dr. Luh Made Mas Rusyati, Sp.

KK

Psoriasis

Seborrheic Dermatitis

Pityriasis Rosea

Erythroderma

Lichen Planus

 Difinition:

recurrent, kronik, skin inflammatory ds with variations in clinical presentations Belongs to dermatosis erythroskuamous lesionsmarked by increase in vascularization (erythema) and scales production in the epidermis Universal, variations in incidence 0,111,8% Highest incidence in Europe (Denmark 2,9%), no case has been reported from India

 Psoriasis

may began at any ages Uncommon under the age of 10 years It most to appear between ages of 15 and 30 Christophers Divided into Type I and II Type I before 40 yr and HLA associated, type II after 40 yr, lacking HLA associated No evidence that type I and type II respond differently to different therapies.

Psoriasis Classification and Clinical Patterns of Skin Presentation

Psoriasis

Vulgaris Eruptive (guttate) psoriasis Psoriasis eritrodermi Generalized pustular psoriasis (von Zumbusch) Annular pustular psoriasis Localized pustular psoriasis

4 Characteristics findings in psoriatic lesions: 1. Well-demarcated lesions 2. Silvery, layered, rough scales at the surface of the lesions 3. The skin are erythema and coiled beneath the scales 4. Positive Auspitz sign

Koebner phenomenon presents in 20% cases

LESION ON THE NAILS

LESION ON THE KNEES

 Physical

trauma Infections Stress Drugs

DIAGNOSIS Anamnesis Clinical findings Histopathological examinations

DD Seborrheic dermatitis Pityriasis rosea Syphilis PRP

Laboratory Findings
examinationsunspecific Histopathologic findings epidermal and upper dermal changes Initial changes: oedeme of str papillare of the dermis with mononuclear cells infiltrates and spongiosis Late changes: neutrofil migration to the str korneum Munros microabcess
Laboratory

PASI (Psoriasis Area and Severity Index)

Badan

dibagi 4 kuadran dgn bobot : Kepala (K=0.1), Badan (B=0.3), Ekstrimitas Atas (EA=0.2), Ekstrimitas Bawah (EB=0.4) Area (A) yang terlibat diberi bobot : tidak ada=0, < 10%=1, 10-30%=2, 30-50%=3, 50-70%=4, 7090%=5, 90-100%=6 Keparahan (S) diberi gradasi 0-4 Gejala klinis : Eritema (E), Infiltrat (I), Deskuamasi (D) PASI = 0.1(EK+IK+DK)AK + 0.3(EB+IB+DB)AB + 0.2(EEA+IEA+DEA)AEA + 0.4 (EEB+IEB+DEB)AEB

Treatment
Treatment

based on the extent and location of lesions, health problem. - lesions < 5% of the body topical drugs - lesions 5-10% of the body topical drugs + phototherapy/systemic drugs - lesions > 10% of the body phototherapy or systemic drugs

Treatment
Topical

drugs : - Antralin (dithranol) - Vit D3 and analogues - Tazarotene - Tar - Topical corticosteroids - Emolient Ultraviolet light - PUVA (Psoralen Ultra Violet A) - UVB

Treatment
Systemic

therapysevere cases with extensive lesions or pustular or active psoriasis - Metotrexate (MTX) - Cyclosphorine - Retinoid - Esther Fumarat Acid - Glucocorticoids systemic - Macrolactam (Calcineurin Inhibitor) - Excimer Laser

Introduction
Definition

chronic dermatosis papulosquamous disease, associated with increase in sebum production (seborea) Insidence 2 peaks, the first 3 month of life and 4th and 7th decade of adulthood with male preponderence Clinical lesions on the scalp,, face, body parts with plenty of sebaceous follicle, varies in severity

Seborrheic Dermatitis in Infants

Thick,

oily crust on hairy scalp, crease area for examples on the retroauricular fold, ear peak, mid face, neck, chest Sometimes accompanied by fissures (crusta lactea, milk crust, cradle cap)

Desquamative Erythroderma (Leiners Diseases)

Skin

lesions quickly coalescence into wide lesions all over the body, erythematous, covered with scales erythroderma Look severly ill, with anemia, diarrhea, and vomitting Frequently followed by secondary infections

Seborrheic Dermatitis in Adult

Seborrhoeic

eczematid Pityriasis sicca Erythema paranasale Patchy dermatitis seborrhoeic Pityriasiform type seborrheic dermatitis Folliculare type seborrheic dermatitis Chronic Otitis Media Blefaritis

Triggering Factor
Seborrhea
Microbial Drugs

impact

Neurologic/neurotransmitter
Physical

dysfunction

factors Nutritional imbalance

Diagnosis and Differential Diagnosis

Diagnosisanamnesis

+ clinical findings DD/ in infant : atophic dermatitis, psoriasis, scabies, Langerhans Cells Histiocytosis DD/ in adult depends on location : psoriasis, atophic dermatitis, impetigo, contact dermatitis, allergic reactions, pityriasis versikolor, pityriasis rosea, demodocosis/demodicidosis, candidiasis

