DERMATOLOGY

DERMATOLOGY && VENEREOLOGY

VENEREOLOGY DEPARTMENT
DEPARTMENT
FACULTY
FACULTY OF MEDICINE
MEDICINE
HASANUDDIN
HASANUDDIN UNIVERSITY
UNIVERSITY

DIAGNOSE AND MANAGEMENT OF PSORIASIS

Leony Octavia C014202088
A.Fitri Febrianty Fariadi C014202188
M. Farhan Irhamsyah C014202249
Fitri Amalia Djafar C014202166
Andi Devie Yanti C014202223
M. Syauqi Al Asad XC064202001
Residen Pembimbing :
dr. Andi Amalia Nefyanti

Pembimbing :
dr. Siti Nur Rahmah Sp.KK

Departemen Ilmu Penyakit Kulit dan Kelamin

Fakultas Kedokteran Universitas Hasanuddin
2022
 Introduction

Psoriasis is an inflammatory chronic disease of skin.

In Indonesia, it is reported that the prevalence of psoriasis

patients are 1-3 percent of the population.

For the types of psoriasis : psoriasis vulgaris, psoriasis

gutata, small plaques psoriasis, psoriasis inversa, psoriasis
pustula, psoriasis pustula generalisata, nail psoriasis,
psoriasis arthritis
 Etiology

The other factor :

Etiology has been not known, • Genetic
the recovery of epidermis is
• Immunologic
faster become 3-4 days, while • Phycological stress
in normal skin it can be 27 • Local infection
days • Metabolic disorders
• Drugs
• Alcohol, and smoking

• ​ an de Kerkhof PC., Nestle FO. Psoriasis. In: Bolognia JL, Schaffer J V, Cerroni L, editors. Dermatology. 4th ed. USA: Elsevier; 2018. p. 138–60.
V
• ​Ogawa E, Sato Y, Minagawa A, Okuyama R. Pathogenesis of psoriasis and development of treatment. J Dermatol. 2018;45(3):264–72.
 Definition
Psoriasis is an inflammatory chronic disease of
skin. The lesions can be erythematous plaques
with a circumscriptive white layered scales. Can
be localized, such as on the elbows, knees, scalp,
and other extensor areas.

Jacoeb TNA. Psoriasis. In: Menaloi SL, editor. Ilmu Penyakit Kulit dan Kelamin. 7th ed. Jakarta: Badan Penerbit FKUI; 2016. p. 213-22.
 EPIDEMIOLOGY
• Cases of psoriasis are often found universally in parts of the world and
reach 125 million human.
• Prevalence of man and women is same.
- Children : 0 – 2,1%
- Adult : 0,98 – 8%
• In Indonesia, prevalence of psoriasis reach 1-3 percent from population of
Indonesia.
• Psoriasis vulgaris is the most common form of psoriasis. found in about
90% of patients.

• Jacoeb TNA. Psoriasis. In: Menaloi SL, editor. Ilmu Penyakit Kulit dan Kelamin. 7th ed. Jakarta: Badan Penerbit FKUI; 2016. p. 213-22.
• World Health Organization. 2016. Global Report on Psoriasis. Switzerland, h:7- 10.
 Etiopathogenesis of Psoriasis
• Psoriasis → Sustained inflammation →
uncontrolled keratinocyte proliferation and
dysfunctional differentiation.
• Psoriasis has a genetic component that is
supported by patterns of familial aggregation.

Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
 Etiopathogenesis of Psoriasis
The pathogenesis of psoriasis can be conceptualized
into:
• initiation phase possibly triggered → by trauma
(Koebner phenomenon), infection, or drugs.

• maintenance phase characterized by a chronic

clinical progression → disturbances in the innate
and adaptive cutaneous immune responses.

Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
 Etiopathogenesis of Psoriasis

Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
 Clinical Manifestation

• The classic lesion of psoriasis is well demarcated , raised , red

plaques with a white scaly surface
• It is manifested by itching dan pain
• The predilection area are scalp, elbow, knee, back, lumbal and
retroauriculer
Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 CLINICAL SIGNS
• Auspitz sign: Bleeding points appear when the scales is removed , traumating the
dilated cappillaries below

Before After

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
• Koebner phenomenon is traumatic
induction on psoriasis non lesion skin

• Wax Spot phenomenon

If the surface of psoriatic plaque
is scraped with a blunt
scalpel, squamae fall off as layers
of white lamellae much like candle
wax

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 PSORIASIS TYPES
1) Psoriasis Vulgaris
2) Psoriasis Inversa
3) Psoriasis Gutata
4) Psoriasis Pustulosa
5) Erythroderma
6) Nail Psoriasis
7) Psoriasis Arthritis

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Psoriasis Vulgaris
• Psoriasis vulgaris is the most
common form of psoriasis
• The Primary lesion is Red, scaly
systematically distributed plaques

• It is symmetrically distributed
plaques to the extensor aspects of
the extremities; particularly the
elbows and knees, along with
scalp, lower lumbosacral,
buttocks, and genital involvement

