescent porphyrins)
• Tx: erythromycin
Wood’s lamp
Infeksi Jamur Superfisial
Tinea cruris
“Black dot” tinea capitis
Tinea Infection with fractures of the hair leaving the
infected dark stubs visible in the follicular orifices
Capitis
Kerion
heavily crusted, hairless plaque Tinea capitis “gray patch”
Heals with scarring and permanent A large, round hyperkeratotic plaque of alopecia due
alopecia to breaking off of hair shafts close to the surface.
Most common in
Exothrix Endothrix
• Perkembangan • Adanya
arthrocodinia di perkembangan
bagian eksterior ahtrocodinia
batang rambut. hanya di dalam
Kutikula rambut batang rambut
hancur kuning kronis.
kehijauan di Kutikula rambut
bawah sinar intak dan tes
lampu Wood lampu Wood (-)
• Paparan hewan • Black dot
peliharaan
• Gray patch
Tinea manuum
Wood’s lamp
PVC - Tx
Terapi Antifungal
Terapi Sistemik diberikan untuk lesi luas dan/ cegah kekambuhan
Griseofulvin TINEA
• Dosis: 1x500mg atau 2x250mg
• Utk tinea PEDIS dan ONYCHOMYCOSIS 2x500mg atau 4x250mg.
• Lama terapi tergantung jenis
• 2 to 4 weeks for tinea barbae, tinea corporis, and tinea cruris
• 4 to 6 weeks for tinea capitis
• 4 to 8 weeks for tinea pedis
• 4 months for onychomycosis of the fingernail
• 6 months for onychomycosis of the toenail.
Nystatin CANDIDIASIS
• Drop oral thrush
• Suppositoria candidiasis vaginal, apalagi ibu hamil
• Tablet Esophagus & GIT. Langsung bekerja on site, tdk diserap sistemik
• Untuk Candidiasis Cutis lokal berikan Ketoconazole, Miconazole, atau Clotrimazole topical
Ketoconazole
• Ketokonazol: 200 mg/hari (10 hari)
• Itrakonazol: 200 mg/hari (7 hari) PVC, 100 mg/ hari (10-14 hari) Tinea
Candidiasis Tinea PVC
Trichophyon,
Candida Albicans Epidermophyton, Malassezia furfur
Microsporum
Makula-patch,
Area lipatan, lesi Tepi aktif, central
skuama halus
satelit healing
Finger nail sign (+)
Kuning kehijauan
--- Kuning keemasan
(capitis)
Wood’s lamp
Fluoresensi pada pemeriksaan dengan wood lamp
Fluoresensi Diagnosis
Fluoresensi merah bata Eritrasma
Skabies
Pedikulosis
Pruritus nokturna
Menyerang secara
kelompok
Pemeriksaan Penunjang
• Burrow Ink test
– Tinta di gosokkan pada area kulit
yang gatal bersihkan dengan kapas
alkohol bila ada terowongan
(burrow), maka tinta akan tertinggal
sebagai garis hitam
• Skin scrapping
– sampel kulit diambil dengan
meneteskan mineral oil ke burrow
dan mengerok kulit dengan blade
(hindari perdarahan) cek
mikroskop (hindari menggunakan
KOH karena dapat melarutkan mite
pellets) scabies mites, eggs, or
faeces
– Hasil dilihat dengan dermoscopy
(10x magnification tool) atau dengan
mata telanjang
Khusus crusted scabiesadd KOH 10% untuk
melarutkan kelebihan keratin sehingga dapat
diperiksa dibawah mikroskop
Terapi Scabies
Permethrin 5% Sulfur Presipitatum Emulsi Benzoil Gameksan 1%
4-20% (salep 2-4) Benzoat (EBB) (Lindane)
20-25%
Cara pemberian 1x malam, diulang 1x malam, 3 hari 1x malam, 2 hari 1x malam, cuci
1 minggu berturut-turut berturut-turut, setelah 8-12 jam.