Treatment
Aim:

releasing the scales, inhibiting yeast colonization, preventing secondary infections, reducing pruritus and oedeme Treatment depends on the location of the lesion Some therapeutic modalitiesantifungal, topical Steroid topikal

Prognosis
Infantgood

prognosis, mostly mild and healed spontaneously Adultchronic disease, treatments for reducing symptoms and not for healing patients education

Introduction
The term first used by Gilbert in 1860 Definition: common, acute, self-limited

skin eruption that typically begins as a single thin oval scaly plaque on the trunkherald patch Followed by numerous similar-appearing smaller lessions along the lines of cleavage of the trunkchristmas tree pattern Usually asymptomatic, sometimes associated with pruritus and mild flu-like symptoms

Epidemiology
Reported

in all races, irrespective of the

climates Average annual incidence: 0,16% Occurs most commonly in teenagers and young adultbetween 10-35 years old Slight female preponderance 1.5:1 Recurrences are raresuggests lasting immunity after initial episode

Etiology and Pathogenesis

Historically

pityriasis rosea has been considered to be caused by an infectious agent Scientific evident theory that pityriasis rosea represents a viral exanthem associated with reactivation of human herpesvirus (HHV7) and (HHV-6) The mech of reactivation is unknown The characteristic distribution of the lesions are unexplained

Clinical Findings
Historysingle

truncal lesion followed by numerous smaller lession in several days to weeks later, asymptomatic-pruritic, flu like symptoms Cutaneous lesions: - herald patch well demarcated, 2-4 cm, oval/round, salmon coloured, with fine scales - secondary lesions small plaque resembling primary plaque with christmas tree pattern or small, red, non-scaly papules spread peripherally

Differential Diagnosis
Secondary

syphilis Tinea corporis Nummular dermatitis Guttate psoriasis Pityriasis lichenoides chronica Pityriasis rosea like drug eruption

Treatment
Self-limited

Education

dan reassurance Pruritic lesion topikal corticosteroids medium potency Flu-like symptoms and extensive lesions acyclovir oral 5 x 800 mg for a week Special considerationphototherapy

Prognosis and Clinical Course

All

patients have spontaneous resolutions Disease durations 4-10 weeks No residual effects secondary to occurance of pityriasis rosea Reccurency is possible, but rare

Introduction
Exfoliativa

dermatitis, exfoliativa erythroderma, Red Man syndrome Definitioninflammatory skin ds with erythematous and scales formation all over the body either idiopathic or caused by extention of other skin ds (psoriasis, atophic dermatitis, drug eruption, cutaneus T-cell lymphoma) almost 50% associated with underlying ds 25% idiophatic

Epidemiology
Rare case male : female = 2:1 to 4:1 Average age of onset are 40-60

years old, but can also affecting neonates and infants In the adulthood mostly related to psoriasis, atophic dermatitis, drug eruption, idiophatic In neonates and infants mostly caused by atophic dermatitis, seborrheic dermatitis, drug eruption, psoriasis, infections (for example Staphylococcal Scalded Skin Syndrome)

Etiopathogenesis
Pathogenesisunclear Increase in germinativum

cells mitosis and shortening of functional epidermal keratinization Increase in scales degradation rate Increase in vascular endothelial growth factor/vascular permeability factorincrease in permeability and vascularization Increase in adhession molecules expressionaffecting production and proliferation of inflammatory mediators

Etiopathogenesis
Drug

eruption eritroderma: alopurinol, ampisillin/amoxcysilin, dapson, carbamazepine, fenbarbital, sulfonamide, Cachannel blockers, simetidine, gold, obat tradisional Eritroderma ec systemic disease : malignancy (solid tumor and haematologic), infection (syphillis, HIV) Psoriatic erythroderma : effect of the disease, corticosteroid, methotrexate, phototherapy, lithium, pregnancy, infection

Clinical Manifestation
Eritema generalisata, 90% with scales formation, without affecting the mucousa Acute: erithemawhite/yellowish fine scales starting in flexures areaforming platelike leson on the palmsgrey, dry scales, with light red skin lesions Secondary infections: wet lesions, tightly adherent scales, bad odour caused by colonization of bacteria Chronic: thick skin and nails, induration, oedeme and lichenifications, hair fall, subungual hyperkeratosis, onykilosis, beau lines of the nails Drug eruption: shoreline feature in the nails

