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S K EN A R IO 5

P S O R IA S IS V U LG A R IS

SUSIANTY HUKUBUN

LEARN IN G O BJECTIVES
Patogenesis dan faktor pencetus

penyakit
Gejala klinik dan pemeriksaan klinik
Gambaran histopatologi
Alur diagnosa banding dan diagnosa
kerja penyakit
Edukasi kepada pasien

PEN G ERTIAN
Psoriasis Vulgaris merupakan

penyakit autoimun, bersifat kronik


dan residif yang tidak dapat
diprediksi
Ditandai dengan adanya bercakbercak eritema berbatas tegas
dengan skuama kasar, berlapis-lapis
dan transparan;
Disertai dengan fenomenon tetesan
lilin, Auspitz, dan Kobner.

ETIO LO G I
Penyebab tidak pasti
Faktor-faktor:
Pemendekan turn over epidermis
Predisposisi genetik

Faktor Pencetus
Infeksi
Infeksi Beta Hemoliticus
Infeksi HIV
Infeksi saluran pernapasan
Stress
Trauma menggaruk, bekas operasi
Obat tertentu anti malaria, lithium,

Beta adrenergik blocker, NSAID.


Perubahan iklim

Predileksi
Tempat mudah terkena truma
Siku
Lutut
Sakrum
Kepala
Genitalia

Patogenesis
Genetik
Ditemukan gen psoriasis
Bisa autosomal dominan atau
poligenik
Ada hubungan pada kembar
monozygot (70%) dan kembar
dyzygot (30%)
Ada hubungan resiko dengan HLACW6 meningkat 20%

Patogenesis
Perubahan
morfologik dan
kerusakan sel
epidermis

Akumulasi sel
monosit dan
limfosit pada
puncak papil
dermis dan di
dalam stratum
basalis

Pembesaran dan
pemanjangan
papil dermis.

Sel
epidermodermal
bertambah luas,
lipatan di lapisan
bawah stratum
spinosum
bertambah
banyak.

Pertumbuhan
kulit lebih cepat
dan masa
pertukaran kulit
menjadi lebih
pendek dari
normal, dari 28
hari menjadi 3-4
hari.

Stratum
granulosum tidak
terbentuk dan di
dalam stratum
korneum terjadi
parakeratosis.

Patogenesis
Perubahan morfologik dan kerusakan sel epidermis
Akumulasi sel monosit dan limfosit pada puncak

papil dermis dan di dalam stratum basalis


Pembesaran dan pemanjangan papil dermis.
Sel epidermodermal bertambah luas, lipatan di
lapisan bawah stratum spinosum bertambah
banyak.
Proses ini menyebabkan pertumbuhan kulit lebih
cepat dan masa pertukaran kulit menjadi lebih
pendek dari normal, dari 28 hari menjadi 3-4 hari.
Stratum granulosum tidak terbentuk dan di dalam
stratum korneum terjadi parakeratosis.

G ejala klinik
Keluhan:
Sedikit gatal
Panas
Kosmetik
Di Kulit:
Eritema makula batas tegas, tertutup skuama
tebal, transparan
Kaarsvlek phenomena fenomena bercak lilin.
Autpits sign bintik perdarahan
Fenomena koebner pd daerah kulit yang
terkena trauma berulang.

Di Kuku
Keruh
Punktate
berlobang
Hiperkeratosis
sublingual
Kuku tangan >>
kaki
Menyerang mukosa
dan sendi

Di Sendi dan
Mukosa
Psoriasis
arthromatica
Psoriasis
vasculosa di
telapak tangan

G am baran H istoPA
Hiperplasia regular

epidermis dengan
parakeratosis
konfluen serta
adanya
peningkatan
neutrophil pada
straum korneum
(Munro Microabses)
dan epidermis
(Kogoj mikroabses)
Plaza JA, Prieto VG. Inflammatory skin disorder. New York: Demos Medical
Publishing, 2012.

Lanjutan
Pada pembesaran

yang lebih besar


menunjukan
adanya
parakeratosis
konfluen
Hilangnya lapisan

granular,
Adanya dilatasi

pembuluh darah
pada permukaan
dermis
Serta penebalan

suprapapilary plate.

Plaza JA, Prieto VG. Inflammatory skin disorder. New York: Demos Medical
Publishing, 2012.

1.

Hiperkeratosis dengan parakeratosis (Maturasi abnormal).

2.

Hilangnya Granular layer.

3.

Akantosis epidermal dan elongasi dari rete ridges (hiperproliferasi)

4.

Dilatasi Vaskuler. Inflamasi meluas pun dapat terlihat dengan adanya


Limfosit-T pada dermis dan epidermis.

