ORIGINAL ARTICLE

PSORIASIS IN DERMATOVENEREOLOGY CLINIC OF DR. WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR : A RETROSPECTIVE STUDY IN PERIOD OF JANUARY 2006 DECEMBER 2010
Wendy Posumah, Dirmawati Kadir, Fitriyani Sennang Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar

ABSTRACT
Background : Psoriasis is an inflammatory sk in disease that is often found, are chronic and recurrent, are influenced by genetic and environmental factors. Objectives : To det ermine the profile of psoriasis patients in dermatovenereology clinic of RSWS Mak assar for five years. Methods : A retrospective study conducted in patients with ps oriasis at the dermatovenereology clinic of RSWS based on patients medical records from January 2006 to December 2010. Recording made on gender, age, complaint of itching, the affected part of body, the examination, type of psoriasis and management, then presented descriptively. Results : Obtained 80 patients, 50 (52.5%) were men and 30 (37.5%) were women. 38 people (47.5%) in the age group of 25-44 years. 72 patients (90% ) had complaints of reddish spots or plaque, scaly sk in with itching. 49 people (61.25%) had universalis lesions. There is a phenomenon of wax droplets, Auspitz's sign, and Koebner phenolmenon, as well as histopat hologic examination support the diagnosis. 74 people (92.5%) is Psoriasis Vulgaris. All patients received oral antihistamines and topical combination therapy. Other therapy are systemic corticosteroids, tar shampoos, ultraviolet light, methot rexate. Conclusion : Psoriasis is often found in young adults, with itching and universalis distribution of the lesion. Psoriasis vulgaris is the most common. Therapy varies according to clinical circumstances. Key words : Psoriasis, retrospective study.

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar : a retrospective study in period of january 2006 december 2010

INTRODUCTION Psoriasis is an inflammatory skin disease that is often found, are chronic and recurrent, are influenced by genetic and environmental factors. It characterized by circumscribed, erythematous, dry, scaling plaques of various sizes. The lesions are usually covered by silvery white lamellar scales. The lesions have a predilection for the scalp, nails, extensor surfaces of the limbs, umbilical region and sacrum. Subjective symptoms, such as itching or burning, may be present and may cause extreme discomfort. (1-3) The early lesions are small erythematous macules, which from the beginning are covered with dry, silvery scales. The lesions increase in size by peripheral extension and coalescence. The scales are micaceous, meaning that they peel in layers. They are looser toward the periphery and adherent centrally. When removed, bleeding points appear (Auspitzs sign). Although plaques typically predominate, lesions may be annular or polycyclic. Involved nails can demonstrate distal onycholysis, random pitting, oil spots, or salmon patches. Thick ungual hyperkeratosis may resemble onychomycosis.(1-3) The most comon laboratory examination to confirm the clinical diagnosis of psoriasis is a skin biopsy using hematoxylin eosin staining. Other than skin biopsy, there are no specific laboratory abnormalities associated with psoriasis. Histopathologic features in early stage of psoriasis, there are parakeratosis, irregular thickening of the epidermis, but thinning over dermal papillae with the neutrophil aggregation in the stratum corneum formed Munros microabscesses, thinning of the granulosum layer, dilated and tortuous capillary loops in the dermal papillae, with the T-lymphocyte infiltrate in 2

upper dermis and the spongiform intraepidermal pustule can be found. The fully developed lesions are characterized by acanthosis (thickening of the epidermis), elongated rete ridges and thinning of the suprapapillary layers of the epidermis. The granular layer is absent. (3-7) Therapy should address the different aspects of psoriatic skin lesions : it should supress keratinocyte proliferation, be anti-inflammtory and immunosuppressive. There are : 1) topical therapy such as topical steroids, vitamin D analogue, tazarotene and calcineurin inhibitors, 2) phototherapy, narrrow band UVB (NB-UVB), broad band UVB (BB-UVB), psoralen and UVA light (PUVA) and excimer laser, 3) systemic therapy, cyclosporine A, methotrexate, acitretine, ester fumaric acid, hydroxyuric, 6-thioguanin, micophenolate mophetil and sulfasalazine, and 4) biologic therapy, alefacept, efalizumab, etanercept, infliximab and adalimumab.(2,7-11) The Objectives The objectives of this study is to describe the profile of psoriasis patient at the dermatovenereology departement dr. Wahidin Sudirohusodo (RSWS) general hospital Makassar in Januari 2006 Desember 2010 periode. The Methods The secondary data had been taken from patients registration book in dermatovenereology policlinic RSUP dr. Wahidin Sudirohusodo Makassar from January 2006 to December 2010. The data had been clasified by the sex, age, itching symptom, predilection, dermatologys sign, variant of psoriasis dan the treatment. Then, it has been tabulated and finally being presented in graphics.

