KEPANITERAAN KLINIK PERIODE 21 February 26 March 2011 Dermatologic Status UKRIDA School of Medicine SMF ILMU KESEHATAN KULIT

T DAN KELAMIN RSUD R. SYAMSUDIN, SH - SUKABUMI

I.

Patient identification

Name : Mr.DN Date of Birth : 15 July 1988 Marital status : Single Job : Merchant

Gender : Male Race : Javanese Religion : Islam

Adress : Jl Karamat RT 04/ RW 04, gunung puyuh, Sukabumi

II.

ANAMNESIS

History taken by autoanamnesis on 25 February 2011, 10.15 am.

Chief complaint Appearance of distinctly red scaly rashes on head, arms and legs since 2 months ago.

Additional complaint Itchiness and burning sensation on the arms, head and ankles since few months back.

Current medical history : The symptom started as small red rashes on the head of the patient 6 months ago. The rashes kept increasing in size, Itchiness (+), burning sensation (+), loss of hair (-). 4 Months ago, the rashes appeared on both of the ankles. Itchiness (+), burning sensation (+). The scaly rashes on the left ankle left a small bleeding point when it was scratched. 2 Months ago, the rashes started to appear on both of the wrists. The rashes appeared equally on both left and right wrists. Itchiness (+), burning sensation (+). The patient never seeks any medical help for these symptoms. He only used talcum powder to relieve his itchiness.
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The patient claimed that he is not taking any medication at the moment that might cause this condition.

Prior medical history: The patient admitted that he experienced the same problem on his arms 8 years ago, which he ignored and healed on its own. The patient denied any allergic reaction prior to food, chemical substances etc. The patient claimed that he had no other dermatologic disease before. The patient claimed that he had no history of diabetes Mellitus, hypertension, or asthma.

Prior family history : There is no family member with the same complaints. There is no family history of diabetes Mellitus, hypertension, or asthma.

III. General status General condition: good Awareness: compos mentis Vital signs: Blood pressure 120/80 Pulse 88x/ min Temperature 36.4 Respiration rate 18x/ min Anemic Oedema Cyanosis Icterus : (-) : (-) : (-) : (-)

IV. Dermatologic stats Region/ location of lession - Scalps - Left and right ankles - Left and right wrists

Skin lesion Primary Secondary : sharply marginated erythem, papules : silvery scales, plaques

Description of the skin lesion Size : milier to numular

Patterns: polycyclic Distribution and predilection sites : bilateral on both wrists and ankles and the lining of the scalp Enlargement of regional lymph nodes : none

V. Laboratory test: Not done

VI. Recommended test for diagnostic: Removal of scale results in the appearance of minute blood droplets (auspitz sign +)

VII. Medical resume A patient, 22 Years old male complained about red rashes and pruritus on his head, arms and legs. The symptoms initially appeared as small sharply marginated red rashes at lining of the scalp accompanied by burning sensation and unbearable itchiness 6 months ago. 4 months ago, the rashes appeared on both of his ankles. 2 months ago, the rashes started to appear on both of his wrists. The rashes appeared equally on both arms and legs. The rashes increase in size, pruritus (+), burning sensation (+).The patient never seek any medical help for these symptoms. He only used talcum powder to relieve his itchiness. The patient claimed that he is not taking any medication at the moment that might caused this condition. The patient admitted that he experienced the same problem on his arms 8 years ago, which he ignored and healed on its own. The patient claimed that he had no other dermatologic disease before. There is no family members with the same complaints. The patient also denied for having any history of allergic reactions to food, chemical substances etc. On dermatologic examination, a few sharply marginated erythematous papule and plaques with silvery- white scale on both wrists, ankles and at the lining of the scalp. These lesions forming a polycyclic pattern. Removal of the scale results in the appearance of minute blood droplets (auspitz sign +).

