CASE REPORT

PSORIASIS VULGARIS TREATED WITH TOPICAL CORTICOSTEROIDS

Solecha Setiawati1, Dirmawati Kadir1, Wiwiek Dewiyanti1, Ni Ketut Sungowati2
1

Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar 2 Department of Phatology Anatomy Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar

ABSTRACT
Psoriasis vulgaris is a chronic papulosquamous disease and is associated with genetic and environmental factors. Clinical manifestations in the form of red plaques with thick silvery-white squama and demarcated, predilection on the scalp and extensor extremities. Various therapeutic modalities for psoriasis vulgaris include corticosteroid topical, derivatives of vitamin D, tar preparations, biological agents and systemic agents. Reported one case of psoriasis vulgaris in a male patient aged 26 years who were treated with topical corticosteroids, seem significant improvement as measured by PASI scores (Psoriasis Area and Saverity Index). Keywords:, psoriasis vulgaris,PASI scores,topical corticosteroids.

Address for correspondence : Solecha Setiawati, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar Blok B/12 Jl. Poros Makassar Maros Griya Azikrul Toaha Makassar, South Sulawesi, Indonesia dr.ikasolecha@gmail.com

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psoriasis vulgaris treated with topical corticosteroids

INTRODUCTION Psoriasis is a chronic inflammatory skin disease that has a close relationship with genetic factors, characterized by complex changes in the growth and differentiation of epidermal abnormalities and various biochemical, immunological, and vascular. Psoriasis is considered as a primary disorder of keratinocytes. [1] Having a form of patches lesion demarcated erythema with squama rough, layered and transparent with wax drip phenomenon, the phenomenon kobner , and Auspitz sign. (2,3,4) Psoriasis can be found all over the world. although the frequency varies in some ethnic. According to published reports, the prevalence varies among populations ranging from 0.1% to 11.8%. Highest incidence in Europe, in Denmark (2.9%) and the Faeroe Islands (2.8%), with the northern European average is around 2%. In the United States the prevalence ranged from 2.2% to 2.6% with about 150000 new cases are diagnosed each year. (1) The incidence of psoriasis appears to be lower in Asia, with a prevalence of about 0.4% . Psoriasis can affect all ages, both children and adults. But, rarely occurs in people under 10 years old. More common in the age 15 to 30 years. (1) The incidence of the same in men and women. (4) Underlying cause of psoriasis remains unclear. (1) According to Gunnar Lomholt in 1963 said that the genetically induced psoriasis. (1.2) Some risk factors that can increase the development of psoriasis in addition to family history (genetics), is the presence of trauma, infection, drugs, metabolic factors, physiogenic factors, smoking, and alcohol consumption. (1,2,7,9,11) There are several types of psoriasis include plaque psoriasis, pustular psoriasis, psoriasis guttata, 67

psoriasis erythroderma, and in certain locations such as scalp psoriasis, flexural psoriasis, psoriasis of the oral mucosa, nail psoriasis, and psoriatic arthritis. Plaque psoriasis is the most common type, found about 80-90% of patients with psoriasis. Plaque psoriasis (also known as psoriasis vulgaris or chronic stable plaque psoriasis or psoriasis chronic stationair).
(2,7,9)

Psoriasis vulgaris diagnosis is established through clinical picture, also by histopathological examination. Histopathological picture of psoriasis vulgaris varies, depending on the stage of the lesion, namely: the initial lesion; fully developed lesions, or lesions further / final
(2)

There are a variety of safe and effective treatment, such treatment can improve skin condition and reduce complaints of itch. The main goal of treatment is to reduce the severity and extensive skin lesions that the disease no longer interfere with work, personal life / social, and the livelihoods of people, as well as reduce the symptoms of psoriasis. (10) There are three basic therapeutic modalities available are topical agents, phototherapy and systemic agents, to achieve therapeutic success it is necessary to understanding the mechanism of action, toxicity, and side effects of therapy . (10) CASE REPORTS A man, 26 years old, Bugis, the Honorary Governor's office in Mamuju, went to the clinic of skin and venereal Wahidin Sudirohusodo hospital on March 11, 2013, with complaints of red and scaly skin over most of the body, which was experienced approximately 1 year ago, and was advancing from 3 months, originally appeared on the legs, appeared red and scaly patches of itchy lesions, especially

