SITUASI TERKINI

PSORIASIS DI INDONESIA
Dr. Danang Tri Wahyudi SpKK FINSDV FAADV
Kelompok Studi Psoriasis Indonesia
PATOGENESIS PSORIASIS

• Exposure to microbial or mechanical

injury damage associated molecular
patterns/ pathogen associated
molecular patterns leads to activaton of
antigen presenting cells like
macrophages and dermal dendritic
cells;
• failure to maintain skin barrier due to
late cornified envelope proteins 3C/3B
deletion leads to continous exposure to
such antigens.
• Interaction of APC and T cells leads to
activation of Th1 and Th17 cells
mediated by IL-23.
• Liberation of IL-17 and IL-22 by Th17
cells, and tumour necrosis factor-α and
IFN-γ by Th1 cells further perpetuates
the keratinocyte injury creating a
vicious positive feedback cycle
Psoriasis versus normal skin

From http://www.where2infuse.com.au/psoriasis. Accessed February 2014

Psoriasis versus normal skin

http://www.where2infuse.com.au/psoriasis;
http://www.where2infuse.com.au/psoriasis. Last accessed February 2014; Declercq S, et al. Scientific
World Journal. 2013 Jul 1;2013:980419.
BEBAN PENYAKIT (DISEASE BURDEN)

• Psikologis
• Kehilangan pekerjaan
• Kehilangan jam kerja karena perawatan
• JKN  biaya konsultasi dan obat2an
• Kecacatan
 Psychological burden
of psoriasis and impact on quality of life
Psoriasis has been associated with:
Psychological and social problems
– Depression1-3 and anxiety3
– Stress1,3
– Anger3
– Feelings of stigmatisation1,3
– Suicidal ideation1-3
– Alcohol abuse1,3
– Smoking3
– Effects on social interactions at home1,2 and in the workplace2
Reduced quality of life
– Compared with individuals without chronic conditions4
– Compared with other chronic conditions5

1. Kimball AB et al. Am J Clin Dermatol. 2005;6:383–392. 2. Krueger G. et al. Arch Dermatol. 2001;137:280-4. 3. van de Kerkhof P, editor.
Textbook of Psoriasis. 2nd ed. Oxford: Blackwell Publishing; 2003. p. 45-47. 4. Weiss SC, et al. J Am Acad Dermatol. 2002;47:512-8.
5. Rapp SR et al. J Am Acad Dermatol. 1999;41(3);401-7.
DIAGNOSIS DINI

• Plak kemerahan dengan sisik

berlapis warna keperakan
diatasnya
• Pada lokasi yang sering
• Sering gatal
• Riwayat keluarga dengan Psoriasis
• Ditemukan fenomena :
• Koebner
• Tetesan lilin
Medical Care

Lebhwol M, et al. Patient perspectives in the management of psoriasis: Results from the population-based Multinational
Assessment of Psoriasis and Psoriatic Arthritis Survey . J Am Acad Dermatol 2014;70:871-81
JENIS PSORIASIS

• Plaque Psoriasis
• Scalp Psoriasis
• Gutatte Psoriasis
• Pustular/palmoplantar psoriasis
• Inverse Psoriasis
• Nail Psoriasis
• Generalized Pustular Psoriasis / Von Zumbusch
• Erytrodermic Psoriasis
Generalized pustular psoriasis

Images courtesy of Dr SE Choon

DERAJAT KEPARAHAN PENYAKIT

Ringan Sedang Berat

BSA < 3% BSA 3-10% BSA > 10%

DLQI 2-5 DLQI 6-10 DLQI > 10

Disease severity (patient perspective)

Lebhwol M, et al. Patient perspectives in the management of psoriasis: Results from the population-based Multinational
Assessment of Psoriasis and Psoriatic Arthritis Survey . J Am Acad Dermatol 2014;70:871-81
PENYAKIT PENYERTA (KOMORBIDITAS)

• Terutama pada psoriasis derajat sedang-berat

• Memperburuk kondisi psoriasis
• Meningkatkan risiko kematian
• Dapat dicegah dengan pengobatan dini
• HIT HARD AND HIT EARLY
Inflammatory dysfunction is likely to contribute
to the development of comorbidities in psoriasis
The psoriatic march2
• Immune dysregulation
Obesity Psoriasis Smoking/alcohol
and inflammation plays
an important role in the
development and Systemic inflammation
progression of psoriasis1,2
• As the disease progresses,
persistent inflammatory Insulin resistance

dysfunction has been

proposed to drive the Endothelial dysfunction
development of comorbid
conditions such as
Atherosclerosis
cardiovascular disease1,2

