KULIAH

REGULER 2015
 ERYTHRO
SQUAMOUS
SKIN DISEASE
Dr. YF. Rahmat Sugianto, SpKK

Bagian Ilmu Kesehatan

Kulit & Kelamin
Fakultas Kedokteran UNDIP
 Erythrosquamous Skin Disease
Skin Lesions :
macule, papule or plaque with scales,consists of :
1. Psoriasis
2. Parapsoriasis
3. Pityriasis rosea Gibert
4. Pityriasis rubra pilaris
5. Erythroderma
6. Seborrheic Dermatitis
7. Lichen planus
8. Lichen nitidus
9. Lichen striatus
Discussion :
1. Psoriasis
2. Pityriasis Rosea Gibert
3. Erythroderma
Psoriasis
Definition:
Chronic relapsing disease of the skin
characterized by erythema, papules /
plaques with silvery and lamellar
scales

Synonym : psoriasis vulgaris

Epidemiology :
- Worldwide
- Incidence 1-3% of the population
- Females = males
- Age of onset : lifelong threat (adult >>)
Aetiology

- Unknown
- Genetic factors
- Epidermis turn over time ( 3 – 4 days )
- Trigger Factors : trauma, infection, hormonal,
drugs, stress , sun exposure, alcohol & smoking,
metabolic factors

Clinical Features

- Predilection : scalp borders, extensor site of the limb,

lumbosacral area
- Skin Lesions: Erythematous papules/plaques,
sharply demarcated with clear cut borders, covered
with silvery and lamellar scales
- Size of lesions : lenticular, nummular, confluence
Specific sign :

- Candle sign ( “Kaarsvetvlek phenomenon”)

- Auspitz Sign: when hyperkeratotic scales
mechanically removed by scrapping, within few
seconds small blood droplets appear

Auspitz Sign
 Non specific sign

- Köebner phenomenon: after trauma, lesions develop

in areas where they were not present previously.Also
found in lichen planus, lichen nitidus, verucca plana

Lesi psoriasis timbul

akibat terbakar matahari
 Pitting nail ( specific ) :
miliar minor defect in the nail plate
Other nail disorders : yellowish macules beneath the
nail plate, onycholysis, onychodysthrophy

Nail
disorders

yellowish macules
Onikolisis
beneath the nail
distal
plate

Pitting nail onikodistrofi

Arthritis :
- Polyarthricular
Predilection : distal interphalanx joint, swelling,
ankylosis dan contracture
- Rare
Clinical Variations

1. Flexural / Inversus psoriasis

2. Guttate ( Eruptive ) psoriasis
Rough, small drop lesions
3. Seborrheic psoriasis (seboriasis)
Overlapping conditions. Seborrheic dermatitis evolve into
psoriasis. Lesions on seborrheic area
4. Pustular psoriasis
a. Localized pustular psoriasis ( Barber )
Chronic, miliar pustules on palms & soles
b. Generalized pustular psoriasis ( von Zumbusch )
acute with fever, group of pustules. Due to abrupt stop
systemic Corticosteroid/potent topical steroid
5. Psoriatic erythroderma
Chronic, generalized psoriasis.
Clinical Variations

Flexural / Inversus psoriasis

Clinical Variations

Guttate ( Eruptive ) psoriasis :

Rough, small drop lesions
Clinical Variations

Localized pustular psoriasis ( Barber )

Chronic, miliar pustules on palms & soles
Generalized pustular psoriasis ( von
Zumbusch ) :
acute with fever, group of pustules.
Due to abrupt stop systemic
Corticosteroid/potent topical steroid
Psoriatic erythroderma
Chronic, generalized psoriasis.
Histopathology

Epidermis :
1. Hyperkeratosis, parakeratosis, acanthosis
2. Munro’s Abscess
3. Stratum granulosum thinner
4. Kogoj’s micropustules

Dermis :
1. Papillomatosis
2. Capilarry vasodilatation
3. Dermal Infiltrat
Kogoj’s micropustules

Munro’s Abscess
Differential diagnosis

1. Dermatophytoses
Very itchy, central healing (+)
KOH preparation : Fungus elements (+)
Differential diagnosis
2. Seborrheic Dermatitis
Yellowish scales
Predilection : Seborrheic area
Differential diagnosis

3. Secondary syphilis psoriasiform

Generalized lymphadenopathy.
Serologic Tests for Syphilis (+)
Coitus suspectus (+)
Pencatatan PASI (Psoriasis Area Severity Index)

- Untuk evaluasi klinis

- Diukur 4 bagian tubuh :
- Kepala (h)
- Ektremitas atas (u)
- Badan (t)
- Ekstremitas bawah (I) dan masing-masing
disesuaikan dengan persentasi luas lesi.
 Karakteristik bagian lesi :
- Eritema (E),
- Infiltrasi (I),
- Deskuamasi (D)
Yg diukur dengan skala 0 – 4
 Rumus :
0.1(Eh+Ih+Dh)Ah}+{0.2(Eu+Iu+Du)Au}
+{0.3(Et+It+Dt)At}+{0.4(Ei+Ii+Di)Ai}
 Pemilihan terapi
Pengobatan tergantung pada :
 Bentuk klinis
 Luas/keparahan penyakit :
- Ringan <5% atau PASI <8
- Sedang 5-20% atau PASI 8-12
- Berat >20% atau PASI >12
 Lokasi lesi (kulit kepala, wajah, lipatan,
telapak tangan/kaki, genitalia)
 Strategi Pengobatan
Eritroderma, pustulosa,
Langkah 3 : Sistemik PV parah,
Artritis