kemudian diulangi 1 minggu TIDAK DIULANG
kemudian
Efek samping Rasa terbakar dan Iritasi kulit Iritasi kulit Stimulasi CNS
menusuk (dizziness-seizure),
(transien), DKI
pruritus
Kontraindikasi Bayi <2 bulan Hamil, anak <6
tahun, norwegian
scabies, penderita
kejang
FDA pregnancy B C C C
category
Pediculosis
Sky Blue Spot:
Over at the lice
feeding sites,
there may be
small blue
macules seen
Pediculosis Corporis
Pediculosis Pubis TERAPI:
• Medikamentosa:
• First line: Permethrin cream rinse 1%
(2 jam)
• Alternative: - Malathion 0.5% lotion
(semalam)
- Gameksan 1% 12 jam
Pediculosis Capitis
Terapi nonmedikamentosa
• Cuci dengan air hangat. Lice and eggs are
killed by exposure for 5 minutes to
temperatures >53.5°C
• Obati sekeluarga
Cutaneus Larva Migrans
( creeping’s eruption)
• Larva Ancylostoma
braziliensis
• Treatment:
– Albendazole 1x400
mg (3d) OR
– Ivermektin 2x6mg
– Topical
corticosteroid
– Use liquid nitrogen
cryotherapy for
progressive end of larval
burrow
TB Chancre
Exogeneous
TB Verucosa Cutis
(Direct inoculation
(TVC)
into the skin)
Lupus Vulgaris
(LV)
Cutaneous TB Scrofuloderma
Contiguous
Infection Orificial TB
• Mycobacterium tuberculosis
• Mycobacterium bovis TB Milier Akut
Lupus Vulgaris
(LV)
Lupus Vulgaris
Lymphogenous
(LV)
TB Chancre
• Primary inoculation TB
typically follows a penetrating
injury that results in the direct
introduction of
mycobacterium into the skin
or mucosa of an individual
with noprevious TB
infection.
• Papul shallow firm
nonhealing nontender ulcer
• Predileksi: wajah, ekstremitas
TB verukosa kutis
• (Anatomist’s warts, Prosector’s wart,
Verruca negrogenica)
• direct inoculation of TB into the skin of
people who were previously
infected.
• a painless, solitary, purplish or brownish-
red warty plaque that may extend
peripherally causing central atrophy or
form fissures that exude pus or keratinous
material.
• Hiperkeratosis (verrucous)
• May persist for years but can clear up even
without treatment
• Predileksi: anak pergelangan kaki, pantat
| dewasa jari dan punggung tangan
Lupus Vulgaris
• Chronic and progressive form of CTB
that is widely described as the most
common form of CTB with a multitude
of presentations.
• Lesions occur in normal skin as a result
of direct extension from underlying
deeper TB focus, by lymphatic or
hematogenous spread, after primary
inoculation, after BCG vaccination, or
in scars of old scrofuloderma.
• small, solitary, nodular, sharply
defined, reddish-brown lesions with a
gelatinous consistency (called apple-
jelly nodules) on the head and neck,
lower extremities or buttocks
• persist for years, leading to
disfigurement and sometimes skin
cancer
• The lesion begins as painless redish brown soft nodules
slowly enlarge to form irregularly shaped plaque
• Central healing with periphery continues to spread
• Autoinokulasi
Multiple Multiple
erythematous anesthetic ulcers
nodules, painful
Klasifikasi Lepra menurut WHO
Clinical features Paucibacillary (PB) Multibacillary (MB)
Erythema Multiforme
Urticaria
Urticaria
• Akut: <6 weeks
• Terapi:
– Antihistamin H1
• Bila gagal ganti/ naikkan dosis/ kombinasi
– Kortikosteroid, indikasi
• Angioedema (+)
• Refractory effect of antiH1
Jenis-jenis antihistamin
DRUG ERUPTION
Farmakoterapi
• Kortikosteroid sistemik:
Prednison 3x10 mg/hari (1
minggu)
• Antihistamin sistemik:
Obat pencetus: antibiotik, NSAID
– Setirizin2x10 mg/hari (7
Reaksi hipersensitivitas tipe IV hari) k/p
– Loratadin 10 mg/hari (7
Erupsi makulopapular hari) k/p
eritematosa tersebar • Topikal:
morbiliformis, simetris – Bedak salisilat 2% dan
antipruritus (Menthol 0.5%
Predileksi: Tungkai, lipat paha, - 1%)
dan lipat ketiak
Fixed Drug Eruption
Reexposure obat lesi pada tempat yang
sama.
