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Penyakit
Dermatology
diperantarai imun
Citra Cahyarini
Dematitis
Dermatitis Atopik
Dermatitis Kontak
Urtikaria-angioedema
Penyakit vesikobulosa : Pemfigus vulgaris
Erupsi obat : FDE, Makulopapular
Pathogenesis : ???
Complex interaction of skin barrier, genetic,
Adult
Infantile
Infantil
AD
Childhood AD
The classic locations are the antecubital, and the popliteal spaces, the
wrist, eyelids, and the face and in collarette about the neck
Itching
Childhood AD
Associated features
Susceptibility to infection
:
S.aureus, generalized Herpes simplex or vaccinia virus
infections to produce Kaposis varicelliform eruption
Diagnosis
Hanifin & Rajka , Svenson, SCORAD criterias
Hanifin & Rajka criteria :
Major criteria
1.
Pruritus
2.
Typical morphology and distribution
3.
Tendency toward chronics or chronically relapsing dermatitis
4.
Personal or family history of atopic diseases (asthma, allergic rhinitis,
AD)
Minor criteria :
1.
Xerosis / ichthyosis/ hyperlinear palms
2.
Pityriasis alba
3.
Keratosis pilaris
4.
Facial pallor / infraorbital darkening
5.
Elevated serum IgE
6.
Keratoconus
7.
Tendency to non spesific hand eczema
8.
Tendency to repeat cutaneous infections
Differential diagnosis
Nummular Dermatitis
Seborrhoic Dermatitis
Contact Dermatitis
Psoriasis
Scabies
General management
1.
External irritation
b.
Antihistamin systemically
c.
d.
2.
In adults :
a.
The emosional stress should be controlled
b.
Avoid extremes cold and heat
c.
Hydrated xerotic skin
d.
Antihistamin
e.
Topical steroid ( be ware of the potentiallity)
f.
Antiobiotics ( if nedded)
Physical exam
acute
: erythema & edema
subacute : plaques of mild erythema,
dry scales
chronic
: plaque of lichenification
Lab
PATCH TEST
Irritants:
strong irritant severe inflamation at the first
contact
Weak irritants: less toxic substances which require
repeated or prolinged contact to
cause inflamation (detergent, organic
solvents, excessive exposure to water)
Incidence:
The incidence of cases of ICD (each type)
depending mainly on the degree of exposure
and the causative agent
acute ICD
Symptom :
- subjective : burning, stinging, smarting
Physical exam :
- < 24 h
- erythema vesiculation
vesicles/ blisters
chronic ICD
Physical exam :
dryness chapping erythemahyperkeratosis & scaling fissure & crusting
Treatment
Preventive :
Once the causative agent has been identified, further
contact should be avoided
Topical therapy :
in acute state : wet dressing : Burowi solution 1/20 1/40,
Permanganate 1/10.000, followed by topical steroid.
in chronic state : moderate topical steroid
Systemic therapy :
Antihistamin (severe pruritus) and steroid (severe /
extensive eruption
Contact
Dermatitis
Def :
* URTICARIA
is compoused of wheals (transient edematous papules &
plaques, usually pruritic and due to edema of papilary body).
The wheals are superficial, well defined.
