INTRODUCTION Psoriasis is a chronic inflammatory skin disease that has a close relationship with genetic factors, characterized by complex changes in the growth and differentiation of various abnormalities and abnormal epidermal biochemistry, immunology, and blood vessels. Psoriasis is regarded as a primary disorder of keratinocytes. Has the form of a patch lesion demarcated erythema with rough scaly, multi-layered and transparent with wax drip phenomenon, and the phenomenon kobner Auspitz sign. 10 Psoriasis affects both sexes equally and can occur at any age, although it most commonly appears for the first time between the ages of 15 and 25 years. Psoriasis was first diagnosed before age 40 in 40% of patients with psoriasis. 2 Psoriasis can be classified according to the clinical picture, namely, guttate psoriasis, erythrodermic psoriasis, napkin psoriasis, inverse psoriasis, psoriasis arthritis, psoriasis vulgaris, pustular psoriasis and sebopsoriasis. 12 Psoriasis vulgaris is a chronic skin disease characterized by recurrent and presence of macular erythematous, round or oval shape can be covered scaly thick, transparent or grayish white. Smallsingle lesion might be confluent with firm boundaries resembles a map (psoriasis geographica). 11 It may be associated with other inflammatory disorders such as psoriatic arthritis, inflammatory bowel disease, and coronary artery disease. 7 1
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INTRODUCTION
Psoriasis is a chronic inflammatory skin disease that has a close relationship with genetic
factors, characterized by complex changes in the growth and differentiation of various
abnormalities and abnormal epidermal biochemistry, immunology, and blood vessels. Psoriasis
is regarded as a primary disorder of keratinocytes. Has the form of a patch lesion demarcated
erythema with rough scaly, multi-layered and transparent with wax drip phenomenon, and the
phenomenon kobner Auspitz sign.10
Psoriasis affects both sexes equally and can occur at any age, although it most commonly
appears for the first time between the ages of 15 and 25 years. Psoriasis was first diagnosed
before age 40 in 40% of patients with psoriasis.2
Psoriasis can be classified according to the clinical picture, namely, guttate psoriasis,
Psoriasis vulgaris is a chronic skin disease characterized by recurrent and presence of
macular erythematous, round or oval shape can be covered scaly thick, transparent or grayish
white. Smallsingle lesion might be confluent with firm boundaries resembles a map (psoriasis
geographica).11 It may be associated with other inflammatory disorders such as psoriatic arthritis,
inflammatory bowel disease, and coronary artery disease.7
Psoriasis vulgaris is one of the most common inflammatory skin diseases among
Caucasians worldwide. With its early onset – usually between the ages of 20 and 30 – as well as
its chronic relapsing nature, psoriasis is a lifelong disease that has a major impact on affected
patients and society. Patients with psoriasis face substantial personal expense, strong
stigmatization, and social exclusion. Management of psoriasis includes treatment, patient
counselling, and psychosocial support.7 Nearly 30% of psoriasis patients have arthritis problems.
The onset of the disease occurs most commonly at about the age of 20 years. 10 to 15 % of
people have psoriatic arthritis.1
In the United States, about 7 million people (2%-3% of people) have psoriasis. About
150,000-260,000 new cases are diagnosed each year10. Most people who have psoriasis of the
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nails also have skin psoriasis (cutaneous psoriasis). Only 5% of people with psoriasis of the nails
do not have skin psoriasis. In people who have skin psoriasis, 10%-55% have psoriasis of the
nails (also called psoriatic nail disease). About 10%-20% of people who have skin psoriasis also
have psoriatic arthritis, a specific condition in which people have symptoms of both arthritis and
psoriasis. Of people with psoriatic arthritis, 53%-86% have affected nails, often with pitting.
Psoriasis tends to run in families. If you have a parent or a sibling who has psoriasis, you have a
16%-25% chance of having psoriasis, too. If both of your parents have psoriasis, your risk is
75%. Males and females are equally likely to have psoriasis. Psoriasis can occur in people of all
races.1
Psoriasis vulgaris with incidence in Western industrialized countries of 1.5% to 2%. In
more than 90% of cases, the disease is chronic. Patients with psoriasis vulgaris have a
significantly impaired quality of life. Depending on its severity, the disease can lead to a
substantial burden in terms of disability or psychosocial stigmatization. Indeed, patient surveys
have shown that the impairment in quality of life experienced by patients with psoriasis vulgaris
is comparable to that seen in patients with type 2 diabetes or chronic respiratory disease. Patients
are often dissatisfied with current therapeutic approaches, and their compliance is poor. Patient
surveys have shown that only about 25% of psoriasis patients are completely satisfied with the
success of their treatment, while over 50% indicate moderate satisfaction and 20% slight
satisfaction. The rate of non-compliance with systemic therapy is particularly high, ranging up to
40%.8
The prevalence of psoriasis is low in certain ethnic groups such as the Japanese, and may
be absent in aboriginal Australians2 and Indians from South America.6 Cause of psoriasis is still
unknown however, there are several factors such as : Genetic, inherited autosomal dominant with
incomplete penentrance and is associated with human leukocyte antigen (HLA)-B13, B17,
Bw57, Cw6, B27, and CW2. Immunologic factors, the genetic defect is expressed on T
lymphocytes, Langerhans cells, and keratinocytes. Several factors are thought to aggravate
psoriasis such as a streptococcal infected, stress, excessive alcohol consumption, and smoking.
