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SKEN ARIO 5

PSO RIASIS VU LG ARIS

SUSIANTY HUKUBUN

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LEARNING OBJECTIVES

Patogenesis dan faktor pencetuspenyakit

Gejala klinik dan peeriksaan klinik Ga!aran "istopatologi

Alur diagnosa !anding dan diagnosa

kerja penyakit #dukasi kepada pasien

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PENGERTIAN

Psoriasis $ulgaris erupakanpenyakit autoiun% !ersifat kronikdan residif yang tidak dapatdiprediksi

&itandai dengan adanya !ercak'!ercak eritea !er!atas tegas

dengan skuaa kasar% !erlapis'lapisdan transparan(

&isertai dengan fenoenon tetesan

lilin% Auspit)% dan Ko!ner*

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ETIOLOGI

Penye!a! tidak pasti

+aktor'faktor,

Peendekan turn o-er epideris Predisposisi genetik

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Faktor Pencetus

Infeksi

Infeksi Beta Heoliticus

Infeksi HI$ Infeksi saluran pernapasan

Stress

Traua enggaruk% !ekas operasi

.!at tertentu anti alaria% lit"iu%Beta adrenergik !locker% NSAI&*

Peru!a"an ikli

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Predileksi

Tepat uda" terkena trua

Siku

/utut Sakru

Kepala

Genitalia

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Patogenesis

Genetik

&iteukan gen psoriasis

Bisa autosoal doinan ataupoligenik

Ada "u!ungan pada ke!ar

ono)ygot 01234 dan ke!ardy)ygot 05234

Ada "u!ungan resiko dengan H/A'678 eningkat 923

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Patogenesis

Perubahanmorfologik dankerusakan sel

epidermis

Akumulasi selmonosit danlimfosit padapuncak papildermis dan didalam stratum

basalis

Pembesaran danpemanjanganpapil dermis.

Selepidermodermalbertambah luas,lipatan di lapisan

bawah stratumspinosum

bertambahbanyak.

Pertumbuhankulit lebih cepat

dan masapertukaran kulit

menjadi lebihpendek darinormal, dari 28hari menjadi 3!

hari.

Stratumgranulosum tidakterbentuk dan di

dalam stratumkorneum terjadiparakeratosis.

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Patogenesis

Peru!a"an orfologik dan kerusakan sel epideris

Akuulasi sel onosit dan lifosit pada puncakpapil deris dan di dala stratu !asalis

Pe!esaran dan peanjangan papil deris* Sel epideroderal !erta!a" luas% lipatan di

lapisan !a:a" stratu spinosu !erta!a"!anyak*

Proses ini enye!a!kan pertu!u"an kulit le!i"cepat dan asa pertukaran kulit enjadi le!i"pendek dari noral% dari 9; "ari enjadi 5'< "ari*

Stratu granulosu tidak ter!entuk dan di dalastratu korneu terjadi parakeratosis*

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Geala klinik

Kelu"an,

Sedikit gatal

Panas

Kosetik

&i Kulit,

#ritea akula !atas tegas% tertutup skuaate!al% transparan

Kaars-lek p"enoena fenoena !ercak lilin* Autpits sign !intik perdara"an

+enoena koe!ner pd daera" kulit yangterkena traua !erulang*

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&i Kuku

Keru"

Punktate

!erlo!ang Hiperkeratosis

su!lingual

Kuku tangan ==kaki

>enyerang ukosadan sendi

&i Sendi dan>ukosa

Psoriasisart"roatica

Psoriasis-asculosa di

telapak tangan

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Ga! "aran #istoPA

Hiperplasia regularepideris denganparakeratosis

kon?uen sertaadanyapeningkatanneutrop"il padastrau korneu0>unro >icroa!ses4dan epideris0Kogoj ikroa!ses4

Pla)a @A% Prieto $G* In?aatory skin disorder* Ne: York, &eos >edicalPu!lis"ing% 929*

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Lanutan$

Pada pe!esaranyang le!i" !esarenunjukanadanyaparakeratosiskon?uen

Hilangnya lapisangranular%

Adanya dilatasi

pe!ulu" dara"pada perukaanderis

Serta pene!alansuprapapilary plate*

Pla)a @A% Prieto $G* In?aatory skin disorder* Ne: York, &eos >edicalPu!lis"ing% 929*

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* Hiperkeratosis dengan parakeratosis 0>aturasi a!noral4*9* Hilangnya Granular layer*

5* Akantosis epideral dan elongasi dari rete ridges 0"iperproliferasi4

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%iagnosa "anding

/ues stadiu II 0psorisisfor4

Skuaa !er:arna coklat te!aga dan

&ering disertai dea pada ala "ari(dolores nocturnal).