Clinical Manifestation
Primary type(idiopathic)erythem starts in the trunk, spreading with scales production mostly in old man, chronic, relaps, severe pruritus, limfadenopati, dermatopati, extensive keratoderma palmoplantarRed Man Syndrome Secondary typewith associated underlying ds - topical drug eruption: initial lesion as dermatitis - systemic drug eruption: initial lesion morbiliformis/skarlatiniformis -2/3 histopathologic findings are consistent with underlying ds - exacerbation occurs in lesion with sunlight exposure

Systemic Findings in Erythroderma

62%

cases present with axillaris and inguinalis limfadenopati, >37% hepatomegaly, 23% splenomegaly Poikilothermia Decrease in systemic blood flowheart failure 80% cases presents with fever and tachycardia Dehidration Increase in blood ureum level Protein loss dan nitrogen, potassium, folate imbalancehipoalbuminemia, oedeme, reduce in muscle mass

Commonly find erythroderma

Psoriasis
Athopic

Rare form of erythroderma

Cutaneus

dermatitis Drug eruption Idiophatic

T-Cell Lymphoma (CTCL) Pitiriasis Rubra Pilaris (PRP) Dermatosis Bulosa - Pemfigus foliaseus - Pemfigoid bulosa - Pemfigus paraneoplastik

Laboratory Findings
Anemia,

limfositosis, eosinofilia, increase in ESR (erythrocyte sedimentation rate) Decrease in serum protein Decrease in electrolytes and renal function Increase in IgE serum Sezary Syndrome>20% sel Sezary Erythroderma idiophatic bone marrow biopsy: eosinofilia (32%)

Pathologic Examinations
Multiple

consecutive biopsy needed Erythroderma psoriatic histopathologic findings have >90% accuracy, but in erythroderma associated with CTCL histopathologic examinations are difficult

Treatment
Adequate nutrition, fluid and electrolytes balance, high protein diet, folic acid supplementation Warm and moist environmet Hospitalizationsevere cases, observation in fluid intake and renal function, possibility of cardiac failure Supportive skin careemolient, weak to mid potency topical corticosteroids Antibiotics for bacteria superinfections, antihistamin and behavioural therapy to decrease itch and scratch Consider corticosteroids and immunosuppresant therapy in severe/refracter cases

Introduction
Definition

unique, common inflammatory disorders efecting skins, mucous membranes, nails, hairs
symmetric, grouped, erythematous-violaceous, flat-topped, polygonals papules

Lessions

Epidemiology
Overall

prevalence less than 1% worlwide 2/3 of the cases occur between 30-60 years old No sexual predilection is evident Predilection in flexural aspects of arms and legs Familial lichen planus have been reported

Etiology & Pathogenesis

Lichen

planus almost certainly immunological mediated The most characteristic change in lichenoid reactionsapoptosis Cell-mediated immunity plays major role Humoral immunity as a secondary response Both CD4+ and CD8+ T cells are found in the skin lesions

Clinical Findings
Cutaneous

lessions: faintly erythematous violaceous, flattopped, polygonal papules Thin, transparent, adherent scales at the top Wickham striae Lessions are symmetrically and bilaterally distributed over the extrimities Asymptomatic-quite pruritic

Histopathologic Diagnosis
pathologic findings basal epidermal keratinocyte damage Epidermal changeshyperkeratosis, hypergranulosis, elongation of rete ridges Multiple apoptotic bodies or colloid-hyaline (Civatte) bodies at dermal-epidermal junction
Major

Differential Diagnosis
Classic:

psoriasis, drug eruption, lichen simplex chronicus Annulare: granuloma annulare, tinea Linear: nevus unius lateris, lichen striatus, linear epidermal nevus Hypertrophic: lichen simplex chronicus, prurigo nodularis, lichenoid cutaneous, amylidosis, kaposi sarcoma Atrophic: lichen sclerosus Follicular: lichen nitidus, lichen spinulosus Childhood: lichen nitidus, lichen striatus, pityriasis lichenoides, papular acrodermatitis of childhood

Treatment

Cutaneous Lichen planus - first line: topical topical steroids, intralesional steroids, tacrolimus, pimecrolimus physical psoralen and UVA systemic systemic steroids, etretinate, acitretin, isotretinoin
- second line (systemic): cyclosporine, dapsone, hydroxychloroquine, azathioprine - special forms (systemic): doxycycline, tetracycline, nicotinamide, interferon -2b, metronidazole, cyclophosphamide, methotrexate

Treatment
Oral

Lichen Planus

- first line: topical topical steroids, intralesional steroids, tacrolimus, pimecrolimus, lidocaine, tretinoin gel, isotretinoin gel systemic anti candidal-systemic steroids, etretinate, acitretin, isotretinoin - second line : topical cyclosporine mouthwash physical extracorporeal photochemotherapy, photodynamic therapy systemic cyclosporine, griseovulfin, hydroxychloroquine, azathioprine, mycophenolate mofetil, thalidomide, cyclophosphamide