Certain medicines, including lithium salt and beta blockers, have been reported to trigger or
aggravate the disease. Excessive alcohol consumption, smoking and obesity may exacerbate
psoriasis or make the management of the condition difficult. Individuals suffering from the
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advanced effects of the human immunodeficiency virus, or HIV, often exhibit psoriasis.
Sometimes food can also trigger the disease process. For e.g. citrus fruits, sour foods, sauces,
coffee, tea, alcohol and soft drinks.1
The diagnosis of psoriasis vulgaris is based almost exclusively on the clinical appearance
of the lesions. Auspitz’s sign (i.e. multiple fine bleeding points when psoriatic scale is removed)
may be elicited in scaly plaques. Involvement of predilection sites and the presence of nail
psoriasis contribute to the diagnosis. Occasionally, psoriasis is difficult to distinguish from
nummular eczema, tinea, or cutaneous lupus. Guttate psoriasis may resemble pityriasis rosea. In
rare cases, mycosis fungoides must be excluded. If the skin changes are located in the
intertriginous areas, intertrigo and candidiasis must be considered. In some cases, histological
examination of biopsies taken from the border of representative lesions is needed to confirm the
clinical diagnosis.8
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CASE REPORT
2.1. Identity Of Patient
Name : Mrs.K
Sex : Female
Registration number : 0-87-14-52
Age : 40 years old
Address : Ds. Blang Bintang
Occupation : Housewife
Examination Date : May, 26th 2014
2.2. Anamnesis
The Chief Complaint :
itching and red spots on the back of the left ear and body.
Additional Complaints :
Itchy on the lesion.
History of Present Illness :
The patient came to the clinic with complaints of itching and red spots on the back of the left ear and body since 3 years ago. In the first of the symptom start with a small of white lesion with the severe itching then the patient starching the lesion every time until the last year before she goes to polyclinic the lesion begin a red spot with the bigger plaque and much.
History of Previous Illness :
The patient admitted she had ever felt like this condition 8 year ago
History of Family Disease :
None of her family had the same disease or complaint like her.
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History of Treatment:
Last treatment on the polyclinic of dermatology dept (May 26th 2014)
2. Asam salisilat 3% + Diflucortolone valerate cream (afternoon)
3. Asam salisilat 3% + Vaselin album cream (night)
History of Social Habits :
The patient experiences stress in terms of its economy. Patient difficulties in
terms of school fees of his children.
2.3. Physical Examination
Vital Sign :
1. Blood pressure : 120/80 mmHg
2. Pulse : 80 beats/ minute
3. Respiratory Rate : 18 breaths/ minute
4. Temperature : 36,7˚C
Dermatological status :
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Figure 2.1 On regio posterior thoracalFigure 2.2 On regio ante bracii dextra and sinistra
Figure 2.1 At regio thorax posterior, erythematous plaques appeared, demarcated, irregular edges, the size of miliary up plaque, the number of multiple, over rough scaly lesions found generalized distribution.premises.
Figure 2.3 On regio extrimitas inferior
Figure 2.3 At regio extrimitas inferior, erythematous plaques appeared, demarcated, the number of multiple, irregular edges, the size of miliary up plaque, generalized distribution, and there is a scaling on it.
2.4 Resume :
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Figure 2.2 At regio extrimitas superior,
erythematous plaques appeared,
demarcated, irregular edges, the size of
miliary up plaque, the number of multiple
over smooth scaly lesions found
generalized distribution.premises.
The Patient came to the clinic with complaints of itching and red spots on the back of the
left ear and body since 3 years ago. In the first of the symptom start with a small of white lesion
with the severe itching then the patient starching the lesion every time until the last year before
she goes to polyclinic the lesion begin a red spot with the bigger plaque and much. On
Dermatological status At regio thorax posterior, erythematous plaques appeared, demarcated,
irregular edges, the size of miliary up plaque, the number of multiple, over rough scaly lesions
found generalized distribution.premises. At regio extrimitas superior, erythematous plaques
appeared, demarcated, irregular edges, the size of miliary up plaque, the number of multiple over
smooth scaly lesions found generalized distribution.premises. And at regio extrimitas inferior,
erythematous plaques appeared, demarcated, the number of multiple, irregular edges, the size of
miliary up plaque, generalized distribution, and there is a scaling on it.
2.5 Differential Diagnosis :
1. Psoriasis Vulgaris
2. Tinea Korporis
3. Morbus Hansen Type TT
4. Pytriasis Rosea
5. Ekzema Seborrheic
2.6 Diagnose :
Psoriasis Vulgaris plaque type
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2.7 Planning :
Skin test :
- Kaarsvlek examination phenomen (+) : On examination karsvlek phenomenon in the
hands and feet be obtained which the positive
outcome when done scraping the lesions look
like a murky color was scrapings.
- Auspitz Sign Checks (+) : On examination Autspitz sign positive results which when
pursued scour the lesion seen on the bleeding point.
:
- Koebner examination (+) : On examination Koebner phenomenon also obtained positive
results when performed in which a healthy scratch on the skin
a few days later new lesions appear on the skin healthy.