IJDV

Vol.1 No.4 2013

The Results The total psoriasis patients are 80 from 17.082 derm atovenereologys pa-tients (0,47%) that came to dermato-venereologys policlinic RSUP dr.Wahidin Sudirohusodo Makassar from January 2006 to December 2010. There are 50 males (52,5 %) and 30 females (37,5 %). Table 1. The frequency distribution characterictics of patients by sex Year 2006 2007 2008 2009 2010 Total
14 12 10 8 6 4 2 0 2006 2007 2008 2009 2010

Male 10 5 10 13 12 50

Female 8 1 7 9 5 30

total 18 6 17 22 17 80

% 22,5 7,5 21,25 27,5 21,25 100

Male Female

Graphic 1. The frequency distribution characterictics of patients by sex Based on the age of the patient, most case are found in the group of age 25-44 years which is 38 people (47.5%),with the youngest patient is one year old and the oldest is 75 years old. Table 2. The frequency distribution characterictics of patients by age Age < 1 year old 1 4 year old 5 14 year old 15 24 y.o. 25 44 y.o. 45 64 y.o. >65 y.o. Total 2006 0 1 0 2 6 8 1 18 2007 0 0 0 1 3 2 0 6 2008 0 0 0 0 6 10 1 17 2009 0 0 1 1 15 3 2 22 2010 0 0 1 2 8 5 1 17 Total 0 1 2 6 38 28 5 80 % 0 1,25 2,5 7,5 47,5 35 6,25 100

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar : a retrospective study in period of january 2006 december 2010

16 14

12 10
8 6 4

1-4 years old 5-14 years old 15-24 years old 25-44 years old 45-64 years old > 65 years old
2006 2007 2008 2009 2010

2
0

Graphic 2. The frequency distribution characterictics of patients by age

Most of the patients came with complaint scaly rashes associated with itchy, 72 people (90%), while another eight people (10%) came without complaint of itchy. Table 3. The frequency distribution characterictics of patients by itching symptoms Complaints Scaly rashes, with itchy Scaly rashes, without itchy Total 2006 16 2 18 2007 2008 2009 2010 6 0 6 16 1 17 19 3 22 15 2 17 Total 72 8 80 % 90 10 100

20 15 10 5

Gatal Tidak gatal

0
2006 2007 2008 2009 2010

Graphic 3. The frequency distribution characterictics of patients by itching symptoms Obtained 80 patients, about 49 people (61.25%) had lessions on all over their body (universal) and only one of them experienced psoriasis on nails. Nine people (11.2%) had lessions on scalp, superior extremities, abdomen; six people (7.5 %) on scalp, facial, trunk; five people experienced on trunk, superior et inferior extremities (6.25 5%), and four people (5%) had lesions only on the scalp.

IJDV

Vol.1 No.4 2013

Table 4. The frequency distribution characterictics of patients by predilection Location of lession Universal Superior et inferior extremities Scalp, superior extremities, abdomen Scalp, facial, trunk Trunk, superior et inferior extremities Scalp Total
20 15

2006 8 3 4 3 0 0 18

2007 5 0 0 0 0 1 6

2008 15 0 0 0 1 1 17

2009 2010 14 1 2 2 1 2 22 7 5 1 1 3 0 17
Universal

Total 49 9 7 6 5 4 80

% 61,25 11,25 8,75 7,5 6,25 5 100

10 5
0 2006 2007 2008 2009 2010

Superior et inferior extremities Scalp, superior extremities, abdomen Scalp, facial, trunk Trunkus, superior et inferior extremities

Graphic 4. The frequency distribution characterictics of patients by predilection The dermatology's sign that were observed are wax drop phenomenon, Auspitzs sign, and Koebner phenomenon. From 80 patients, wax drop phenomenon gave about 16 people (20 %), six people (7,5 %) with Auspitzs sign positive and four people (5 %) with Koebner phenomenon. For the other patients, there is no record about their examinations have been done. Table 5. The frequency distribution characterictics of patients by dermatologys sign The dermatologys sign Wax drop phenomenon Auspitzs sign Koebner phenomenon
15 10 5

