dr.

Purnamaniswaty Yunus
LO
- Mahasiswa mampu mengetahui agen parasit yang
menyebabkan penyakit integumen
- Mahasiswa mampu mengetahui patomekanisme
nematoda menyebabkan kelainan integumen
- Mahasiswa mampu mengetahui patomekanisme
terjadinya CLM
- Mahasiswa mampu mengetahui patomekanisme
terjadinya filariasis
- Mahasiswa mampu mengetahui patomekanisme
terjadinya Scabies
- Mahasiswa mampu mengetahui patomekanisme
terjadinya Pediculosis
● skin disease caused by various parasites
● This disease is often found in :
o Crowded areas
o Low socio-economic condition
o Poor sanitation and hygiene
● In the eradication effort, these attempts
are needed:
◦ Early diagnosis and prompt treatment
◦ Public health education about :
- Prevention
- Proper hygiene
- Reservoir-host-vector control
 The causes of this disease are divided into
3 major groups :
1. PROTOZOA : - Amoebiasis
- Trichomoniasis
2. NEMATODA : - Oxyuriasis / enterobiasis
- “Ground itch”
- Cutaneous larva migrans
- Current larva
- Filariasis
- Dracunculiasis
3. ARTROPODA : - Scabies
- Pediculosis
● Causative agent : Ancylostoma braziliensis,
Ancylostoma caninum, Ancylostoma ceylanicum,
Ancylostoma duodenal, Necator americanus

● Mostly affects children, miners and farmers.

 Pathogenesis :
Adult hookworm in dogs’ / cats’ small intestines
↓
Eggs (in animal faeces)
↓
Rhabditiform larvae (soil)
↓
Filariform larvae (soil)
↓ penetrate ground itch
The skin
↓
“Creeping eruption”
Clinical features :

- Common locations are on the buttocks,

feet, & hands.

- The diameter of the lesion is 1 – 4 mm,

red in color, a bit raised,
like a coiled thread.
Typical track of CLM located on plantar aspect of foot.
Vesiculobullous lesion of CLM.
● Diagnosis : typical lesion manifestation

● Treatment :
○ Topical :
- Classic : Chlorethyl spray, CO2, liquid N2
- Thiabendazole 10%
- Albendazole 2%
○ Systemic :
- Thiabendazole 25 mg/kgBW/day → 2 days
- Albendazole 50 mg/kgBW/once a week
FILARIASIS
–W. Bancrofti (90%)
Found throughout tropics

–Brugia malayi, Only

SE/East Asia

–Brugia timori, Only

Timor islands
– 120 million people
infected
– 1 billion at risk
– 80 countries: but 70% of
cases found in India,
Nigeria, Bangladesh, and
Indonesia
– Men to women is 10:1,
thought due to clothing
– Adult worms live in
lymphatic vessels for
5‐10 years
– Microfilariae can live
for up to 1.5 years
– Mosquitoes: Aedes,
anopheles, culex, or
mansonia
CLINICAL MANIFESTATION
–Asymptomatic (at least 50%)
– Lymphatic dilatation and abnormal lymph flow without symptoms
– Microscopic hematuria and proteinuria
– Study with U/S showed ó of adult men with asymptomatic microfilaraemia had
nests of motile adult worms in their scrotal sacs
–Acute attacks
– Episodic
– Lymphadenitis, lymphangitis, fever and malaise
–Lymphadenopathy/Lymphedema
– Adult worms blocking the lymphatics, inflammation very important to process
– Inguinal, crural, axillary, intrascrotal lymphatic vessels
– Can be seen in children
– Legs, scrotum, penis, and arms
– Elephantiasis
– Clinical feature, not synonymous
– Recurrent infections, inflammation and fibrosis
– Chronic skin infections from streptococcal species and
fungal infections
– Travelers
– Acute filarial lymphangitis
– 2‐6 months after exposure
– Acute inflammation (usually leg, scrotum, or arm),
progresses distally
– Indurated, tender, erythematous,
– Tropical Pulmonary Eosinophilia
(TPE)
– Asthma‐like symptoms
– 1/3 of children with cough and
wheeze had filarial infection,
symptoms improved after
treatment with DEC
– Peripheral eosinophilia, elevated IgE,
low grade fever, lymphadenopathy
– Typically found in men 20‐40 years
old
– Chyluria
– Passage of lymph in the urine so that
it appears milky
DIAGNOSIS
–Microfilariae on a thick blood smear
–Filtration of 1‐5ml of blood with filter is more
sensitive
–Highest blood specimen concentrations at night
–Distinguish the three species morphologically
–Children often negative
– Assays to detect W. bancrofti antigen are available
TREATMENTS
–Diethylcarbamazine (DEC) is the drug of choice, used since 1947
–Microfilaricidal + Macrofilaricidal
–Single dose of 6mg/kg/day as effective as 12 day therapy per CDC
–Cooking salt medicated with DEC has been used for mass treatment
programs
–Severity of reaction to treatment is dependent on microfilarial
density
– Usually self limited
–DEC not used in areas that have co‐endemicity with onchocerciasis or
loa loa for risk of severe reactions, instead use 400mg of Albendazole
+ 150ug/kg of ivermectin
–DEC not recommended during pregnancy
–Treat children with TPE with DEC
FUTURE
–ICT Filarial antigen test
– Rapid
– Simple enough to use in the field
– Nearly immediate results
– 100% sensitivity, 96% specificity
– Some vaccine work underway using cloned filarial antigens
– Promising work with treating the wolbachia bacteria
– Tetracycline and doxycycline have been shown to inhibit motility,
viability, and release of microfilariae
– Consider pre‐treating with Doxy 100mg PO BID x 4 weeks then 1 dose of
DEC
ONCHOCERCIASIS
WHO Distribution of onchocerciasis, worldwide, 2013
– Larva drop from proboscis
 human subcutaneous
tissues  grow to adults (3‐
12months) female
nematode makes fibrous
capsule, males migrate
female sheds 100,000s
microfilariea which migrate
 microfilariae taken up by
blackfly during meal fly’s
gut  muscles  grow to
larva proboscis
CLINICAL FINDING
–SKIN  Papular dermatitis, intensely
pruritic ,
–TH1 Immune Response, Chronic disease
can develop asymptomatic
depigmentation Hypo vs
Hyperpigmentation, “Leopard skin”
– TH2 Immune response 
Lichenification, “Lizard skin,” “Elephant
Skin”
–Eosinophilic response to onchocerca
breakdown products  Bacterial
superinfection common
CLINICAL FINDING
–SKIN NODULE
–Ocular findings
– Anterior Disease: punctate or sclerosing
keratitis, uveitis
– Posterior Disease: Chorioretinitis,
optic atrophy
LOA-LOA
– Transmitted by
Tabanid fly
– Microfilariae climb
into dermis through
hole cut in skin by fly
– Move on to
lymphatics
– Adult worms set up
shop in the tissue
between the fascial
layers of muscle and
the skin
– Microfilariae live for ~ 6‐12 mos
– Diurnal periodicity: Densities of
microfilariae peak by noon, and
decrease to low levels at night
– Chrysops flies active in daytime
– Calabar Swellngs: Subcutaneous, non‐pitting,
non tender edemas
– Hematuria, proteinuria, MPGN, Renal failure
– Cardiomyopathy
– Pulmonary infiltrates and pleural effusions
– Arthralgia (knees and wrists) and arthritis
– Most specific sign is passage of adult worm
under conjunctiva
– Can last for 30‐60 minutes to more than 24
hours
– Itching, photophobia, congestion of eye
– Seen in 50% of people who live in
hyperendemic areas
● Method of transmission :
- Direct → handshake, sexual contact
- Indirect → through objects

