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KEPANITERAAN KLINIK PERIODE 21 February 26 March 2011
Dermatologic Status
UKRIDA School of Medicine
SMF ILMU KESEHATAN KULIT DAN KELAMIN
RSUD R. SYAMSUDIN, SH - SUKABUMI
I. Patient identification
Name : Mr.DN Gender : Male
Date of Birth : 15 July 1988 Race : Javanese
Marital status : Single Religion : Islam
Job : Merchant
Adress : Jl Karamat RT 04/ RW 04, gunung puyuh, Sukabumi
II. ANAMNESISHistory 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. Therashes kept increasing in size, Itchiness (+), burning sensation (+), loss of hair (-).
4 Months ago, the rashes appeared on both of the ankles. Itchiness (+), burningsensation (+). 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 appearedequally on both left and right wrists. Itchiness (+), burning sensation (+).
The patient never seeks any medical help for these symptoms. He only used talcumpowder to relieve his itchiness.
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The patient claimed that he is not taking any medication at the moment that mightcause 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 : (-)
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IV. Dermatologic stats
Region/ location of lession
- Scalps
- Left and right ankles
- Left and right wrists
Skin lesion
Primary : sharply marginated erythem, papules
Secondary : 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
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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 andplaques 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. Psoriasis2. Dermatitis seborrhoid3. Eczema4. 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 mayhappen. Seek medical help if the rashes reappear.
2. Education not to sratch the lessionMedicaments
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 : Bonam
Ad functionam : Bonam
Ad sanationam : 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 atmany triggers, the "master switch" that turns on psoriasis is still a mystery.
There are several different types of psoriasis includingplaque psoriasis (common
type),guttate psoriasis (small, drop like spots),inverse psoriasis (in the folds like of the
underarms, navel, and buttocks), andpustular 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
http://www.emedicinehealth.com/script/main/art.asp?articlekey=11888http://www.medicinenet.com/script/main/art.asp?articlekey=20684http://www.medicinenet.com/script/main/art.asp?articlekey=20790http://www.medicinenet.com/script/main/art.asp?articlekey=20681http://www.medicinenet.com/script/main/art.asp?articlekey=20789http://www.medicinenet.com/script/main/art.asp?articlekey=20684http://www.medicinenet.com/script/main/art.asp?articlekey=20684http://www.medicinenet.com/script/main/art.asp?articlekey=20684http://www.medicinenet.com/script/main/art.asp?articlekey=20789http://www.medicinenet.com/script/main/art.asp?articlekey=20681http://www.medicinenet.com/script/main/art.asp?articlekey=20790http://www.medicinenet.com/script/main/art.asp?articlekey=20684http://www.emedicinehealth.com/script/main/art.asp?articlekey=11888 -
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papule and plaques with silvery- white scale on both wrists, ankles and at the lining of the
scalp. Plaquepsoriasis 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 severedandruff 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.
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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.
Adiagnosis 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 alsopapilomatosis 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 (8-
methoxypsoralens) in combination with UVA irradiation to treat patients with more extensive
disease.
http://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Biopsyhttp://en.wikipedia.org/wiki/Auspitz%27s_signhttp://en.wikipedia.org/wiki/Auspitz%27s_signhttp://en.wikipedia.org/wiki/Auspitz%27s_signhttp://en.wikipedia.org/wiki/Auspitz%27s_signhttp://en.wikipedia.org/wiki/Biopsyhttp://en.wikipedia.org/wiki/Medical_diagnosis -
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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.