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on the head but not with pain. Patients complaining of skin lesions spread almost throughout the body. Complaint is not found on the face and nails. History of treatment in clinical practice dermatologist in Mamuju, given ointment and oral medication, but felt no change, so it was given a referral to the clinic of skin and venereal Wahidin Sudirohusodo hospital. Family history of suffering from the same disease exist (aunt), history had previously the same disease denied. Smoking history until now. History consume alcoholic beverages 2 years ago. 68

Physical examination showed the patient's general condition is good and vital signs within normal limits. Physical examination of the heart, lungs, liver, spleen and kidney abnormalities not found. Dermatologist status obtained in the region of thoracic, abdominal, trunk posterior et anterior, glutea, extremities superior et inferior. Skin lesions are found in the form of plaques erythematous , demarcated, varied forms, from round, oval, irregular, and vary in size with a diameter of about 1-10cm, above there squama psoriasiform, dry and white. The

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psoriasis vulgaris treated with topical corticosteroids

phenomenon of wax droplets (+), the phenomenon auspitz (+). PASI score (Psoriasis Area and Saverity Index) in these patients was 11.7 (Figure 1) From the results of laboratory tests of blood and urine complete in normal limit. Examination test of skin scraping with 10% KOH (Potassium Hydroxide) is negative. The differential diagnosis of this disease is psoriasis vulgaris, pityriasis rubra pilaris, and seborrheic dermatitis. Working diagnosis was psoriasis vulgaris or chronic plaque psoriasis. Then performed on the skin biopsy for histopathological examination. Patients were assigned topical treatment desoximetasone 0.25% ointment , salicyl acid 3%, 3% LCD, and vaseline. Cetirizine 10mg once a day. Antibiotics and analgesics, given after biopsy was done ciprofloxacin 500 mg twice a day, mefenamic acid 500 mg three times a day. Histopathological examination showed epidermal hyperplasia, psoriasiform, hyperkeratosis, parakeratosis, spongiosis, suprapapillary plate thinning, blood vessels dilated dermal papilla contains erythrocytes, upper dermis are pretty solid inflammatory cells infiltrates, limphohistiositic with some neutrophils, abscess munro, conclusions support psoriasis vulgaris (figure 3). Control during three days later, the patient showed improvement, plaques erythema thinning, and itching started skuama reduced and reduced. PASI score 10.3. Therapy with desoximetasone 0:25% ointment 20 grams, 3% Salicyl acid, Lcd 3%, and vaseline. Cetirizine 10mg 1x1 tablet per day. Control day 7, showed better results; plaques erythema thinning and fine scales. PASI score of 6.3.

DISCUSSION Psoriasis is a chronic skin disease that commonly occurs, and attack the 15% of the world population (5). According to Henseler and Christopherm psoriasis split in two, type I and type II. Where the prevalence of type I before the age of 40 years, and type II after the age of 40. years. (1.6,7) In this case, patients aged 26 years and there is a family history of the same disease, so it can be included in psoriasis type I. Diagnosis in these patients is psoriasis vulgaris, based on history, clinical features, histopathologic examination support. In this patient , lesions found in the form of plaques erythematous, varied forms, from round, oval, irregular, and vary in size with a diameter of about 1-10cm, squama psoriasiform, dry and shiny white, which is found on the area back, chest, abdomen, superior and inferior extremities, neck and head. Lesions characteristic of psoriasis vulgaris is erythematous plaques, demarcated, symmetrical, accompanied layered squama and shiny on scalp, extensor arms, legs, knees, elbows, back, and body .2.8) Are also perceived complaint of itchy especially on the head, there were a history of stress, smoke and drinking alcohol. Itching is an additional symptom that usually occurs in patients with psoriasis, especially scalp and anogenital regions. (4.8) As for the allegation that is considered the factors that can trigger psoriasis are: physical trauma (Koebner phenomenon), streptococuss infection, stress, drugs & alcohol. (2,4,8) Physical examination found the phenomenon of wax droplets and Auspitz mark and score Pasi 11.7. Phenomenon that is scratch squama on the lesion wax droplets so it looks uneven and tangled white lines. 69