● Etiology : Sarcoptes scabiei var hominis

Life cycle : Female mites in stratum corneum

↓
Eggs
↓ 3–4 days
Larvae 10–14
↓ days
Mites
Clinical features :

- Predilection : in-between fingers,

flexor of the wrists,
genitalia, axillae folds,
lower abdomen, buttocks.

- Lesion → papule, vesicle,

excoriation/secondary infection,
sometimes forming burrows.
Clinical variations :
 “Incognito” scabies
 Scabies in infants &
children
 Noduler scabies
 Scabies transmitted
by animals
 Scabies “in a clean”
 Norwegian scabies
● Additional examinations :
- Microscopic → mites, eggs, faeces
- Burrows → tetracycline
- Skin biopsy

● Diagnosis :
- Itch, especially at night-time
(nocturnal itching)
- History of infection on members of the
family / people living under the same roof
- Characteristic distribution of lesion
- Characteristic lesion → burrows
- Definite diagnosis → mites, eggs, faeces
- Tx antiscabies → improvement
● Treatment :
– Gamexan 1%
– Crotamiton 10%
– Sulfur 5 – 10%
– Benzoil benzoate 20 – 35%
– Permethrin 5%

● To achieve treatment success :

- Treat every contact person
- Correct drug administration
- Washing clothes and towels with hot water,
air mattress under the sun
- Avoid excess treatment
– P. capitis → P. humanus var capitis
– P. corporis → P. humanus var corporis
– P. pubis → Phtirus pubis

Pathogenesis :
- Direct contact
- Indirect contact
P. CAPITIS
● Clinical manifestation : often affects children
● Symptoms :
- itch, especially on the occipital &
temporal parts → excoriation, erosion /
secondary infection
- swelling of the lymph glands

P. CORPORIS
● Clinical features :
- hemorrhagic macules / papules with
punctum in the middle
- urtica
P. PUBIS
● Mites → pubic hair, eyebrows, eyelashes,
axillae region, sometimes body hair
● Clinical features :
- itch → excoriation / secondary infection
- Characteristic → “maculae cerulae”
Diagnosis :
P. capitis : shiny eggs on hair, mites
P. corporis : eggs / mites on clothes’ folds
P. pubis : eggs / mites on pubic hair,
eyelashes, body hair
Treatment :
P. capitis : - gamexan 1% shampoo
- permethrin 1% cream
- crotamiton 10% cream / lotion
P. corporis : - gamexan 1%
- Washing clothes / bed sheets
using hot water / ironing them
P. pubis : - petrolatum
- physostigmine 0,025% eye oint
 QUIZ

1. Jelaskan patogenesis terjadinya creeping

eruption?
2. Sebutkan 3 species yang dapat
menyebabkan terjadinya filariasis?
3. Jelaskan cara pengobatan pada scabies?
4. Sebutkan 3 species yang menyebabkan
pediculosis?