A group of skin disorder, where scaly erythematous papule,

plaque or patch becoming the major skin sign.

PSORIASIS
PITYRIASIS ROSEA
PITYRIASIS RUBRA PILARIS
LICHENOID ERUPTION
PITYRIASIS LIKHENOIDES and PARAPSORIASIS
DERMATITIS EKSFOLIATIVA/ERYTHRODERMIA
 IMMUNOLOGIC PROCESS

1. ANTIBODY/AUTO ANTI BODY PRODUCTION

2. EXPRESSION OF SPEC. ANTIGENIC PROTEIN
3. COMPLEMEN ACTIVATION
4. RELEASE OF SPECIFIC IMMUNE REACTANT
5. INDUCTION OF SPECIFIC CELL RESPONSES IT Y
N T
.E
DIS
I FIC
PEC
S
WHAT ARE THE “SKIN LESIONS” CONCERNING
TO ERYTHRO SQUAMOUS ERUPTION
LESION CONFIGURATION
 PSORIASIS
 UNKNOWN CAUSE (MULTIFACTORIAL)
 CHRONIC AND RECIDIVE COURSE
 ERYTHROSQUAMOUS PLAQUE WITH
MICACEOUS MULTILAYERD SCALE

BASIC PATHOLOGY OF LESION

• CONTINOUS WOUND HEALING TYPE OF
KERATINOCYTE HYPER PROLIFERATION
•CONTINOUS INDUCTION BY INFLAMATORY CELL
• SHORTHERNING OF KERATINOCYTE TURN OVER
 PATHOGENESIS OF PSORIASIS

Triggering factors
ENVIRONMENTAL FACTORS
PHYSICS,BIOLOGIC AND
EMOTIONAL  emotional stress
 season
 trauma
 drugs
 infection PSORIATIC SKIN
PREPSORIATIC
SKIN
genetic :
HLA DR. BW IMUNOLOGIC AND
NON IMUNOLOGIK
Disease of
diet PROCESSES
modern society
race
Schematic representation of generating psoriasis inflammatory lesion from
normal psoriatic skin. Starting from activation of native APC’s to the
maintenance of psoriatic lesion

Adapted from Prinz, 2003

 Schematic representation of trafficking CLA+ LyT to
inflamed skin. Note the complexes of proteins involved in
the process
 EVIDENCE IN PSORIASIS

KERATINOCYTE HYPERPROLIFERATION
FUNGSIONAL CHANGES
ABNORMALITIES

DERMAL CELLS PRODUCTION OF

PROINFLAMMATORY
FUNCTION
CYTOKINES
ABNORMALITIES

PATTERN OF TISSUE SKIN PG

OXIDATIVE STRESS
HISTOPATOLOGICAL FINDING

 DIFFUSE PARAKERATOSIS,
THINING OF SUPRA
PAPILARY EPIDERMIS,
 MICRO ABSES MUNRO,
 REGULER ACANTHOSIS,
 FINGER LIKE DERMAL
PAPILLAE
 EDEM OF DERMAL
PAPILLAE,
 SPARSE PERIVASCULAR
LYMPHO HISTIOCYTIC
INFILTRATRATION
PSORIASIS VULGARIS

COMMONEST FORM ,
SPECIFIC
ERYTHROSQUAMOUS
PLAQUE OVER
PROMINENCE AREA
OF THE SKIN
 FLEXURAL / INVERSE PSORIASIS

SPECIFIC PLAQUE
AT FLEXURAL
AREA

SEBORIASIS -
PSORIASIS
SEBORHEIC
 GUTTATE PSORIASIS
ERUPTIVE
MULTIPLE, SMALL SIZE
DROP LIKE LESIONS
>> IN CHILDREN AS NEW
LESIONS
GENERALIZED PUSTULAR
PSORIASIS (von zumbusch)
generalized steril pustules, which
are eruptive accompanied high fever,
WBC > 20.000/ML
DECREASE [Ca++] serum

PSORIASIS PUSTULAR
PALMOPLANTAR
Pustular Eruption limitted at
palmoplantar , recurrence
some time happen together
with the plaque type
PSORIASIS ARTHROPATHY

arthritis seronegative
•predilection: small joint
•persisten
•specific Radiologic pattern
Psoriasis of the nail