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Psoriasis Gutata
• It is characterized by eruption of
small (0.5–1.5 cm in diameter)
papules over the upper trunk and
proximal extremities
• It typically manifests at an early age
• It has the strongest association to
HLA-Cw6

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Psoriasis Inversa
• The lesions show a glossy sharply
demarcated erythema
• Psoriasis lesions may be localized in
the major skin folds, such as the
axillae, the genitocrural region, and
the neck

• Scaling is usually minimal or absent

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Psoriasis postulosa
• The attacks are characterized by fever
that lasts several days and a sudden
generalized eruption of sterile
pustules 2 to 3 mm in diameter
• The pustules are disseminated over
the trunk and extremities, including
the nail beds, palms, and soles.

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Erythroderma
• Erythema is the most prominent
feature with superficial scaling
• Affects all body sites, including the
face, hands, feet, nails, trunk, and
extremities

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Nail Psoriasis
• Pits range from 0.5 to 2.0 mm
in size and can be single or
multiple
• Other forms are yellowish
dish discoloration or oil spot ,
onycholysis , hyperkeratosis
subungual

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Psoriasis Arthritis
• Most commonly a
seronegative oligoarthritis
• Skin lesions include scaly,
erythematous plaques; guttate
lesions; lakes of pus; and
erythroderma
• Psoriasis may occur in
hidden sites, such as the
scalp, perineum, intergluteal
cleft, and umbilicus

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Algorithm diagnosis and treatment of psoariasis

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Diagnose
Clinical Manifestation Onset of the Disease
( Symptoms and Signs ) ( When did it start ? )

Family History Risk Factors

( Is there any of the same ( Environmental , Physical
condition in patient’s Trauma, infection , Stress ,
family ? ) Obesity and Drugs )

Physical Examination
( Symetrical Lesions , Its
distribution , Circumscribed
lesion , Thick white scally
layers )
Gudjonsson,
Gudjonsson, J.E.
J.E. dan
dan J.T.
J.T. Elder.
Elder. 2019.
2019. Psoriasis.
Psoriasis. Dalam:
Dalam: Kang,
Kang, S.,
S., Amagai,
Amagai, M.,
M., Bruckner,
Bruckner, A.L.,
A.L., Enk,
Enk, A.H.,
A.H., Margolis,
Margolis, D.J.,
D.J., McMichael,
McMichael, A.J.,
A.J., Orringer,
Orringer, J.S.
J.S. (editor).
(editor). Fitzpatrick’s
Fitzpatrick’s
 Laboratory Findings
• Histopathology : hyperkeratosis, parakeratosis,
acanthosis

Ogawa E, Sato Y, Minagawa A, Okuyama R. Pathogenesis of psoriasis and development of treatment. J Dermatol. 2018;45(3):264–72.
 Differential Diagnosis

Seborrheic dermatitis
Secondary syphilis

Tinea corporis
Pityriasis Rosea
• Tucker D, Masood S. 2021. Seborrheic Dermatitis. Aga Khan University Hospital karachi. [Accessed 28 des 2021]Seborrheic Dermatitis - StatPearls - NCBI Bookshelf (nih.gov)
• Rukin N. 2018. Sexually Transmitted Infection. [Accessed 28 des 2021] Sexually transmitted infections | Urology News
• Yee G, Ahmad M. 2021. Tinea Corporis. King Abdullah Medical City. [Accessed 28 des 2021]Tinea Corporis - StatPearls - NCBI Bookshelf (nih.gov)
• Gudjonsson, J.E. dan J.T. Elder. 2019. Pityriasis Rosea. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
 Treatment

The choice of therapy for psoriasis

is determined by disease severity,
comorbidities, and access to
health care.

Gudjonsson, J.E. dan J.T. Elder. 2019. Psoriasis. Dalam: Kang, S., Amagai, M., Bruckner, A.L., Enk, A.H., Margolis, D.J., McMichael, A.J., Orringer, J.S. (editor). Fitzpatrick’s
• Psoriatic patients are frequently categorized
into three groups: mild, moderate and severe
psoriasis.
• Depending on the clinical severity of the
lesions (Psoriasis Area and Severity Index), the
percentage of affected body surface area (Body
Surface Area), and patient quality of life
(Dermatology Life QuaIity Index).

Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
Psoriasis Area and Severity Index
 Body Surface Area
&
Dermatology Life QuaIity Index
 Topical therapy
• Topical application of corticosteroids is generally
suitable for limited plaques.
• Liquor Carbonis Detergens, can be compounded into
agents for topical use.
• Salicylic acid is used as a keratolytic agent It can
promote the absorption of other topical agents.
• Treatment with the vitamin D analog calcipotriene
• Phototherapy for widespread psoriasis.