Myocardial infarction
= association

1. Kourosh AS, et al. Skin Ther Lett. 2008;13(1):1-5. 2. Boehncke W-H, et al. BMJ. 2010;340:200-3.
Psoriasis associated
CVD and CV risk factors
Psoriasis has been associated with an increased risk of1-5:

CVD CV risk factors

Atherosclerosis/coronary heart disease Diabetes
Heart failure Obesity
Myocardial infarction Metabolic syndrome
Ischaemic heart disease Insulin resistance
Cerebrovascular disease Hypertension
Peripheral vascular disease Dyslipidaemia
Coronary artery calcification

1. Wu Y, et al. J Drugs Dermatol. 2008;7(4):373-7. 2. Mrowietz U, et al. Arch Dermatol Res. 2006;298(7):309-19. 3. Gottlieb AB, et al. J Dermatolog
Treat. 2008;19(1):5-21. 4. Han C, et al. J Rheumatol. 2006 Nov;33(11):2167-72. 5. Ludwig RJ, et al. Br J Dermatol. 2007;156(2):271-6.
 Psoriasis associated increased prevalence of
non-cardiovascular comorbidities

Psoriasis has been associated with an increased risk of1-3:

Systemic inflammatory disorders Other comorbidities

Psoriatic arthritis Anxiety

Crohn’s disease Depression

Chronic obstructive pulmonary disease Gastroesophageal reflux disease

Pain

Sleep disorder/insomnia

1. Wu Y, et al. J Drugs Dermatol. 2008;7(4):373-7. 2. Mrowietz U, et al. Arch Dermatol Res. 2006;298(7):309-19.
3. Gottlieb AB, et al. J Dermatolog Treat. 2008;19(1):5-21.
ALGORITMA PENGOBATAN
 Target of treatment
Gain initial rapid control of the disease

Decrease Maintain Avoid Improve

erythema, long-term adverse quality of life
scaling remission effects
thickness
minimize
relapse
Treatment goals for severe plaque psoriasis
Poor clearance Moderate clearance Good clearance

∆PASI ≥50 and <75

∆PASI ＜5 ∆ PASI ≥75

Poor QoL Good QoL

DLQI >5 DLQI≤5

MODIFY TREATMENT

•Increase dose
•Decrease dose interval
•Add systemic medication
•Add topical medication
•Switch to another drug/class CONTINUE TREATMENT

Continuation or cessation of the treatment regimen is dependent upon PASI score

BSA, Body Surface Area;

DLQI, Dermatology Life Quality Index;
PASI, Psoriasis Area and Severity
Mrowietz et al. Arch Dermatol Res 2011;303:1–10
Treatment Patterns

Lebhwol M, et al. Patient perspectives in the management of psoriasis: Results from the population-based Multinational
Assessment of Psoriasis and Psoriatic Arthritis Survey . J Am Acad Dermatol 2014;70:871-81
Reason for discontinuation of treatment

Howa Yeung BS, et al. Patient-reported reasons for the discontinuation of commonly used treatments for moderate to
severe psoriasis . J Am Acad Dermatol 2013;68:64-72
PERAN DOKTER DI FKTP

• Diagnosa dini
• Pencegahan komorbiditas
• Penanganan psoriasis ringan
• Disease awareness di masyarakat, lingkungan dan keluarga
• Rujuk balik
PERAN KOMUNITAS PASIEN

• Saling menguatkan
• Memberikan rasa kebersamaan bahwa penyakit ini bukan hanya
psobat seorang
• Saling berbagi info dan pengalaman
• Penapisan terapi yang tidak berguna
• Mengurangi beban penderitaan
• Membantu tenaga kesehatan untuk memberikan pengetahuan
tentang penyakit dan cara penanganannya
OPTIMALISASI TERAPI

• Kerjasama yang baik antara dokter dan pasien

• Merancang ekspektasi pengobatan realistis bersama
• Melakukan rencana terapi sesuai kemampuan pasien
• Membina kebersamaan dalam komunitas pasien
• Komunikasi yang terbuka dan setara
TERIMA KASIH ATAS PERHATIAN ANDA