>>hand nails
 pitting nail
 yellowish
discoloration
 subungual
hyperkeratosis
 lateral onycholysis
Psoriasis erythrodermia
• reactive psoriasis
•exfoliation > 75% body surface
BEFORE TREATMENT

8 WEEK AFTER TREATMENT

DIAGNOSIS OF PSORIASIS

Specific clinical feature

course of disease
specific pathologic feature correspond to its
clinical form

Disease severity measured by PASI (Psoriasis Area

and Severity Index) score
correspond to % area affected ( estimation using rule
of nine in burns), degree of erythema, infiltration and
scaling ) MILD pasi SCORE << 10 %
Severe pso >>1 0 %
 Koebner phenomen ( isomorphic)
isomorphic eruption following
repetitive trauma ( LESIONS ARRANGED IN A LINE)
Wax drop phenomen
The micaceous scale be-
coming dull if scratched

Auspitz sign
pin point bleeding when pull off
the scale
BASIC MEDICAMENTAION

hTOPICAL : TAR, SALICYLIC ACID,

STEROID,TACROLYMUS
h SYSTEMIC : CYTOSTATIC AGENT (Cy-A, Mtx) ,
ISOTRETINOIN, “steroid”
hCOMBINATION : Irrad UV-B + tar ( Reg.Gaukerman)
Drug considerance irrad UV-A + psoralen (PUVA)
 diseases severity ( PASI score )
 treatment history including
medication side effects
 patient situational status
Social/holistic approach
Sosialization of the illness to the patient
and family
PASI < 5 MILD. ( >5 – 10) MODERATE, > 10 SEVERE
<5 : indication of topical treatment, mainly new cases
5-10 : new cases try topical treatment, no respons systemic treatment
> 10 : systemic treatment

Resistant to topical treatment  foto therapy/cytostatic agents in

rotation model (refer)
Known drugs adverse effect (toxic or allergic)  refer
Unknown drugs adverse effects but have sign of toxicity or
allergy  refer
 DERMATITIS EXFOLIATIVA (DE)
An eruptive skin disease as whole body erythema and
scaling.

Cause : several kinds of dermatosis (skin disease) which

undergone an eruptive state,ie:
1. Psoriasis/ other erythrosquamous eruption
2. Dermatitis ( Atopik, Seborrheic, Contact Allergic)
3. Drug eruption
4. Malignancy (cutaneous lymphoma)
5. Ichtyosis
8. Bullous disease (Pemphigus foliaceous)

Clinical sign and course

Generalized erythema and scaling
Lymphadenopathy, ectropion of the eyelid, edem at
lower extremities, some times fever, hypoproteiaemia,
leucocytosis, depletion [Ca]++ serum.
CLINICAL COURSE

DEPEND ON THE BACK GROUND OF THE

ERUPTION

MANAGEMENT
DEPEND ON DESEASE BACK GROUND

UVA-PHOTO THERAPY + PSORALEN

UVB PHOTOTHERAPY
CYTOSTATIC
CORTICOSTEROID
Retinoic acid

Diet control with high calory and protein

water balance control
Itch control
example of Before and during treatment with UVB photo therapy
in a case of psoriatic erythro dermia
Case 1 What is your suggestion ?

A lymphocyte with specific

nuclei (Sezzary cell)
 PITYRIASIS ROSEA
E S E specific oval
erythematous patch,
multiple, fine scale ,
long axis in line with
Langer’s line,
spontaneous
regression
Etiology : unknown
(viral ?)
Herald patch, bigger
size surrounded by
the new lesions
(corymbi form pattern)
clinical course
start as single lesian
accompanied with
other sall lesions
generalized --- > faded Herald patch

Herald patch, close up

 Epidemiology: world wide, male/ female equal
child/ adult equal

Clinical manifestation:
Herald patch ----> smallest lesion surrounding
spread all-over body but face and palm/sole
Full blown on the back ---> tree form appearance
Lesions tend to distribute on clothed area.