VIII. Differential diagnosis 1. Psoriasis 2. Dermatitis seborrhoid 3. Eczema 4. Pityriasis rosea

IX. Working diagnosis

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Plaque psoriasis

X. Treatment General 1. Education that the lession may disappear after the theraphy, but recurrence may happen. Seek medical help if the rashes reappear. 2. Education not to sratch the lession Medicaments Histrine 1x1 for 7 days Imunos caps 1x1 for 7 days Asthin force 1x1 for 7 days Oint intercon gram 30, acid salicyl 2% m.d, sue

XI. PROGNOSIS Ad vitam Ad functionam Ad sanationam : Bonam : Bonam : Dubia

CASE ANALYSIS Psoriasis is a non-contagious common skin condition that causes rapid skin cell reproduction resulting in red, dry patches of thickened skin. The dry flakes and skin scales are thought to result from the rapid build-up of skin cells. Psoriasis commonly affects the skin of the elbows, knees, and scalp. Some people have such mild psoriasis (small, faint dry skin patches) that they may not even suspect that they have a medical skin condition. Others have very severe psoriasis where virtually their entire body is fully covered with thick, red, scaly skin. In this case, Mr. DN, 22 years old male had complained about the emergence of red rashes and pruritus on his head, arms and legs. The symptoms initially appeared as small sharply marginated red rashes at lining of the scalp accompanied by burning sensation and unbearable itchiness 6 months ago. 4 months ago, the rashes appeared on both of his ankles. 2 months ago, the rashes started to appear on both of his wrists. The rashes appeared symmetrically on both arms and legs. The rashes increase in size, pruritus (+), and burning sensation (+).
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These complaints are in lines with the psoriasis symptoms theoretically. Psoriasis typically looks like red or pink areas of thickened, raised, and dry skin. It classically affects areas over the elbows, knees, and scalp. Essentially any body area may be involved. It tends to be more common in areas of trauma, repeat rubbing, use, or abrasions. Psoriatic plaques tend to be symmetrically distributed over the body. Lesions typically have a high degree of uniformity with few morphologic differences between the 2 sides.However, psoriasis has many different appearances. It may be small flattened bumps, large thick plaques of raised skin, red patches, and pink mildly dry skin to big flakes of dry skin that flake off. Psoriasis is considered a non-curable, long-term (chronic) skin condition. It has a variable course, periodically improving and worsening. Sometimes psoriasis may clear for years and stay in remission. Psoriasis is seen worldwide, in all races, and both sexes. Although psoriasis can be seen in people of any age, from babies to seniors, most commonly patients are first diagnosed in their early adult years. As in the case, this patient admitted that he experienced the same problem on his arms 8 years ago (at the age of 14), which he ignored and healed on its own. Referring to the case, the patient claimed that he had no other dermatologic disease before. There is no family members with the same complaints. The patient also denied for having any history of allergic reactions to food, chemical substances etc and never seek any medical help for these symptoms or taking any medication at the moment that might caused this condition. The cause of psoriasis is not fully understood. There may be a combination of factors, including genetic predisposition and environmental factors. It is common for psoriasis to be found in members of the same family. Some suggest that stress is also associated with an unfavorable prognosis. Environmental factors (particularly sunlight and warm weather) help alleviate the disease and are considered advantageous. The immune system is thought to play a major role. Despite research over the past 30 years looking at many triggers, the "master switch" that turns on psoriasis is still a mystery. There are several different types of psoriasis including plaque psoriasis (common type), guttate psoriasis (small, drop like spots), inverse psoriasis (in the folds like of the underarms, navel, and buttocks), and pustular psoriasis (liquid-filled yellowish small blisters). Additionally, a separate entity affecting primarily the palms and the soles is known as palmoplantar psoriasis. In this case, it has been diagnosed as plaque psoriasis as on the dermatologic examination for this patient has found a few sharply marginated erythematous
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papule and plaques with silvery- white scale on both wrists, ankles and at the lining of the scalp. Plaque psoriasis is the most common type of psoriasis. Approximately, 9 out of 10 people with psoriasis have plaque psoriasis. The skin is red and covered with silvery scales. These lesions are forming a polycyclic pattern that circular- to oval-shaped red plaques which sometimes itch or burn are typical of plaque psoriasis. The patches usually are found on the elbows, knees, trunk, or scalp but may be found on any part of the skin. Most plaques of psoriasis are persistent (they stay for years and do not tend to come and go). In this case, there is also no sign of other types of psoriasis such as pustule, exudates, or oily flakes (seborrhea-like).