2006 2 2 0

2007 0 1 0

2008 1 1 2

2009 10 1 1

2010 3 1 1

Total 16 6 4

% 20 7,5 5

wax drop phenomenon Auspitz's sign Fenomena Koebner

Graphic 5. The frequency distribution characterictics of patients by dermatologys sign

2006

2007

2008

2009

2010

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar : a retrospective study in period of january 2006 december 2010

Histological examination on 24 patients (30 %) supporting the diagnosis of psoriasis, while others diagnosis are still unknown. Table 6. The frequency distribution characterictics of patients by histopathology Histopathology Supporting Unknown Total 2006 2 16 18 2007 2 4 6 2008 7 10 17 2009 8 14 22 2010 5 12 17 Total 24 56 80 % 30 70 100

20 15
10 5 0 2006 2007 2008 2009 2010

supported AP result Unknown

Graphic 6. The frequency distribution characterictics of patients by histopathology Obtained from 80 patients, 74 people (92,5 %) are psoriasis vulgaris, two people (2,5%) are psoriasis gutata, two people (2,5 %) are psoriasis pustulosa and another two people (2,5 %) are small-plaque psoriasis. Table 7. The frequency distribution characterictics of patients by psoriasis variants Psoriasis variants Psoriasis vulgaris Psoriasis gutata Psoriasis pustulosa Small-plaque psoriasis Total 2006 16 0 2 0 18 2007 6 0 0 0 6 2008 14 1 0 2 17 2009 21 1 0 0 22 2010 17 0 0 0 17 Total 74 2 2 2 80 % 92,5 2,5 2,5 2,5 100

25
20 15 Psoriasis Vulgaris Psoriasis Gutata Psoriasis Pustulosa Small-Plaque Psoriasis

10
5 0

Graphic 7. The frequency distribution characterictics of patients by psoriasis variants 6

2006

2007

2008

2009

2010

IJDV

Vol.1 No.4 2013

The patients are treated with oral antihistamin and topical combination therapy. Most of the topical combination therapy that have been used to 20 patients (25 %) are cortikosteroid (CS) + salicylic acid (SA) 3 5 % + liquor carbones detergent (LCD) 2 %. About 10 patients (12,5 %) are systemic corticosteroid. Nine patients (11,25 %) are given ter shampoo, six patients (7,5 %) get ultraviolet therapy ( narrowband ultraviolet/NB-UVB), and 14 patients (17,5 %) are treated with methotrexate (MTX). Table 8. The frequency distribution characterictics of patients by treatment Treatment Oral antihistamines Systemic corticosteroids Topical combination Topical corticosteroids Ter shampoo NB - UVB Methotrexate 2006 2007 18 6 2 0 18 6 5 1 7 2 0 3 2 2 2008 2009 2010 17 22 17 1 5 2 17 22 17 4 10 8 0 0 0 3 0 0 1 8 1 Total 80 10 80 28 9 6 14 % 100 12,5 100 35 11,25 7,5 17,5

25 20

Oral Antihistamin Systemic cortikosteroid

15
10

Topical combination Tropical cortikosteroid

Ter Shampoo NB - UVB

5
0

Methotrexate

Graphic 8. The frequency distribution characterictics of patients by treatment Table 9. The frequency distribution characterictics of patients by topical combination
Type of Topical combination CS +SA 3-5% + LCD 2% CS + SA 3-5% + Lanolin 2-5% CS + Lanolin 2-5% CS + SA 3-5% + LCD 2% + Lanolin 2-5% CS + SA 3-5% + Sulfur pp 5% CS + SA 3-5% CS + SA 3-5% + LCD 2% + Sulfur pp 5% Total 2006 7 2 3 4 0 2 0 18 2007 0 3 1 0 0 2 0 6 2008 6 4 5 1 0 1 0 17 2009 4 4 3 5 4 0 2 22 2010 3 4 2 3 2 0 3 17 Total 20 17 14 13 6 5 5 80 % 25 21,25 17,5 16,25 7,5 6,25 6,25 100

