TATA LAKSANA RASIONAL LIKEN SIMPLEKS KRONIKUS

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TATALAKSANA RASIONAL LIKEN SIMPLEKS KRONIKUS

dr. Agustina Tri Pujiastuti SpKK


OUTLINE

DEFINISI PATOGENESA MANIFESTASI KLINIS DIAGNOSIS TATALAKSANA PROGNOSIS


DEFINISI

• Liken Simpleks Kronikus (LSK): Suatu peradangan kulit kronik yang sangat gatal berupa penebalan kulit dan likenifikasi berbentuk sirkumskripta, akibat garukan berulang

• Nama lain : Neurodermatitis Sirkumskripta • ICD 10 : L28


Epidemiologi

• 12% populasi dunia menderita penyakit liken simplex kronikus/neurodermatitis

• Umumnya terjadi pada usia 30 hingga 50 tahun


PATOGENESA

Penebalan kulit dan

likenifikasi

Gosokan/

Rubbing

Garukan/

Scratching

PRURITUS (SEKUNDER/KRONIS)



Faktor Pencetus Pruritus

Kelainan Kulit

• Dermatitis Atopik

• Superimposed pada dermatosis lain misalnya psoriasis, dermatitis kontak, ineksi kandida dan tinea

Psikologis

• Gangguan anxietas

• Depresi

• Obsessive-compulsive disorder

Kelainan Sistemik

• Renal insufficiency

• Hiper- or hipotiroid

• Liver failure

• Hepatitis B and C

• HIV

• Infeksi Helicobacter, mycobacterial atau parasit

• Keganasan hematologi atau organ padat


ANAMNESIS

• Gatal - Bisa paroksimal /terus menerus/sporadik - Eksaserbasi saat stres

• Dapat mengganggu tidur


Manifestasi Klinis

• Predileksi : daerah yang mudah dijangkau tangan seperti kulit kepala, tengkuk, ekstremitas ekstensor, pergelangan tangan, dan area anogenital (vulva, skrotum, perianal)

• Lesi kulit berupa likenifikasi - Dapat tunggal atau multipel - Ukuran lentikular hingga plakat

Eritema/edema/

papul/pustule

Plak likenifikasi dengan skuama dan ekskoriasi, hiperpigmentasi

atau hipopigmentasi



Lichen Simplex Nuchae



PEMERIKSAAN PENUNJANG 1. Pemeriksaan Histopatologi • Berbagai derajat hiperkeratosis dengan

parakeratosis dan orthokeratosis, hipergranulosis dan hiperplasia epidermis psoriasiformis

• Penebalan kolagen dengan bundle kolagen kasar dan garis vertikal pada papila dermis

• Infiltrat sel inflamasi seperti limfosit, histiosit dan eosinofil pada sekitar plexus vaskular

Torales J, Barrios I, Lezcano L and Di Martino B. Lichen Simplex Chronicus: Easy Psychological Interventions that Every Dermatologist Should Know. SM J Dermatolog. 2016; 2(1): 1005


2. Pemeriksaan lain sesuai diagnosis banding, seperti imunofluoresens direk, pemeriksaan KOH, patch test


DIAGNOSIS BANDING



TATA LAKSANA

Identifikasi penyakit

yang mendasari

Perbaiki fungsi lapisan

barier kulit

Kurangi inflamasi

Putuskan siklus gatal-

garuk


TATA LAKSANA


KORTIKOSTEROID TOPIKAL



STUDY OBJECTIVE CONCLUSION

Guzzo CA, Weiss JS, Mogavero HS, et al. A review of two controlled multicenter trials comparing 0.05% halobetasol propionate ointment to its vehicle in the treatment of chronic eczematous dermatoses. Journal of the American Academy of Dermatology. 1991;25(6):1179-1183. Kantor I, Cook PR, Cullen SI, Willis I, Gibson JR, Stanfield JW. Double-blind bilateral paired comparison of 0.05% halobetasol propionate cream and its vehicle in patients with chronic atopic dermatitis and other eczematous dermatoses. J Am Acad Dermatol. 1991;25(6 Pt 2):1184-1186.

The efficacy of halobetasol propionate in reducing disease severity in patients with LSC

Significant reduction in pruritus, erythema, scaling, and lichenification in treated patients compared to controls



Datz B, Yawalkar S. A double-blind, multicenter trial of 0.05% halobetasol propionate ointment and 0.05% clobetasol 17-propionate ointment in the treatment of patients with chronic, localized atopic dermatitis or lichen simplex chronicus. Journal of the American Academy of Dermatology. 1991;25(6 II SUPPL.):1157- 1160 Brunner N, Yawalkar S. A double-blind,multicenter, parallel-group trial with 0.05% halobetasol propionate ointment versus 0.1% diflucortolone valerate ointment in patients with severe, chronic atopic dermatitis or lichen simplex chronicus. Journal of the American Academy of Dermatology. 1991;25(6 II SUPPL.):1160-1163

Comparing the efficacy of halobetasol propionate to diflucortolone valerate and clobetasol 17-propionate respectively

Halobetasol had higher success rates and onset of action compared to diflucortolone, and higher healing rates than clobetasol, though these results were not statistically significant



Rajan VS. Controlled double blind trial with supracortin cream. Singapore Medical Journal. 1976;17(4):216-218

Compare the efficacy of once daily application of fluprednidene- 21-acetate to thrice daily application of betamethasone 17-valerate