Lesi tidak gatal,

dapat diteukan di telapak tangan dan

telapak kaki% terdapat pe!esaran kelenjar geta" !ening yang

generalista dan

Tes serologi untuk silis 0TSS4 positif*

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Pytirlasic rosea

Biasanya !erjalan su!akut%lesi

!er!entuk o-al% tepi sedikit eninggi dan ditutupi

skuaa "alus*

Predileksi !iasanya didaera" !adanyang tertutup pakaian*

>or!us "ansen

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&eratitis se!oroik

Biasanya enunjukkan kulit yang

!erinyak tanpa Skuaa yang !erlapis'lapis*

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%iagnosa kera &en'akit

Ananesis

Pes

Peeriksaan Penunjang

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Penatalaksanaan

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State o( t)e Ar! a! entariu!

7ide range of t"erapies for t"etreatent of oderate to se-erepsoriasis

None induce a peranent reission

All "a-e side eCects t"at can placeliits on t"eir use

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State o( t)e Ar! a! entariu!

T"erapies Topical 6orticosteroids Topical $itain &5 Analogues

Topical Detinoids P"oto0c"eo4t"erapy Systeic T"erapies

.ral Parenteral

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To&ical Corticosteroids

Hig" potency and Super potent topicalsteroids

T"ese include +luocinonide faily 0crea% ointent%

gel4 Betaet"asone dipropionate crea

6lo!etasol propionate faily 0crea%ointent% gel% foa% lotion4 &i?orasone diacetate ointent Betaet"asone dipropionate

ointent

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To&ical Corticosteroids

Side eCects associated :it" use Skin atrop"y

Burning and stinging

Suppression of t"e "ypot"alaic'pituitary'adrenal 0HPA4 aEis

T"is ay occur after 9 :eeks of use :it"

certain topical corticosteroids

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To&ical Vita! in % *Analogues

Prototype for t"is group iscalcipotriene

5 forulations F crea% ointent%and scalp solution

+orer t:o are appro-ed for plauepsoriasis

/atter for oderate to se-erepsoriasis of t"e scalp

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To&ical Vita! in % *Analogues

Side #Cects 6utaneous

Burning

Stinging

Pruritus

Skin irritation

Tingling of t"e skin

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To&ical Retinoids

Ta)arotene Gel and 6rea A-aila!le in t:o strengt"s2*23 and 2*3

Side #CectsPruritusBurningStinging#ryt"ea

7orsening of psoriasis IrritationSkin painHypertriglycerideia

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To&ical Ta+arotene

Additional Indications 2*3 gel ' appro-ed for t"e treatent

of facial acne -ulgaris of ild to

oderate se-erity 2*3 crea appro-ed as an

adjuncti-e agent for use in t"eitigation of facial ne :rinkling%facial ottled "yper' and"ypopigentation% and !enign faciallentigines in patients :"o usecopre"ensi-e skin care and sunlig"ta-oidance progras

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To&ical Ta+arotene ,con-t.

Bot" products are pregnancy categoryJ

Are contraindicated in :oen :"o areor ay !ecoe pregnant

Deuireents !efore and duringt"erapy

A negati-e pregnancy test 9 :eeksprior

T"erapy initiated during a noralenses

7oen of c"ild!earin otential

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P)oto,c)e! o.t)era&'

T:o types of p"otot"erapy

Ultra-iolet B 0U$B4 Ultra-iolet A psoralen 0PU$A4

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/VB

T:o types Broad!and U$B

Narro:!and U$B 05'55 n4

Treatent is tie consuing 9'5 -isits:eek for se-eral ont"s

Side eCect F possi!ility of

eEperiencing an acute sun!urnreaction

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P/VA

6onsists of ingestion of or topical treatent:it" a psoralen follo:ed !y U$A

Usually reser-ed for se-ere% recalcitrant%

disa!ling psoriasis Tie consuing F 9'5 -isits:k( at least 8

:eeks

Precautions Patients ust !e protected fro furt"er U$

lig"t for 9< "ours post treatent 7it" oral psoralen% :rap around U$'!locking

glasses ust !e :orn for 9< "ours posttreatent

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P/VA

Side eCects :it" oral psoralen Nausea &i))iness Headac"e

Side eCects :it" PU$A #arly

Pruritus /ate

Skin daage Increased risk for skin cancer% particularly

suaous cell 0S664 and after 922 ' 92treatents% increased risk for elanoa

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Contraindications to P/VA

Patients less t"an 9 years of age

Patients :it" a "istory of lig"t

sensiti-e disease states Patients :it"% or :it" a "istory of

elanoa

Patients :it" in-asi-e S66

Patients :it" ap"akia

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S'ste! ic T)era&ies

.ral >et"otreEate Neoral 0cyclosporine4 Soriatane 0acitretin4

Parenteral Ae-i-e 0alefacept4

Dapti-a 0efali)ia!4 #n!rel 0etanercept4

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0 et)otre1ate

+olic acid antagonist

Usually reser-ed for se-ere%

recalcitrant% disa!ling psoriasis >aEiu ipro-eent can !e

eEpected after ; '9 :eeks

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Contraindications 2 0 et)otre1ate