2006

2007

2008

2009

2010

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar : a retrospective study in period of january 2006 december 2010

8 7 6 5 4 3 2 1

KS + AS 3-5% + LCD 2%

KS + AS 3-5% + Lanolin 2-5%

KS + Lanolin 2-5% KS + AS 3-5% + LCD 2% + Lanolin 2-5%

KS + AS 3-5% + Sulfur PP 5%
KS + AS 3-5% KS + AS 3-5% + LCD2% + Sulfur PP 5%

0
2006 2007 2008 2009 2010

Graphic 9. The frequency distribution characterictics of patients by topical combination

DISCUSSION
During the periode January 2006 December 2010, the number of psoriasis patient are 80 people out of 17 082 patients (0.47%) who came for treatment at the clinic of dermato genitalia department in RSUP dr. Wahidin Sudirohusodo Makassar. The prevalence of psoriasis in varies populations is from 0.1% to 11.8%. (2) Worldwide epidemiologic study of psoriasis estimated the prevalence is 0.6% to 4.8%. (12) The prevalence of psoriasis in 10 teaching hospitals in Indonesia are varies between 0.59% to 0.92%. (13) In this study, the prevalence is slightly lower. From 80 patients with psoriasis, 50 people (52.5%) are male and 30 (37.5%) are female (Table 1). According to references, women and men have equal chances to get psoriasis. (1 to 3.14) Some studies suggest that psoriasis may be slightly more common among men than women. (11) Most of the case are found in the age of 25-44 years is 38 people (47.5%) (Table 2). This is corresponding with the references that psoriasis can occur at any age, but is rarely found in less than 10 8

years old, and more often appears at the ages of 15 to 40 years. (2.5) Most of the patients present with scaly red patches with itching, which is 72 people (90%), while eight people (10%) did not have any complaints of itching (Table 3). This is consistent with the references that psoriasis lesions are demarcated, elevated, in the form of patches or plaques reddish with white scaly surface. (1,2,3,5) According to the references, two-thirds of psoriasis patients have complaint of itching.(11) In this study, most of the patients have complaints of itchy. Most of them had lesions on all over the body (universal) in 49 people (61.25%) and only one of them who also have psoriasis of the nails (Table 4). The other patients had lesions on the superior et inferior extremities (11.25%), scalp, superior extremities and abdomen superior (8.75%), scalp, facial, trunk (7.5%), trunk, superior et inferior extremities (6.25 5%), scalp (5%). According to the reference, patients with psoriasis commonly have lesions on the extensor surfaces of elbows and knees, scalp, anterior and posterior trunk, sacral region, and genitalia. At the area around the umbilicus and

IJDV

Vol.1 No.4 2013

intergluteal also be affected. The affected part of the body are varies from one patient to another patient.(1- 3,6,11) Nail changes usually happen in psoriasis, about 40 percent of patients are found, and rarely occurs in the absence of skin disease with an image of "pitting" onycholysis and sometimes subungual hyperkeratosis. (2.5) In this study, patients with nail psoriasis also have psoriatic lesions on other parts of the body. Physical examination that had been done are wax droplets phenomenon, Auspitz's sign, and Koebner phenomenon. From the 80 patients, the wax drop phenomenon are 16 people (20%), positive Auspitz's sign in six people (7.5%) and Koebner phenomenon is four people (5%). The other patients is unknown whether the examination had been done or not (Table 5). This is consistent with the references, that the scaly layered shows by a long way, known as the scratch grattage methodique which is scratching the scaly with a scalpel or nails until uneven white and wrinkled appear (looks like scratched wax drop). (14) Under the scaly, the skin looks erythema homogenous and shiny and bleeding spots will appear when the scale is taken out and the dilated capillaries will injured (Auspitz sign). Koebner phenomenon (also called isomorphic response) is psoriasis lesions that induced by trauma that occurs to the skin without lesions. Koebner phenomenon is not specific to psoriasis but can assist in establishing the diagnosis when found. (1-3) Histopathological examination in 24 patients (30%) supported the diagnosis of psoriasis, whereas in other patients is unknown whether or not the histopathologic examination had been done (Table 6). Histopathologic view seen in psoriasis patients is psoriasiform hyperplasia, hyperkeratosis, parakeratosis, elongated rete 9