No significant differences in the reduction of symptomatology scores were noted in either group after 2 weeks of treatment (mean change in score 5.3 for fluprednylidene-21-acetate and 3.8 for betamethasone p=.17) suggesting that fluprednylidene applied once daily was as effective as thrice daily application of betamethasone, allowing for smaller quantities of a potent steroids to be applied with potentially fewer side effects



Geraldez MCB, Carreon‐Gavino M, Hoppe G, Costales A. Diflucortolone Valerate Ointment With and Without Occlusion in Lichen Simplex Chronicus. International Journal of Dermatology. 1989;28(9):603- 604

The utility of occlusion as adjunctive therapy with topical corticosteroids

A significantly lower improvement of lichenification and pruritus (p<.001 for both) and even led to development of more side effects

Volden G. Successful treatment of chronic skin diseases with clobetasol propionate and a hydrocolloid occlusive dressing. Acta Dermato-Venereologica. 1992;72(1):69-71

Once weekly application of clobetasol propionate and duoderm occlusive dressing led to complete remission of disease in 89% patients in two weeks


EFEK SAMPING KORTIKOSTEROID TOPIKAL

• Atrofi kulit • Reaksi akneiformis

• Perubahan pigmentasi • Hipertrikosis • Infeksi kulit • Reaksi alergi


PREPARAT ANTIPRURITUS NON STEROID



Drake LA, Millikan LE. The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Doxepin Study Group. Arch Dermatol. 1995;131(12):1403-1408

Assess the efficacy of doxepin cream applied four times daily for one week in reducing pruritus in patients with LSC

Significantly more patients in the treatment arm had improved pruritus severity scores compared to controls at 1 day and one week of treatment (45% vs 23% respectively within 24 hrs, p=.01, and 76.5% vs 57% respectively within one week, p=.01) as well as a significant improvement in physician global evaluation for pruritus relief scores (p=.003)

Breneman DL, Dunlap FE, Monroe EW, Schupbach CW, Shmunes E, Phillips SB. Doxepin cream relieves eczema-associated pruritus within 15 minutes and is not accompanied by a risk of rebound upon discontinuation. Journal of Dermatological Treatment. 1997;8(3):161-168

Investigating the onset of action of topical doxepin and whether discontinuation of therapy would be associated with rebound worsening

Onset of action occurred within 15 minutes of application (p<.001) and sustained reductions in pruritus occured through one week of treatment. Additionally, no rebound effect was seen after discontinuing therapy with doxepin cream (p<.001)


Calcineurin Inhibitor Topikal

• Salep Takrolimus 0,1% • Krim Pimekrolimus 0,1%

2x sehari selama 12 minggu

Risiko rendah terjadi atrofi dan striea → utamanya untuk studi LSK genital



Goldstein AT, Parneix-Spake A, McCormick CL, Burrows LJ. Pimecrolimus cream 1% for treatment of vulvar lichen simplex chronicus: An open-label, preliminary trial. Gynecologic and Obstetric Investigation. 2007;64(4):180-186

Observational studies : the efficacy of immunomodulators in treating genital LSC across

Complete resolution of pruritus by week 4 of treatment with sustained resolution until the end of treatment at 12 weeks. Disease severity scores as measured by the Investigators Global Assessment (IGA) decreased from a moderate-tosevere baseline score to no disease by the end of treatment with concomitant improvements in erythema, excoriation, and lichenification for all patients

Kelekci HK, Uncu HG, Yilmaz B, Ozdemir O, Sut N, Kelekci S. Pimecrolimus 1% cream for pruritus in postmenopausal diabetic women with vulvar lichen simplex chronicus: A prospective non-controlled case series. Journal of Dermatological Treatment. 2008;19(5):274-278

Significant decreases in pruritus by 4 and 12 weeks of treatment compared to baseline (pruritus score 3.75 at baseline, 2.17 at 4 weeks p<.01, 0.42 at 12 weeks p<.001) and complete cure of disease in 83% of treated patients

Tan E, Tey HL, Tan ES, Tan AS. Tacrolimus ointment 0.1% in the treatment of scrotal lichen simplex chronicus: An open-label study. Annals of the Academy of Medicine Singapore. 2013;42(9):S284

0.1% topical tacrolimus significantly decreased mean itch scores, itch frequency, and overall affected surface area after treatment (p<.001 for all) in 40 patients with scrotal LSC


FOTOTERAPI STUDY OBJECTIVE CONCLUSION

Esen Salman K, Kivanc Altunay I, Salman A. The efficacy and safety of targeted narrowband UVB therapy: a retrospective cohort study. Turkish journal of medical sciences. 2019;49(2):595-603.

Weekly treatments of NBUVB in patients with LSC resistant to prior topical treatment

After a mean of 29 treatment sessions, complete response (>90% improvement) occurred in 30% of patients, and 73.8% of patients showed moderate or better (>50% improvement) responses. Additionally, there was a 75% improvement in mean pruritus scores. Side effects were minimal and primarily included erythema


Emolien

• Dapat sebagai kombinasi dengan kortikosteroid topikal

• Sebagai terapi tunggal pada lesi di vulva


SISTEMIK

• Antihistamin sedatif • Antidepresan trisiklik


TINDAKAN

• Kortikosteroid intralesi (triamsinolon asetonid) : 3-10mg/ml



PROGNOSIS

• Kronis • Durasi rata-rata LSK : 30.6 bulan • Apabila berhubungan dengan penyakit sistemik→

durasi lebih lama • Eksaserbasi dikaitkan dengan respon terhadap stres

dan stimuli eksogen


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TATA LAKSANA RASIONAL LIKEN SIMPLEKS KRONIKUS