Atypical forms : vesicular lesions

Self limitted in 6 - 12 weeks
cleared lesions left hypo - pigmented patch.

Therapy: symptomatic, anti inflammatory drugs ( steroid)

erythomycin systemic, UV-B photo therapy
PITYRIASIS RUBRA PILARIS

• RARE
• SPECIFIC :
ERYTHROSQUAMOUS
PAPULES, ACCUMINATE,
FOLLICULAR, TEND TO
COALESCE/
CONFLUENCY
• OLD LESION LEAVE
SMALL ISLANDS OF
HEALTHY SKIN
ETIOLOGY
• FAMMILIAL (Aut.Domin)
• VIT.A DEFFICIENCY ?
 LESION ON THE PALM AND SOLE

Yellowish colour

Keratotic sandal

Diffuse hyper keratosis on palms

The nail changes not specific

 PATHOGENESIS
INCREASE OF EPIDERMO-POIESIS UP TO 2-3 x NORMAL

CLINICAL MANIFESTATION
New Lesion : erythro squamous patches on the head (seborrhoiformis)
start with follicular erythematous papules.
Coalescence of lesions
In the palm and sole thick, luminence wax yellow colored
(keratodermic -sandal)
Old lesions : islands of normal skin between the plaque
Eruptive form: similar with dermatitis exfoliative of any cause

HISTOPATHOLOGY
• NOT DIAGNOSTIC BUT SPESIFIC
• HYPERKERATOSIS, PARAKERTOSIS ALTERNATING/FOLIKULER
• EUGRANULOSIS
TREATMENT
TOPICAL : STEROID
TAR + UV-B
SYSTEMIC: RETINOIC ACIOD
 LICHEN PLANUS
A COMMON CHRONIC INFLAMATORY SKIN DISEASE
WITH SPECIFIC CLINICAL AND HISTOPATHOLOGICAL
MANIFESTATION, UN KNOWN CAUSE

CLINICAL VARIATION
ERYTHRO SQUAMOUS, VESICO BULLOUS, HYPER-
TROPHIC,
ATROPHIK, ANULAR, FOLLICULAR, ACTINIC OR
ERYTHEMATOUS

ETIOPATHOGENESIS
INFECTION -PSYCHOGEN-GENETIC
ENZYMATIC IMMUNOLOGIC
CLINICAL MANIFESTATION
SINGLE LESION : FLAT TOPPED PAPULE,
POLYGONAL WITH WICKHAM STRIAE, DEEP
PURPLE HUE
DISCRETE
OLD LESION VARIED
MUCOSAL LESION :
WHITISH PLAQUE
(LACY WHITE APPEARANCE)
 Koebner sign

Flat topped polygonal lesion

with striae of Wickham
 LICHEN NITIDUS
• RARE
• PIN POINT PAPULES WHITISH COLOUR
• UN KNOWN CAUSE
• >> ADULT, BLACK SKIN
• SPECIFIC HISTOLOGICAL FINDINGS
• NOT PRURITIC
• IN EFFICIENT TREATMENT

Lesions on trunk Penile lesions

Close up
 LICHEN STRIATUS
 CLINICALLY SPECIFIC
 SPONTANEOUS
HEALING 6 12 MONTHS
 >> CHILDREN
 ERYTHEMATOUS
PAPULE, PURPLE,
DISCRETE, --->
CONFLUENCE -->
LINEAR PLAQUES AT
LATERAL ASPECT OF
EXTREMITIES
 PITYRIASIS LICHENOIDES
AND
OTHER PARA PSORIASIS
 PITYRIASIS LICHENOIDES et
VARIOLIFORMIS ACUTA (PLEVA)
 PITYRIASIS LICHENOIDES CHRONICA
(PLC)
 SMALL PLAQUE PARAPSORIASIS
(GUTATTE P.P.)
 PARAPSORIASIS en PLAQUE
PLEVA
•new lesion papule
eritem --> central
vesiculations
•crusting ---> ulceration -
--> clear ----> cicatrix

0LD LESIONS
Pityriasis lichenoides chronica (PLC)
• Thin Papules with fine scale, erythematous
base
 Sunardi radiono
Dept. of dermatol. and venereol.