1

DISCUSSION

Depression/suicide Psoriasis is associated with lack of self esteem and
increased prevalence of mood disorders including depression. The prevalence of
depression in patients with psoriasis may be as high as 60%. Depression may be
severe enough that some patients will contemplate suicide. In one study of 217
patients with psoriasis, almost 10% reported a wish to be dead and 5% reported
active suicidal ideation. Treatments for psoriasis may affect depression. One study
demonstrated that patients with psoriasis treated with etanercept had a significant
decrease in their depression scores when compared with control subjects.
However, clinically diagnosed depression was an exclusionary criterion for entry
into this study.
3
Therefore, treatment of psoriasis with etanercept lessened
symptoms of depression in patients without overt clinical depression. Increased
rates of depression in patients with psoriasis may be another factor leading to
increased risk of cardiovascular disease. Although there is some suggestive
evidence that treatment of depression with selective serotonin reuptake inhibitors
may reduce cardiovascular events.
3
in case we find the patient she get a stress in
her life and she never talk to her son and daughter. And when he getting start to
remember her kid she always feel the symptom going severe, like itch and red
spot, in that case related with the literatur.
Multivariate analysis demonstrated that the relative risk of developing
psoriasis was highest in those with the highest BMIs. In contrast, a low BMI (21)
was associated with a lower risk of psoriasis, further supporting these findings.
Furthermore, the average weights of pa-tients with psoriasis in the large clinical
trials of the biologic agents have been in the 90-to 95-kg range (although these
clinical trials all enrolled more men than women) whereas the average body
weight for the US population from the NHANES database from 1999 to 2002 was
86 kg. An association between psoriasis and elevated BMI appears to be yet
another factor that predisposes individuals with psoriasis to cardiovascular
disease.
3
in that case the patient occurrence of obesity with psoriasis vulgaris
related with the literature, she have a BMI >30 that condition show she get a
obesity.


2

The major manifestation of psoriasis is chronic inflammation of the skin. It
is characterized by disfiguring, scaling, and erythematous plaques that may be
painful or often severely pruritic and may cause significant. Psoriasis is a chronic
disease that waxes during a patients lifetime, is often modified by treatment
initiation and cessation and has few spontaneous remissions

Inverse psoriasis is
characterized by lesions in the skin folds. Because of the moist nature of these
areas, the lesions tend to be erythematous plaques with minimal scale. Common
locations include the axil-lary, genital, perineal, intergluteal, and inframammary
areas. Flexural surfaces such as the antecubital fossae can exhibit similar lesions.
3
Psoriasis is universal in occurrence how ever different population varies
from 0.1 percent to 11.8 percent. Psoriasis may begin at any age, but is
uncommon under age 10 years. It most likely appears 15-30 years. It certain HL-
A CW6 antigen carier from family. Psoriasis is a chronic inflammation skin
deases with a strong genetic basic characteristic by complex dermal growth
epidermal diferentation and multiple biochemical, immunologic, vascular
abnormality. It caused poor keratinocyte.
4

Initial lesion in the pin head sized macular lesion there marked edema, and
monoclear cell inflarates are found in the upper dermis. the overlying epidermis
soon becomes spogiotic with the focal loss of the granular layyer.
4
Plaque
psoriasis is the most common form, affect-ing approximately 80% to 90% of
patients. The vast majority of all high-quality and regulatory clinical trials in
psoriasis have been conducted on patients with this form of psoriasis. Plaque
psoriasis manifests as well-defined, sharply demarcated, erythematous plaques
varying in size from 1 cm to several centi-meters These clinical findings are
mirrored histologically by psoriasiform epidermal hyperplasia, parakeratosis with
intracorneal neutro-phils, hypogranulosis, spongiform pustules, an infiltrate of
neutrophils and lymphocytes in the epidermis and dermis, along with an expanded
dermal papillary vasculature. Patients may have involvement ranging from only a
few plaques to numerous lesions covering almost the entire body surface. The
plaques are irregular, round to oval in shape, and most often located on the scalp,
trunk, buttocks, and limbs, with a predilection for extensor surfaces such as the


3
elbows and knees. Smaller plaques or papules may coalesce into larger lesions,
especially on the legs and trunk. Painful fissuring
.3
in case we find the lesion at
regio thorax posterior patch demarcated hypopigmented with firm boundaries,
plaque size, the number of multiple over rough scaly lesions found generalized
distribution premises and on regio extrimitas superior patch demarcated
hypopigmented with firm boundaries, plaque size, the number of multiple over
smooth scaly lesions found generalized distribution premises with the chief
complaint Itch and red spot on the back side around the body and hand. itchy
sensation. The red spott were getting bigger 4 months ago. In the first of the
symptom start with a small of white lesion with the severe itching then the patient
starching the lesion every time until the last month before she goes to polyclinic
the lesion begin a red spot with the bigger plaque. The patient admitted she had
ever felt like this condition 5 year ago.
Combination of topical therapies Since all topical medications for the
treatment of psoriasis have limitations, combination regimens, utilizing
medications from different categories, have been studied and shown to be
potentially beneficial.
5
Corticosteroids and salicylic acid The combination of
topical corticosteroids and salicylic acid may be valuable because of the ability of
salicylic acid to enhance the efficacy of corticosteroids by increasing penetration.
To ensure that there is not an increase in steroid toxicities when adding salicylic
acid to topical corticosteroid preparations, it is recommended that this
combination belimited to no more than medium-potency (class 3-4) topical
corticosteroids. The strength of recommendations for the treatment of psoriasis
using topical corticosteroids and salicylic acid.
6
Corticosteroids and vitamin D
analogues The combination of topical corticosteroids and vitamin D analogues
appears to be more efficacious than either therapy alone, with fewer side effects
noted in most, but not all, studies. This point has been demonstrated for several
different corticosteroid - calcipotriol combinations (please also see prior section
on combination calcipotriene/betamethasone ointment). The strength of
recommendations for the treatment of psoriasis using topical corticosteroids and
vitamin D analogues.
5