D iagnosa banding
Lues stadium II (psorisisform)
Skuama berwarna coklat tembaga dan
Dering disertai demam pada malam hari
(dolores nocturnal).
Lesi tidak gatal,
dapat ditemukan di telapak tangan dan
telapak kaki, terdapat
pembesaran kelenjar getah bening yang
generalista dan
Tes serologi untuk sifilis (TSS) positif.

Pytirlasic rosea
Biasanya berjalan subakut,lesi
berbentuk oval,
tepi sedikit meninggi dan ditutupi
skuama halus.
Predileksi biasanya didaerah badan
yang tertutup pakaian.
Morbus hansen

Dermatitis seboroik
Biasanya menunjukkan kulit yang
berminyak tanpa
Skuama yang berlapis-lapis.

D iagnosa kerja penyakit


Anamnesis
Pemfis
Pemeriksaan Penunjang

Penatalaksanaan

State ofthe Arm am entarium


Wide range of therapies for the

treatment of moderate to severe


psoriasis
None induce a permanent remission
All have side effects that can place
limits on their use

21

State ofthe Arm am entarium


Therapies
Topical Corticosteroids
Topical Vitamin D3 Analogues
Topical Retinoids
Photo(chemo)therapy
Systemic Therapies
Oral
Parenteral

22

TopicalCorticosteroids
High potency and Super potent topical

steroids
These include
Fluocinonide family (cream, ointment,
gel)
Betamethasone dipropionate cream
Clobetasol propionate family (cream,
ointment, gel, foam, lotion)
Diflorasone diacetate ointment
Betamethasone dipropionate
ointment
23

TopicalCorticosteroids
Side effects associated with use
Skin atrophy
Burning and stinging
Suppression of the hypothalamic-

pituitary-adrenal (HPA) axis


This may occur after 2 weeks of use with
certain topical corticosteroids

24

TopicalVitam in D 3 Analogues
Prototype for this group is

calcipotriene
3 formulations cream, ointment,
and scalp solution
Former two are approved for plaque
psoriasis
Latter for moderate to severe
psoriasis of the scalp
25

TopicalVitam in D 3 Analogues
Side Effects
Cutaneous
Burning
Stinging
Pruritus
Skin irritation
Tingling of the skin

26

TopicalRetinoids
Tazarotene Gel and Cream

Available in two strengths

0.05% and 0.1%


Side Effects
Pruritus
Burning/Stinging
Erythema
Worsening of psoriasis
Irritation
Skin pain
Hypertriglyceridemia

27

TopicalTazarotene
Additional Indications

0.1% gel - approved for the treatment

of facial acne vulgaris of mild to


moderate severity
0.1% cream approved as an
adjunctive agent for use in the
mitigation of facial fine wrinkling,
facial mottled hyper- and
hypopigmentation, and benign facial
lentigines in patients who use
comprehensive skin care and sunlight
avoidance programs
28

TopicalTazarotene (cont)
Both products are pregnancy category

X
Are contraindicated in women who are
or may become pregnant
Requirements before and during
therapy
A negative pregnancy test 2 weeks
prior
Therapy initiated during a normal
menses
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Women of childbearing potential

Photo(chem o)therapy

Two types of phototherapy


Ultraviolet B (UVB)
Ultraviolet A + psoralen (PUVA)

30

U VB
Two types
Broadband UVB
Narrowband UVB (311-313 nm)

Treatment is time consuming


2-3 visits/week for several months

Side effect possibility of

experiencing an acute sunburn


reaction
31

PU VA
Consists of ingestion of or topical treatment

with a psoralen followed by UVA


Usually reserved for severe, recalcitrant,
disabling psoriasis
Time consuming 2-3 visits/wk; at least 6
weeks
Precautions
Patients must be protected from further UV
light for 24 hours post treatment
With oral psoralen, wrap around UV-blocking
glasses must be worn for 24 hours post
treatment
32

PU VA
Side effects with oral psoralen
Nausea
Dizziness
Headache

Side effects with PUVA


Early

Pruritus
Late
Skin damage
Increased risk for skin cancer, particularly
squamous cell (SCC) and after 200 - 250
treatments, increased risk for melanoma
33

Contraindications to PU VA
Patients less than 12 years of age
Patients with a history of light

sensitive disease states


Patients with, or with a history of
melanoma
Patients with invasive SCC
Patients with aphakia

34

System ic Therapies
Oral
Methotrexate
Neoral (cyclosporine)
Soriatane (acitretin)

Parenteral
Amevive (alefacept)
Raptiva (efalizimab)
Enbrel (etanercept)