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Auspitz sign is a characteristic feature of psoriasis lesions, made with sloughing squama hyperkeratotic lesions in the picture and found a small bleeding spots caused by 'beheading' papillary dermis and dilation and winding blood vessels. This Auspitz sign has greater (1,2,7,12) diagnostic value. Accurate assessment of psoriasis severity is essential in clinic and research. PASI (psoriasis area severity index) is one of indicators to assess the severity of lesions of psoriasis and response to treatment. PASI assessment was first formulated by Fredricksson and Pettersson, is the most widely used method for measuring the severity of psoriasis in clinical trials. This method is a practical and fast with PASI score ranged from 0.0 to 72.0. (7,8,12) Histopathological picture of psoriasis vulgaris varies, depending on the stage of the lesion, the initial lesions, lesions that developed, and advanced lesions. (1.7) In the literature, the results of histopathologic examination is hyperkeratosis, focal parakeratosis there are heaps of neutrophils (munro micro abscesses), and focal hyperplasia psoriasiformis hypogranulosis. Suprapapillary plate area looks thinner. Some dilated capillaries at the papilla, infiltration of inflammatory cells are lymphocytes found in the dermis layer (1) The results of histopathological examination of biopsy specimens of this case, obtained with epidermal hyperplasia, psoriasisform, hyperkeratosis, parakeratosis, hypogranulosis, spongiosis, suprapapillary plate thinning, blood vessels dilated dermal papilla contains erythrocytes, upper dermis inflammatory cells infiltrates are dense enough, limphohistiositic with some neutrophils, microabscesses munro, which support a conclusion of psoriasis vulgaris. The appeal case was diagnosed 70

with seborrheic dermatitis, pityriasis rubra pilaris, linear psoriasis, and tinea corporis. Seborrheic dermatitis can be distinguished with psoriasis vulgaris seborrheic dermatitis where the color is pale patches of erythema, ill defined and covered white - yellow squama and greasy. Some cases of psoriasis overlap with seborrheic dermatitis. Seborrheic lesions can be found on the face, retroauricular, scalp, flexura, axilla and breast crease. Erythematous lesions on the area and a bit wet with smooth squama, but more dominant yellow dry squama than oily. (1,2,7,9) In Pityriasis rubra pilaris is a chronic disease, characterized by redness squama characterized by follicular keratotic papules and plaques reddish orange color that often form between the islands of normal skin (1, 9) In the linear psoriasis, a rare form of psoriasis. Psoriatic lesions appear as lesions especially on the extremities and trunk, likely nevus that covered, it's just the same linear ILVEN (inflammatory linear (1.15) verrucous epidermal nevus) Therefore resembles psoriasis in clinical and histologinya linearbaik. (1). Tinea Corporis can be excluded with KOH examination, presence of hyphae and arthrospora were obtained in skin scraping lesion, (1.4) whereas in this case KOH examination result was negative. Management of psoriasis vary widely and include broad based, severity of lesions, location of psoriasis, type of psoriasis (1.7) In mild psoriasis with PASI <8 or extensive lesions <5%, treated with topical therapy; moderate to severe psoriasis with a PASI score> 8; treated with topical therapy, phototherapy. While on severe psorisis, can be treated systematically. (1,2,6,7,10) In this patient body surface area of> 5%, or PASI score> 8, so that is treated with topical therapy.

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psoriasis vulgaris treated with topical corticosteroids

Topical glucocorticoids are generally the mainstay of therapy in mild to moderate psoriasis. Improvement is usually achieved within 2 to 4 weeks. Mechanism of action of topical corticosteroids by binding to glucocorticoid receptors, gene transcription inhibit Ap-1 and NF-B, including IL-1 and TNF-. This therapy will suppress the hypothalamicpituitary-adrenal (high risk in children), making epidermis and dermis atrophy, striae, and tachiphylaxis This treatment is contraindicated hipersensitive to steroids, active infection skin. (1) This patient was given desoximetasone ointment 0.25%, which is a potent corticosteroid potency (class 2). Expected effectiveness is thinning plaque, a reduction in symptoms and get a repair lesions (7,8). State of lesions in this patient showed improvement, namely erythema plaques thinning, and squama reduced (PASI score 8). Plaque effectively treated if induration was lost . Topical corticosteroid therapy desoximetason 0.25% ointment forwarded. If the lesions respond better circumstances again, it is replaced with a less potent corticosteroid. Tend to fast remission when corticosteroid therapy was stopped. (1) Prognosis of the disease in this case good because lesion showed improvement after topical corticosteroids therapy. But psoriasis is a chronic skin disease and frequent recurrence, disease can be rapidly improved, but one day could be worse. [1-3]. Education should be given to patient that this disease can be recurrent, it is important to avoid the trigger factors and the treatment given and its effectiveness should be monitored to prevent adverse effects the drug.
(1,2,4,13,14)

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