* ANGIODEMA
is a large edematous area that involves the dermis and
subcutaneous tissue, is deep and ill defined
Therapy
Antihistamin : H1, H1 + H2
Systemic corticosteroid
Adrenalin inj subcutis/ ephedrin tab
angioede
ma
urticari
a
Vasculitis
A heterogeneous group of clinical synd characterized
by inflammation of blood vessels
The clinical picture is essensially dependent of size
and extent of vessel involvement purpura
Test : diaskopi
Therapy
Systemic corticosteroid
Anti-inflamatory agents :
salicylates, NSAIDs
Psychoactive agents :
barbiturates
Oral contraceptives
Quinine
Phenolphthaline
Food coloring
Physical examination
Skin :
Characteristic : a sharply demarcated maculae, round or oval
in shape, occurring within hours after ingestion drug
Initially : erythema, then dusky red to viplaceous
After healing : dark brown with violet hue post inflamatory
hyperpigmentation
Solitary, may be multiple
Distribution : genital skin, but any site involved
Management
Pathogenesis
Exact mechanism unknown, probably delayed
hypersensitivity
Reaction to spesific drug :
Amoxicicilin
Allupurinol
NSAIDs
Carbamazepine
Barbiturates
Phenothiazines
Nitrofurantoin
Isoniazid
Hydantoin derivatives Sulfonamides
Physical examination :
Skin
Maculae/ papules erithem, a few milimeters to 1 cm
Purpura ~ vasculitis
Scaling/ desquamation
Distribution : symmetric, almost always on thrunk and
extremities
Mucos membranes : ananthem on buccal mucosa
Management :
Penyakit vesikobulosa
Adalah :
Suatu penyakit yang ditandai adanya lepuh
(vesikel-bula) pada kulit
BULA SUPRABASAL
BULA SUBEPIDERMAL
BULA SUBKORNEAL
BULA INTRAEPIDERMAL
LETAK BULA:
1.
Bula Epidermal:
2.
Bula Subepidermal:
Di bawah epidermis
Dinding / atap tebal, tegang tidak mudah pecah,
tahan lebih lama
Toksin epidermolisis:
S. aureus toksin
2.
Reaksi imunologis:
Hipersensitivitas:
Dermatitis kontak edema intersel
(bula intra epidermal)
Autoimun (Autoantibodi):
Sel epidermis substansi semen antar sel larut
epidermis lepas bula intra epidermal
(pemfigus vulgaris)
4.
Membrana basalis rusak
Hubungan antar sel basal dan dermis lepas bula
subepidermal (PB, DH, PKT)
5.
Proses mekanis
3.
P.B. AUTOIMUN:
o
Pemfigus : vulgaris, vegetans, foliaseus, eritema
o
Pemfigoid bulosa
o
Pemfigus sikatrikal
o
Dermatitis herpetiformis
o
Herpes gestasionis
o
Dermatosis IgA linier pada dewasa (LAD)
o
Dermatosis bulosa kronik pada anak (CBD)
o
Epidermolysis bulosa akuisita (EBA)
2.
o
o
o
P.B. LAIN:
3.
o
o
o
o
Eritema multiforme
Nekrolisis epidermal toksik (TEN)
Porfiria kutanea tarda (PKT)
Dll
PE M FI G U S
2.
Superfisial:
Pemfigus foliaseus
Pemfigus eritematosa
Suprabasal:
Pemfigus vulgaris
Pemfigus vegetans
PEMFIGUS VULGARIS:
Paling sering dijumpai
Berat ancam kehidupan
Terutama orang dewasa
dan sama
KLINIS:
Vesikel jernih, dasar kulit non eritem
membesar >1cm bula tipis pecah erosi
superfisial krusta
PREDILEKSI:
Mukosa mulut : lesi dini
Kulit kepala, lipat paha, vulva / mukosa vagina
PEMFIGUS VEGETANS:
PEMFIGUS FOLIASEUS:
PEMFIGUS ERITEMATOSUS:
DIAGNOSIS:
1.
Biopsi
2.
Tes Tzanck
Tanda Nikolsky :
Imunofluoresensi
- Direk
3.
4.
DIAGNOSIS BANDING:
Pemfigoid bulosa
Pemfigoid sikatrikal
Herpes simplek oral
Erupsi obat bulosa
PENGOBATAN:
Antibiotika
Sistemik:
1.
Antibiotika
: ~ kultur dan tes sensitivitas
2. Kortikosteroid : - paling penting
- pilihan : Prednison
Dosis awal:
Lesi kulit 80-100 mg/hr/dosis terbagi, bila lesi
tetap timbul dosis dinaikkan tiap 4 hari, dapat
sampai 200-300 mg/hari
Lesi mulut saja maks 100 mg/hr
Penurunan dosis:
Bila penyakit membaik & stabil slama 2 minggu
3.