ridges, Munro abscesses, hypogranulosis, suprapapilary plate thinning, dilating blood vessels and papillary dermis contains erythrocytes, and infiltration of lymphocytes. Based on references, although histopathological examination is rarely necessary to make a diagnosis, but it can be helpful in difficult cases. Histopathological view that supports the existence of parakeratosis, hyperkeratosis, elongated rete ridges, decreased or loss granulosum layers, Munro abscesses, suprapapilary plate thinned, dilated capillaries and winding, and there is infiltration of lymphocytes. (2,5,15) Obtained from 80 patients that suffering from psoriasis vulgaris were 74 people (92.5%), while other patients are guttate psoriasis, psoriasis pustulosa, small-plaque psoriasis (Table 7). This is consistent with the references which state that psoriasis vulgaris is the most common form of psoriasis, seen in about 90 percent of patients. (2,11,14) All patients treated with oral antihistamines and topical therapy combinations. Other than that, there are also patent who treated with systemic corticosteroids, tar shampoo, ultraviolet light therapy (narrowband ultraviolet / NB-UVB), and some treated with methotrexate (MTX). According some resources, there are many psoriasis treatment that is safe and effective. The treatment is to improve skin condition and reduce complaints of itch. (14) Antihistamines are given in psoriasis treatment because in psoriasis actually mast cells release the histamine. (16) In addition, the sedative effects from antihistamines is to reduce the itching sensation that experienced by patients. ( 1 7) For a topical combination therapy, generally consists of corticosteroids and salicylic acid 3-5%, then there is LCD 2%, lanolin 2-5% and 25% sulfur pp added. According to some

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar : a retrospective study in period of january 2006 december 2010

sources, topical therapy has been and remains a major therapeutic option for the treatment of psoriasis on the skin as it provides a potential therapeutic efficacy and limited treatment effects on target tissues. Topical corticosteroids have long been the mainstay of therapy for mild to moderate psoriasis and can be used alone or in combination with other topical treatments. (8) Additional salicylic acid is efficacious in treating psoriasis because it can reduce the scaly and fine lesions. Salicylic acid is proven to increase the efficacy of steroids by increases its penetration when given with steroids. (8.18) LCD (liquid detergent carbonis) is a coal ter preparations that used to treat mild, moderate or severe psoriasis but the efficacy of antipsoriatic is weak. (19) LCD is often combined with salicylic acid 2-5% with its keratotic effect that helping in absorption of LCD. (2) Lanolin is vehikulum that is charecterize as emollient. ( 20) In psoriasis skin care should be done using emollients to prevent dryness. Emollients can reduce the scaly, prevent the formation of fissures that are painful and can help in pruritus controling. (2) Systemic steroids should not be used as routine treatment for psoriasis patients. However, systemic steroids can be given to persistent psoriasis, uncontrollable, erythrodermic and generalized pustular psoriasis that are fulminating, if other treatments are not effective. (2) Ter shampoos used to treat psoriasis on the head. (1 9) For moderate psoriasis or severe psoriasis that are unresponsive to topical treatment, ultraviolet rays treatment can be used. The most often type used today is a short spectrum ultraviolet B (narrowband UVB / NB-UVB). (9.11) Methotrexate (MTX) is effective for chronic plaque psoriasis and is also indicated for the longterm treatment of severe psoriasis, inclu10

ding erythrodermic psoriatika and pustular psoriasis. (2) Conclusion Psoriasis is an inflammatory skin disease that is chronic and residif, but not contagious. Clinical knowledge and severity assessment of psoriasis should be understood to determine the type of treatment that can be given. Although there are many treatment options but until now there is no cure for psoriasis. The existing therapies only use to reduce the symptoms and lesions of psoriasis for just a while. Patient's lifestyle is also an important factor. In making the patients medical records, should include the history of the disease, presence / absence of other family member with the same complain like this, a history of smoking or alcohol consumption, history of drugs taking, stress and disease history of previous infection. REFERENCES
1. James W, Berger T, Elston D. Psoriasis. In: James W, Berger T, Elston D, editors. Andrews diseases of the skin clinical dermatology. 10th ed. Canada: Elsevier Saunders; 2006. p. 193-201. Gudjonsson J, Elder J. Psoriasis. In: Wolf K, Katz S, Gilchrest B, Paller A, Leffel D, editors. Fitzpatrickss dermat ology in general medicine 7th ed. New York: McGraw-Hill; 2008. p. 169-88. Griffiths C, Barker J. Psoriasis. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rooks textbook of dermatology 8th ed. Ox ford: Blackwell P ublishing Ltd; 2010.p. 20.1-58. Vavricka B, Guitart J. Diagnostic evaluation. In: Gordon K, Ruderman E, editors. Psoriasis and psoriatic arthritis an integrated approach. Germany: Springer Verlag Berlin Heldelberg; 2005. p. 83-91.