Langkah 2 : Fototerapi
PG luas, PV sedang/parah

Langkah 1 : Tx topikal PG, PV ringan

Managements
A. Topical

1. Tar
Fossil : ichthyol
Wood : oleum cadini & oleum ruski
Coal : LCD 2 – 5 %

2. Anthralin/ dithranol 0,2 – 0,8%

Quite effective for psoriasis
Tanning skin and clothes

3. Corticosteroid : high potency steroid

4. Phototherapy
 A. Photochemotherapy ( PUVA )
 B. UVB combined with tar (Göeckerman
Method)
 C. UVB combined with anthralin ( Ingram
Method)
 D. Solarium (combination UVA & UVB)
B. Systemic

1. Photochemotherapy
UVA + Methoxalen (8-MOP) oral 2 hr
before exposure
2. Methotrexate (MTX)
For pustular psoriasis, psoriatic artritis,
psoriatic erythroderma.
S.E : Hepatotoxic, haematotoxic,
nephrotoxic
3. Retinoids ( etretinate & acitretin )
For recalcitrant psoriasis .
4. Cyclosporine
immunosuppressive.
Dosage 2,5 – 3mg/kg/day
5. Corticosteroid
For pustular psoriasis or recalcitrant
psoriasis.
Pitiriasis Rosea Gibert
Definisi :

Penyakit kulit sub akut, dengan papul,

plakat, eritema, tertutup skuama
halus. Tersusun sesuai garis lipatan
kulit

Epidemiologi
- Semua usia, ( 10 – 35 tahun )
- Wanita : Pria = 1,5:1
- Muncul pada musim semi & gugur

Etiologi ?
Virus HHV-7 atau HHV-6
Gambaran klinis

• Biasanya asimptomatik, pruritus, flu like

syndrome
• Lesi primer Herald patch :
- Plak eritem/hiperpigmentasi, skuama halus pd
pinggirnya, batas tegas, ∅ 2-4 cm, oval / bulat
- Lokasi : Badan
HERALD PATCH
Lesi sekunder :
• Timbul beberapa hari- minggu  2 minggu
• Lokasi : badan & ekstremitas proksimal
• Plak kecil , mirip dgn lesi permulaan ø
lebih kecil. Lesi tersusun sejajar dg garis
lipatan kulit shg pada punggung
gambarannya menyerupai pohon cemara
terbalik (Christmast tree pattern)
• Atipikal : bentuk papul, vesikel,urtika dan
plak spt psoriasis
Diagnosis Banding
1.Tinea korporis
2. Sifilis stadium II
3. Psoriasis gutata
Terapi
Self-limited diseases
Simtomatis  Kortikosteroid
topikal potensi sedang

Prognosis
Baik. Swasirna dalam 4-10 minggu
Eritroderma
Definisi
Kelainan kulit berupa eritema di seluruh
atau hampir seluruh tubuh disertai
skuama

Sinonim
Dermatitis eksfoliativa, Eritroderma
eksfoliativa,

Epidemiologi
Semua golongan usia  Dewasa >> (40-60 th)
Laki-laki 2 – 4 kali lebih sering dari wanita
Etiologi
1. Akibat perluasan penyakit kulit :
Psoriasis , dermatitis seboroik,dll
2. Akibat penyakit sistemik termsk keganasan
Sindroma sezary
3. Akibat alergi obat biasanya sistemik
 PATOFISIOLOGI
• Eritem  vasodilatasi pemb darah 
kehilangan panas dingin,
menggigil, hipotermi
• Gangguan termoregulasi
• Penguapan cairan  dehidrasi
• Kehilangan skuama  9 gram/hr 
hipoproteinemia
Gejala
Gatal & panas, malaise, kedinginan

Gambaran klinis
• Eritema difus di seluruh/ hampir slrh tubuh  epidermis
tipis & mengkilat.
• Skuama putih atau kekuningan
• Pada yang kronik dapat terjadi penebalan kulit
• Dapat mengenai kuku dan palmoplantar
• Keln.Lab : Hipoalbumin
• Pd keganasan (Sindr. Sezary) : Limfosit T ganas yg
bersirkulasi (sel sezary), & limfadenopati generalisata
,keratoderma dgn fisur, nyeri, alopesia difus, fasies
leonina, gatal hebat.
Penatalaksanaan
a. Rawat Inap
Pengobatan tergantung etiologi
Koreksi ggn keseimbangan cairan dan
elektrolit,termoregulasi, hipoproteinemia.
b. Topikal
Emolien / lanolin dalam bentuk ointment.
c. Sistemik :
E / Bukan psoriasis : KS Sistemik 40 – 80 mg / hari tdk
berespon dg KS : MTX 2,5 – 7, 5 mg tiap 12 jam, 3 x
per minggu
Antihistamin utk mengurangi gatal.

Prognosis
Tergantung penyebab