On the scalp, it may look like severe dandruff with dry flakes and red areas of skin. It may be difficult to tell the difference between scalp psoriasis and seborrhea (dandruff). However, the treatment is often very similar for both conditions. On the patients head, we could see clearly the thick, red, and scaly skin at the border of the scalp.

Sometimes pulling of one of these small dry white flakes of skin causes a tiny blood spot on the skin. This is medically referred to as a special diagnostic sign in psoriasis called the Auspitz sign. As in this case, the patient claimed that the scaly rashes on his left ankle left a small bleeding point when it was scratched. A diagnosis of psoriasis is usually based on the appearance of the skin. There are no special blood tests or diagnostic procedures. Sometimes, a skin biopsy, or scraping, may be needed to rule out other disorders and to confirm the diagnosis. Skin from a biopsy will show a typical histopathologic picture, namely parakeratosis and acanthosis if positive for

psoriasis. Neutrophils may form localized collections known as Munro microabscesses. The presence of alternating collections of neutrophils sandwiched between layers of parakeratotic stratum corneum is virtually pathognomonic for psoriasis. Besides that, there are also papilomatosis and vasodilatation in sub epidermis. Another sign of psoriasis is that (Auspitz's sign). Since plaque psoriasis is a chronic skin condition, any approach to the treatment of this disease must be considered for the long term. Treatment regimens must be

individualized according to age, sex, occupation, personal motivation, other health conditions, and available resources. Three basic treatment modalities are available for the overall management of psoriasis (ie, topical agents, phototherapy, and systemic agents, including biologic therapies). All of these treatments may be used alone or in combination. Outpatient topical therapy is the first-line approach in the treatment of plaque psoriasis. A number of topical treatments are available (eg, corticosteroids, coal tar, anthralin, calcipotriene, tazarotene). No single topical agent is ideal for plaque psoriasis, and many are often used concurrently in a combined approach. Initiate phototherapy only in the presence of extensive and widespread disease (generally practically defined as more lesions than can be easily counted). Resistance to topical treatment is another indication for phototherapy. Proper facilities are required for the 2 main forms of phototherapy. Now, UVB is more commonly combined with topical corticosteroids, calcipotriene, tazarotene, or simply bland emollients. UVB phototherapy is extremely effective for treating moderate-to-severe plaque psoriasis. PUVA

photochemotherapy, also known as PUVA, uses the photosensitizing drug methoxsalen (8methoxypsoralens) in combination with UVA irradiation to treat patients with more extensive disease.
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Initiate systemic treatment only after both topical treatments and phototherapy have been unsuccessful. Patients who have disease that is physically, psychologically, socially, or economically disabling are also considered candidates for systemic treatment. All patients must be informed of the risks and adverse effects of systemic therapy before treatment is initiated. These relatively new systemic therapies provide selective, immunologically directed intervention at key steps in the pathogenesis of the disease. Similar to the systemic agents, these therapies are typically reserved for more severe and recalcitrant cases. In conclusion, the course of plaque psoriasis is unpredictable. Predicting the duration of active disease, the time or the frequency of relapses, or the duration of a remission is impossible. The disease rarely is life threatening but often is intractable to treatment, with relapses occurring in most patients. Both early onset and a family history of disease are considered poor prognostic indicators. The diagnosis of psoriasis is usually made on the basis of clinical findings, and ancillary laboratory tests are very rarely required. Several cardinal features of plaque psoriasis can be readily observed during the physical examination.

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