2.

3.

4.

IJDV

Vol.1 No.4 2013

5.

Hunt er J, Savin J, Dahl M. Psoriasis. In: Hunt er J, Savin J, Dahl M, editors. Clinical dermatology 3rd ed. Ox ford: Blackwell science Ltd; 2003. p. 48-62. Buxton P. Psoriasis. In: B uxton P, editor. ABC of dermatology 4t h ed. London: BMJ Publishing; 2003. p. 8-12. Prinz J. Psoriasis vulgaris and arthopathica. In: Hertl M, editor. Autoimmune diseases of t he skin. New Y ork: Springer Wien; 2005. p. 291-304. Quinby R. Topical therapy. In: Gordon K, Ruderman E, editors. Psoriasis and psoriatic arthritis an integrat ed approach. Germany: Springer V erlag Berlin Heldelberg; 2005. p. 134-41. Dempsey J, Zanolli M. Phototherapy. In: Gordon K, Ruderman E, editors. Psoriasis and psoriatic arthritis an integrated approach. Germany: Springer Verlag Berlin Heldelberg; 2005. p. 145-57.

6.

15. Tjarta A. Psoriasis, gambaran histopatologis. In: Tjarta A, Sularsito S, dkk, editors. Metode diagnostik dan P enatalaksanaan psoriasis dan dermatitis seboroik. Jakarta: Balai Penerbit FKUI; 2003. p. 1722. 16. Krogstad A, Lonnroth P, Larson G, Wallin B. Increased interstitial histamine concentration in the psoriatic plaque. J Invest Dermatol. 1997; 109: 632-5. 17. Limb S, Wood R. Antihistamines. In: Wolf K, Katz S, Gilchrest B, Paller A, Leffel D, editors. Fitzpatrickss dermatology in ge neral medicine 7th ed. New York: McGraw-Hill; 2008. p. 2168-93. 18. Afifi T, Gannes G, Huang C, Zhou Y. Topical therapies for psoriasis. Can Fam Physician. 2005;51: 519-25. 19. Wiryadi BE. Psoriasis, penat alaksanaan. In: Tjarta A, Sularsito S, dkk, editors. Metode diagnostik dan penatalaksanaan psoriasis dan dermatitis seboroik. Jakarta: Balai Penerbit FKUI; 2003. p. 32-51.

7.

8.

9.

10. J, Menter A. Methotrexate and cyclosporine. In: Gordon K, Ruderman E, editors. Psoriasis and ps oriatic arthritis an integrated approach. Germany: Springer Verlag Berlin Heldelberg; 2005. p. 172-81. 11. Mrowitz U, Rech K. Psoriasis-new insights into pathogenesis and treatment. Dtsch Arztebl Int . 2009;106(1-2):11-9. 12. Neimann AL, Port er SB, Gelfand JM. The epidemiology of psoriasis. Expert Rev. Dermatol. 2006;1(1):63-75. 13. Marlia L, Sutedja E, Muljaningsih S, Supriyadi R. Penurunan k adar soluble tumor necrosis factor receptor type I (s TNFRI) dalam serum penderita psoriasis vulgaris setelah di terapi dengan krim klobetasol propionat 0,05%. MKB.2008; XI(1): 24-8. 14. Jacoeb T. Psoriasis, gambaran klinis dan penilaian keparahan. In: Tjarta A, Sularsito S, dkk, editors. Metode diagnostik dan penatalaksanaan psoriasis dan dermatitis seboroik. Jakarta: Balai Penerbit FKUI; 2003. p. 1-12.

20. Bergstrom K, Strober B. Principles of

topical therapy. In: Wolf K, Katz S, Gilchrest B, Paller A, Leffel D, editors. Fitzpatrickss dermatology in general medicine 7th ed. New York: McGraw-Hill; 2008. p. 2091-6.

11