35

M ethotrexate
Folic acid antagonist
Usually reserved for severe,

recalcitrant, disabling psoriasis


Maximum improvement can be
expected after 8 -12 weeks

36

Contraindications -M ethotrexate
Nursing mothers
Patients with alcoholism
Alcoholic liver disease
Other chronic liver disease
Patients with overt or laboratory

evidence of immunodeficiency
syndromes
Patients who have preexisting blood
dyscrasias
37

M ethotrexate
Pregnancy Category X drug product

Contraindicated in pregnant women

with psoriasis
Pregnancy must be excluded in
women of childbearing potential
Pregnancy should be avoided if either
partner is receiving MTX during and
for a minimum of 3 months after
therapy for male patients and for at
least one ovulatory cycle after
therapy for female patients
38

M ethotrexate Side Eff


ects

Acute or chronic hepatotoxicity


Hepatic cirrhosis
Leukopenia
Thrombocytopenia
Anemia, including aplastic anemia
Rarely, interstitial pneumonitis
Stomatitis
Nausea/vomiting
Alopecia
Photosensitivity
Burning of skin lesions
39

M ethotrexate
Multiple prescreening tests necessary
Recommendations for hepatic

monitoring
Periodic LFTs including serum albumin
Liver biopsy
Pretherapy or shortly thereafter
Cumulative dose of 1.5 grams
After each additional 1.0 to 1.5
grams
40

N eoral
Potent Immunosuppressive
Adult, non-immunocompromised

patients with severe, recalcitrant


plaque psoriasis
Maximum efficacy achieved at 16
weeks of therapy

41

Contraindications -N eoral
Concomitant PUVA or UVB therapy
Methotrexate or other

immunosuppressive agents
Coal tar or radiation therapy
Patients with abnormal renal function
Patients with uncontrolled hypertension
Patients with malignancies
Nursing mothers
42

N eoral Side Eff


ects

Possibility of Irreversible renal damage


Hypertension
Headache
Hypertriglyceridemia
Hirsutism/hypertrichosis
Paresthesia/hyperesthesia
Influenza-like symptoms
Nausea/vomiting
Diarrhea
Lethargy
Arthralgia
43

N eoral
Multiple prescreening tests are

required
Tests must continue throughout
treatment with dosage adjustment as
necessary to prevent end-organ
damage

44

Soriatane
Oral retinoid approved for the

treatment of severe psoriasis in


adults
Significant improvement can be
achieved with 8 weeks of therapy

45

Soriatane -Contraindications
Patients with severely impaired liver

or kidney function
Patients with chronic abnormally
elevated blood lipid values
Patients who are taking
methotrexate
Ethanol use when on therapy and for
2 months following therapy in female
patients
46

Soriatane
Pregnancy Category X drug product

as it is a human teratogen
Contraindicated in pregnant females
or those who intend to become
pregnant during therapy or any time
up to three years post therapy

47

Soriatane Side Eff


ects
Those associated with retinoid therapy
Cheilitis
Alopecia
Skin peeling
Dry skin
Pruritus
Rhinitis
Xeropthalmia
Arthralgia
48

Soriatane Side Eff


ects
Laboratory Abnormalities

Hypertriglyceridemia (66%)
Decreased HDL (40%)
Hypercholesterolemia (33%)
Elevated liver function tests (33%)
Elevated alkaline phosphatase (10-25%)
Hyperglycemia (10-25%)
Elevated CPK (10-25%)
Hepatitis and jaundice occurred in < 1%
of patients in clinical trials on Soriatane

49

Soriatane
Multiple prescreening tests must be

obtained
Continued monitoring throughout
therapy necessary with possible
dosage adjustment

50

ParenteralTherapy
Am evive
Immunosuppressive dimeric fusion

protein
Extracellular CD2-binding portion of the

human leukocyte function antigen-3


(LFA-3)
Linked to the Fc portion of human IgG1

51

Am evive
Indicated for the treatment of adult

patients with moderate to severe


chronic plaque psoriasis
With 12 weeks of therapy, a disease
state of clear or almost clear was
achieved by 11% (via IV) and 14%
(via IM) of patients, respectively

52

Am evive Side Eff


ects
Dose dependent reduction in

circulating CD4+ and CD8+ T


lymphocytes
Should not be administered to patients

with low CD4+ counts


CD4+ counts must be monitored before
and weekly throughout therapy

53

Am evive Side Eff


ects
Lymphopenia
Increase risk of malignancies
Skin cancer BCC and SCC
Lymphoma

Serious infections requiring

hospitalization
Risk of reactivation of chronic, latent
infections
Hypersensitivity reactions
54

Edukasi