William D james , Timothy G Berger , Dirk M Elston , Andrew’s Disease of the skin Clinical Dermatology 11th ed . Elsevier ;2006 . ISBN 978-0-8089-2417-3
 Systemic treatment
• Methotrexate → This folic acid antagonist
remains the standard.
– Indications → psoriatic erythroderma, psoriatic
arthritis, acute pustular psoriasis, or widespread
body surface involvement.
– The patient has no history of liver or kidney
disease.
– Oral doses 2,5 – 5 mg (12 h apart) + Oral folic acid
doses of 1–4 mg/day are used.

William D james , Timothy G Berger , Dirk M Elston , Andrew’s Disease of the skin Clinical Dermatology 11th ed . Elsevier ;2006 . ISBN 978-0-8089-2417-3
 Systemic treatment
• Cyclosporine → The therapeutic benefit of
cyclosporine in psoriatic disease may be
related to down modulation of pro
inflammatory epidermal cytokines.
– Doses of 2–5 mg/kg/day generally produce rapid
clearing of psoriasis.

William D james , Timothy G Berger , Dirk M Elston , Andrew’s Disease of the skin Clinical Dermatology 11th ed . Elsevier ;2006 . ISBN 978-0-8089-2417-3
 Biologic agents
• Target specific inflammatory pathways and are
administered SC or IV on different weekly schedules.
• Biologics presently target two pathways crucial in the
development and chronicity of the psoriatic plaque:
the IL-23/Th17 axis and TNF-α-signaling.
– TNF-α inhibitors → etanercept, infliximab, adalimumab.
– IL-23 → ustekinumab
– IL-17 → Secukinumab

Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
• Mild to moderate psoriasis can be treated
topically with a combination of
glucocorticoids, vitamin D analogues, and
phototherapy.
• Moderate to severe psoriasis often requires
systemic treatment. The presence of
comorbidities such as psoriasis arthritis is also
highly relevant in treatment selection.

Rendon, A., & Schäkel, K. (2019). Psoriasis Pathogenesis and Treatment. International journal of molecular sciences, 20(6), 1475. https://doi.org/10.3390/ijms20061475
 Prevention of Psoriasis
• Avoid the stress
• Avoid the smoking
• Avoid the alchol
• Avoid the drugs lead the psoriasis
• Organize Body Mass Index

• Rousset L, Halioua B. Stress and psoriasis. Int J Dermatol. 2018 Oct;57(10):1165-1172. doi: 10.1111/ijd.14032. Epub 2018 May 4. PMID: 29729012.
• Pezzolo E, Naldi L. The relationship between smoking, psoriasis and psoriatic arthritis. Expert Rev Clin Immunol. 2019 Jan;15(1):41-48. doi:10.1080/1744666X.2019.1543591. Epub 2018 Nov 6. PMID:
30380949
• Svanström C, Lonne-Rahm SB, Nordlind K. Psoriasis and alcohol. Psoriasis (Auckl). 2019 Aug 21;9:75-79. doi: 10.2147/PTT.S164104. PMID: 31687362; PMCID: PMC6709030.
• Roszkiewicz M, Dopytalska K, Szymańska E, Jakimiuk A, Walecka I. Environmental risk factors and epigenetic alternations in psoriasis. Ann Agric Environ Med. 2020 Sep 11;27(3):335-342. doi:
10.26444/aaem/112107. Epub 2019 Nov 12. PMID: 32955211.
• Grželj J, Sollner Dolenc M. The role of xenobiotics in triggering psoriasis. Arch Toxicol. 2020 Dec;94(12):3959-3982. doi: 10.1007/s00204-020-02870-8. Epub 2020 Aug 24. PMID: 32833044.
 Prognose
• The prognose of this disease is bonam if the
patient get an effective therapy.
• But sometimes psoriasis can be chronic
recurrent.
– Ad vitam : Dubia ad Bonam
– Ad functionam : Dubia ad Bonam
– Ad sanationam : Dubia ad Malam

• Van de Kerkhof PC., Nestle FO. Psoriasis. In: Bolognia JL, Schaffer J V, Cerroni L, editors. Dermatology. 4th ed. USA: Elsevier; 2018. p. 138-60.
• Widaty S, Soebono H, Nilasari H, dkk. Panduan Praktik Klinis bagi Dokter Spesialis Kulit dan Kelamin di Indonesia. Jakarta: Perhimpunan Dokter Spesialis Kulit dan Kelamin Indonesia; 2017. h.230-41
 Conclution

Psoriasis is an inflammatory chronic disease of skin.

We can diagnose psoriasis, apart from the history
and physical examination, the characteristic of
psoriasis are also needed in the diagnosis such as
rough scale transparent and layered scales with the
phenomenon of wax droplets, Auspitz and koebner.

Therapy for psoriasis should be topical but if there is

no change can be given systemic treatment or a
combination of both.
 DERMATOLOGY & VENEREOLOGY DEPARTMENT
FACULTY OF MEDICINE
HASANUDDIN UNIVERSITY

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“ PSORIASIS is not Contagious but, Awareness is”

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