Nursing ot"ers

Patients :it" alco"olis

Alco"olic li-er disease .t"er c"ronic li-er disease

Patients :it" o-ert or la!oratorye-idence of iunodeciency

syndroes Patients :"o "a-e preeEisting !lood

dyscrasias

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0 et)otre1ate

Pregnancy 6ategory J drug product 6ontraindicated in pregnant :oen

:it" psoriasis

Pregnancy ust !e eEcluded in:oen of c"ild!earing potential Pregnancy s"ould !e a-oided if eit"er

partner is recei-ing >TJ during andfor a iniu of 5 ont"s aftert"erapy for ale patients and for atleast one o-ulatory cycle aftert"erapy for feale patients

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0 et)otre1ate 3 Side E((ects

Acute or c"ronic "epatotoEicity Hepatic cirr"osis /eukopeniaT"ro!ocytopenia

Aneia% including aplastic aneia Darely% interstitial pneuonitis Stoatitis

Nausea-oiting Alopecia P"otosensiti-ity Burning of skin lesions

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0 et)otre1ate

>ultiple prescreening tests necessary

Decoendations for "epaticonitoring

Periodic /+Ts including seru al!uin

/i-er !iopsy

Pret"erapy or s"ortly t"ereafter

6uulati-e dose of * grasAfter eac" additional *2 to *

gras

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Neoral

Potent Iunosuppressi-e

Adult% non'iunocoproised

patients :it" se-ere% recalcitrantplaue psoriasis

>aEiu eLcacy ac"ie-ed at 8:eeks of t"erapy

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Contraindications 2 Neoral

6oncoitant PU$A or U$B t"erapy

>et"otreEate or ot"eriunosuppressi-e agents

6oal tar or radiation t"erapy

Patients :it" a!noral renal function

Patients :it" uncontrolled "ypertension

Patients :it" alignancies

Nursing ot"ers

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Neoral 3 Side E((ects

Possi!ility of Irre-ersi!le renal daage Hypertension Headac"e

Hypertriglycerideia Hirsutis"ypertric"osis Parest"esia"yperest"esia In?uen)a'like syptos

Nausea-oiting &iarr"ea /et"argy Art"ralgia

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Neoral

>ultiple prescreening tests arereuired

Tests ust continue t"roug"outtreatent :it" dosage adjustent asnecessary to pre-ent end'organdaage

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Soriatane

.ral retinoid appro-ed for t"etreatent of se-ere psoriasis inadults

Signicant ipro-eent can !eac"ie-ed :it" ; :eeks of t"erapy

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Soriatane 2 Contraindications

Patients :it" se-erely ipaired li-eror kidney function

Patients :it" c"ronic a!norallyele-ated !lood lipid -alues

Patients :"o are takinget"otreEate

#t"anol use :"en on t"erapy and for9 ont"s follo:ing t"erapy in fealepatients

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Soriatane

Pregnancy 6ategory J drug productas it is a "uan teratogen

6ontraindicated in pregnant fealesor t"ose :"o intend to !ecoepregnant during t"erapy or any tieup to t"ree years post t"erapy

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Soriatane 3 Side E((ects

T"ose associated :it" retinoid t"erapy

6"eilitis

Alopecia

Skin peeling

&ry skin

Pruritus

D"initis

Jeropt"alia

Art"ralgia

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Soriatane 3 Side E((ects

/a!oratory A!noralities Hypertriglycerideia 08834 &ecreased H&/ 0

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Soriatane

>ultiple prescreening tests ust !eo!tained

6ontinued onitoring t"roug"outt"erapy necessary :it" possi!ledosage adjustent

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Parenteral T)era&'A! e4i4e

Iunosuppressi-e dieric fusionprotein #Etracellular 6&9'!inding portion of t"e

"uan leukocyte function antigen'50/+A'54

/inked to t"e +c portion of "uan IgG

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A! e4i4e

Indicated for t"e treatent of adultpatients :it" oderate to se-erec"ronic plaue psoriasis

7it" 9 :eeks of t"erapy% a diseasestate of clear or alost clear :asac"ie-ed !y 3 0-ia I$4 and 4 of patients% respecti-ely

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A! e4i4e 3 Side E((ects

&ose dependent reduction incirculating 6&

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A! e4i4e 3 Side E((ects

/yp"openia

Increase risk of alignancies

Skin cancer F B66 and S66

/yp"oa

Serious infections reuiring"ospitali)ation

Disk of reacti-ation of c"ronic% latentinfections

Hypersensiti-ity reactions

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Edukasi