4
Corticosteroids and tazarotene Owing to the potential irritancy of topical
tazarotene, adding topical corticosteroids to a regimen of tazarotene is an
appropriate option. In fact, one study has shown that the combination of
tazarotene and either mid- or high-potency topical corticosteroid is more effective
than therapy with tazarotene alone; however, this study did not determine if
tazarotene plus topical steroid is superior to topical corticosteroid alone. There
may be a synergistic effect between tazarotene and topical corticosteroids as a
clinical trial comparing tazarotene gel plus mometasone cream to mometasone
cream alone showed superior efficacy of the combination over mometasone cream
used alone both for efficacy during the therapy and for the duration of therapeutic
effect. Combination therapy may increase the duration of treatment benefit as well
as length of remission. Another potential advantage of using combination
tazarotene and topical corticosteroid is potential decrease in steroid-induced
atrophy. The strength of recommendations for the treatment of psoriasis using
topical corticosteroids and tazarotene.
6
in that case we find the

Patients received
systemic and topical therapy when she get on the polyclinic of dermatology
RSUZA Banda Aceh as follow up of the patient is on the bellow:

S/ -Itch and red spot on the back side around the body and hand
-Stress
- BMI >30 (obesity)
O/ - Status of Dermatology:
At regio: thorax posterior patch demarcated hypopigmented with
firm boundaries, plaque size, the number of multiple over rough scaly
lesions found generalized distribution premises.
At regio: extrimitas superior patch demarcated hypopigmented
with firm boundaries, plaque size, the number of multiple over smooth
scaly lesions found generalized distribution premises






5
A/ DD:
1. Psoriasis Vulgaris
2. Dermatitis Serborreica
3. Morbus Hansen TT Type
4. Uticaria
5. Pitiriasis Rosasea

P/
Planning Diagnosis:
Auspitz sign examination : Positive
Kaarsvlek phenomen examination : Positive
Koebner examination: Positive



Treatment
Pharmacotherapy

1. Asam salisilat 3% + LCD 5%+ vaselin album cream (N 1 MORNING)
2. Asam salisilat 3% + LCD5% + NERILON CREAM (N1
AFTERNOON)
3. Asam salisilat 3% + LCD 5% + INERSON OINT (N 1 NIGHT)
4. Ceterizine 10 mg tab 1x1











6
















DAFTAR PUSTAKA

1. Krueger J.G; Bowcock A.Psoriasis pathophysiology: current concepts of
pathogenesis.Ann Rheum Dis. Hal. ii30-ii36. 2005.
2. Lowes M.A; Bowcock A.M and Krueger, J.G. Pathogenesis and Therapy of
Psoriasis. Volume 445. New York: Nature Publishing Group. Hal. 866-73.
2007.
3. Guidelines of care for the management psoriasis and psoriatic arthritis Section
1. Overview of psoriasis and guidelines of for the treatment of psoriasis with
biologics Work Group: Alan Menter, MD, Chair, Alice Gottlieb, MD, PhD,
Steven R. Feldman, Abby S. Van Voorhees, MD, Craig L. Leonardi, MD,
Kenneth B. Gordon, , California; Birmingham, Alabama; and Cleveland,
Ohio 2013.
4. Johan E gundjonson james t elder Jean of Psoriasis In: Fitzpattricks
Dermatology in General Medicine 7
th
ed. New York: Mc Graw Hill. 2008.p169
-171.


7
5. Lowes MA; Kikuchi T; Duculan JF; CArdinale I; Zaba LC; Haider AS;
Bowman EP; Krueger JG. Psoriasis Vulgaris Lesion contain Discrete
Populations of Th1 and Th17 T Cells. Volume 128. Journal of Investigative
Dermatology. Hal. 1207-211. 2008.
6. Guidelines of care for the management psoriasis and psoriatic arthritis Section
3. Overview of psoriasis and guidelines of for the treatment of psoriasis with
biologics Work Group: Alan Menter, MD, Chair, Alice Gottlieb, MD, PhD,
Steven R. Feldman, Abby S. Van Voorhees, MD, Craig L. Leonardi, MD,
Kenneth B. Gordon, , California; Birmingham, Alabama; and Cleveland,
Ohio 2009.
7. Coimbra S; Oliveira H; Figueiredo A; Pereira PR; Silva AS. Psoriasis:
Epidemiology, Clinical and Histological Features, Triggering Factors,
Assesment of Severity and Psychosocial Aspect. Dalam Odaly J: Psoriasis a
Systemic Desease. China: Intech. Hal. 69-88. 2012.
8. Johan E gundjonson james t elder Jean of Psoriasis In: Fitzpattricks
Dermatology in General Medicine 7
th
ed. New York: Mc Graw Hill. 2008.p169
-171.