Imunosupresan :
- Mengurangi e.s. KS
- Mengurangi dosis KS
- Diberikan segera setelah penyakit dapat dikontrol
PROGNOSIS :
PEMFIGOID BULOSA:
Tes Tzanck
: (-), Akantolisis (-)
Nikolsky
: (-)
Imunofluoresen :
- Direk
: - IgG btk pita pada taut dermo epidermal
- Komplemen
- Indirek : Antibodi yang beredar dalam darah
TERAPI:
~ Pemfigus vulgaris
Kortikosteroid : dosis < Pemfigus vulgaris
Imunosupresan(-)
Dapson
: 100-200 mg/hr
PROGNOSIS:
Dapat terjadi remisi permanen
DERMATITIS HERPETIFORMIS:
(=DUHRINGS DISEASE)
Penyakit Autoimun : IgA granuler pd papila dermis
Insiden : tidak diketahui
: = 3:2
Timbul : dekade 3
Hubungan dg hipersensitivitas terhadap gluten
(enteropati gluten sensitif)
KLINIS:
o Vesikel 2 5 mm, berkelompok, dasar eritem
o Urtika, erosi, krusta
o Bula jarang
o
o
o
o
o
DIAGNOSIS:
Biopsi
: - bula subepidermal
Lekosit p.m.n
IF
: IgA granuler pada dermis bagian atas
Serologis eosinofilia
Radiologik : kelainan di usus halus
DIAGNOSIS BANDING:
Pemfigoid bulosa
Herpes gestasiones
Skabies
Reaksi obat
DKA
TERAPI:
Diit
: Hindari gluten : gandum, alkohol
Topikal : Kortikosteroid krim potensi sedang
Sistemik : - Dapson 200 mg/hr
- Tidak terbentuk lesi baru dosis
HERPES GESTASIONES:
Gambaran Klinis:
DIAGNOSIS:
Biopsi:
Epidermis terbelah
Eosinofil pada lepuh
~ Pemfigoid bulosa
IF :
Direk
: IgG dan C3 pada taut dermo epidermal
Indirek
: (+) pada beberapa kasus
DIAGNOSIS BANDING:
Pemfigoid bulosa
Eritema multiforme
Dermatitis herpetiformis
PUPPP (Pruritic Urticaria Papule and Plaques of
Pregnancy)
TERAPI:
Ringan:
KS topikal potensi sedang, oles 4 6 x/hr
Antihistamin peroral
Berat:
Prednison 40 mg/hr/oral
P.u. dapat atasi penyakit dengan cepat, kemudian
diturunkan sampai 10 20 mg/hr
Plasmaferesis : bila tidak berespon pada KS
Pengobatan pd bayi baru lahir : Tidak perlu, karena
lesi transien
PROGNOSIS
CBDC =
CHRONIC BULLOUS DERMATOSIS OF CHILDHOOD
Jarang dijumpai
Pada masa bayi dan anak ( < 5 tahun)
IgA linier pada taut dermo epidermal
Patogenesis belum diketahui
P.u. didahului infeksi saluran nafas atas
KLINIS:
Vesikel berkelompok
Gatal (+) / (-), kadang hebat
Sembuh
: hipo / hiperpigmentasi
Predileksi
: perioral, genital
50% kasus
: lesi mulut
DIAGNOSIS:
Biopsi
: ~ DH
IF direk : IgA linier pada taut dermo epidermal
IF indirek : otoantibodi anti mbr basalis (80% kasus)
DIAGNOSIS BANDING:
Varisela
Impetigo
Pemfigoid bulosa
Eritema multiforme
TERAPI:
~ DH
Dapson
Sulfapiridin
KS sistemik : sedikit memberi keuntungan
PEMFIGUS VULGARIS
PEMFIGUS ERITEMATOSUS
PEMFIGOID BULOSA