Obat pencetus: Sulfonamid, Barbiturat,
Trimetoprim, dan analgetik
Reaksi hipersensitivitas tipe II
Lesi khas:
• Vesikel, bercak eritema
• Lesi target,bentuk bulat lonjong atau
numular , adang disertai erosi
• Bercak hiperpigmentasi dengan kemerahan
di tepinya, terutama pada lesi berulang
Erythema Erythema
Multifore Multiforme
Mayor Minor
Etiologi Erythema Multiforme
• An acute mucocutaneous
hypersensitivity reaction with a variety
of etiologies.
• Characterized by a skin eruption, with or
without oral or other mucous
membrane lesions
Stevens-Johnson Syndrome
Toxic Epidermal Necrolysis
• potentially life-threatening dermatologic disorder
characterized by widespread erythema, necrosis, and
bullous detachment of the epidermis and mucous
membranes, resulting in exfoliation and possible sepsis
and/or death
• Drug Reaction >50%
SJS dan TEN
-autoimmune caused-
Pemphigus
vulgaris
Pemphigoid
Bullousa
Pemphigus vulgaris
• Penyakit autoimun pada kulit dan
membran mukosa, ditandai dengan
bula intraepidermal yang terjadi
akibat proses akantolisis
• Akantolisis terjadi karena sirkulasi
autoantibodi (IgG) terhadap
desmoglein. Desmoglein adalah
pengikat desmosome sel epidermis.
• Lesi awal di kulit kepala yang
berambut atau di rongga mulut
berlangsung berbulan-bulan bula
generalisata.
• Nikolsky sign positif.
• Pemeriksaan histopatologik &
imunofluoresensi
Pemfigoid Bullosa
• AutoAb directed against two
hemidesmosomal proteins:
• BP 230 or BP antigen 1
(BPAG1)
• BP 180 or BP antigen 2
(BPAG2)
Newborn, children
(almost all <6yo), adult
with chronic disease
Etiology: Staphylococcus
Immune reaction for
exotoxin (exfoliatin)
Management:
Hospitalization
Antibiotics (dikloksasilin)
Dermatitis Dermatitis
Dermatitis atopi
Kontak Iritan Kontak Alergi
Pengobatan pemeliharaan
• Setelah fase akut teratasi, max 4 minggu
• Kortikosteroid topikal q24h
• Krim pelembab q12h
DKI vs DKA
Acute allergic contact dermatitis due to nickel. This papular erythematous eruption with vesiculation and
crusting occurred at the site of contact with the clasp of a watch band. Contact hypersensitivity to nickel
was verified by patch testing.
DKA
Patch test
Dilakukan minimal 2 minggu setelah dermatitis
mereda, pada bagian tubuh yang tidak memiliki
riwayat terpapar dermatitis
Indikasi:
• DKA idiopatik
• Dermatitis yang tidak sembuh dalam waktu singkat/persisten
• Penggunaan terapi topikal kronis
DKI Kumulatif
• Kontak berulang pada iritan lemah (ex:deterjen)
• Predileksi ditangan
Dermatitis kontak iritan akut: • Kelainan muncul dalam hitungan minggu, bulan
• iritan kuat (H2SO4 atau HCl) bahkan tahun
• Lesi: eritem, edema, bula kadang nekrosis
• Tepi berbatas tegas
TOXIC IRRITANT CONTACT DERMATITIS
ec insect bite
Treatment :
• Topical steroids in the mid to high
potency
• Oral antihistamines are useful if
pruritus is severe
• Oral antibiotics are indicated
when secondary infection is
present
Stasis Dermatitis
Most common in lower legs
SS :
Doksisiklin50-100 mg 2x sehari
Palmar Hyperlinearity
Lentigo Simplex
• Most common, appears at birth or early childhood
• Small dark papule distributed widely including in mucosa and
conjunctiva
• Consider syndrome association when numerous an/or involve mucosa
Solar Lentigo
• Age spots / liver spots / actinic lentigine
• Sun exposed areas
• Benign, not associated with any medical conditions, risk for skin cancer
Freckles
• Progressive loss of
terminal hairs over
frontal and vertex
regions of the scalp
• Frontal hairline and
occipital scalp are
usually relatively
spared
Terapi
Dosis, Mekanisme, Efek Samping
Minoxidil dan Finasteride
Produk Dosis Mekanisme Efek Samping
Basal cell carcinoma: rodent-ulcer type. A large ulcer filled with black necrosis
and hemorrhagic crusts is surrounded by a well-demarcated rolled border
consisting of typical nodules of a BCC (translucency, teleangiectasia). It has
destroyed almost the entire cheek.
Squamous Cell Carcinoma