DISCUSSION

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 waes during a patient!s lifetime, is often modified by treatment
initiation and cessation and has few spontaneous remissions

Inverse psoriasis is
characterized by lesions in the skin folds. "ecause of the moist nature of these
areas, the lesions tend to be erythematous plaques with minimal scale. #ommon
locations include the ail$lary, genital, perineal, intergluteal, and inframammary
areas. %leural surfaces such as the antecubital fossae can ehibit similar lesions.
&
In case we find the patient with chief complaint Itch and red spot on the back side
around the body and hand. itchy sensation. The red spott were getting bigger '
months ago. In the first of the symptom start with a small of white lesion with the
severe itching then the patient starching the lesion every time until the last month
before she goes to polyclinic the lesion begin a red spot with the bigger plaque.
The patient admitted she had ever felt like this condition ( year ago.
Psoriasis is universal in occurrence how ever different population varies
from ).* percent to **.+ percent. Psoriasis may begin at any age, but is uncommon
under age *) years. It most likely appears *($&) years. It certain ,-$. #/0
antigen carier from family. Psoriasis is a chronic inflammation skin deases with a
strong genetic basic characteristic by comple dermal growth epidermal
*
%g '. Type the lesion of psoriasis
diferentation and multiple biochemical, immunologic, vascular abnormality. It
caused poor keratinocyte.
'
in case we find the lesion at regio thora posterior
patch demarcated hypopigmented with firm boundaries, plaque size, the number
of multiple over rough scaly lesions found generalized distribution premises and
on regio etrimitas superior patch demarcated hypopigmented with firm
boundaries, plaque size, the number of multiple over smooth scaly lesions found
generalized distribution premises.
Initial lesion in the pin head sized macular lesion there marked edema, and
monoclear cell inflarates are found in the upper dermis. the overlying epidermis
soon becomes spogiotic with the focal loss of the granular layyer.
'
Plaque
psoriasis is the most common form, affect$ing approimately +)1 to 2)1 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 * 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 epanded
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 etensor surfaces such as the
elbows and knees. 3maller plaques or papules may coalesce into larger lesions,
especially on the legs and trunk. Painful fissuring
.&,'
4
5epression6suicide 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 0)1. 5epression may be
severe enough that some patients will contemplate suicide. In one study of 4*7
patients with psoriasis, almost *)1 reported a wish to be dead and (1 reported
active suicidal ideation. Treatments for psoriasis may affect depression. 8ne study
demonstrated that patients with psoriasis treated with etanercept had a significant
decrease in their depression scores when compared with control subjects.
,owever, clinically diagnosed depression was an eclusionary criterion for entry
into this study.
&
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. .lthough there is some suggestive
&
%g (. Picture of pathogenesis lesion on
psoriasis
'
clarification
1.#apillary dilatation increased
the numbered of dermal
mononuclear cells and mast
cell. The process increase in
epidermal thicknes
4.mast cell, macrophages, T
cell 9the component mediator
inflamation:
&. lagerhan cell begin eit the
idermis and inflamtory
dendritic cell, cd+; t cell begin
to epidermal cell
evidence that treatment of depression with selective serotonin reuptake inhibitors
may reduce cardiovascular events.
&
in case we find the patient she get a stress in
her life and she never talk to her son and daughter. .nd 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.
8besity has become an epidemic within the <nited 3tates. . body mass
inde 9"=I: of more than &) is defined as obese with overweight being defined as
a "=I between 4( and &). In the <nited 3tates, 0(1 of people older than 4) years
are either overweight or obese. 8besity has serious health consequences including
hypertension, vascular dis$ease, and type 4 diabetes mellitus. Psoriasis was first
associated with obesity in several large, >uropean epidemiologic studies. 3tudies
from the <nited 3tates also show an elevated "=I in patients with psoriasis.
These analyses of "=I compared subjects with and without psoriasis while
controlling for age, se, and race. .nalysis of data from the <tah Psoriasis
Initiative revealed that patients with psoriasis had a significantly higher "=I than
control subjects in the general <tah population.
&
The ?urses ,ealth 3tudy II,
which contains prospective data from 7+,040 women followed up during a *'$
year period, indi$cates that obesity and weight gain are strong risk factors for the
development of psoriasis in women. In this study, multiple measures of obesity,
including "=I, waist and hip circumference, waist$hip ratio and change in
adiposity as assessed by weight gain since the age of *+ years, were substantial
risk factors for the development of psoriasis. =ultivariate anal$ysis demonstrated
that the relative risk of developing psoriasis was highest in those with the highest
"=Is. In contrast, a low "=I 9@4*: was associated with a lower risk of psoriasis,
further supporting these findings. %urthermore, the average weights of pa$tients
with psoriasis in the large clinical trials of the biologic agents have been in the 2)$
to 2($kg range 9although these clinical trials all enrolled more men than women:
whereas the average body weight for the <3 population from the ?,.?>3
database from*222 to 4))4 was +0 kg. .n association between psoriasis and
elevated "=I appears to be yet another factor that predisposes individuals with
psoriasis to cardiovascular disease.
&
in that case the patient occurrence of obesity
'
with psoriasis vulgaris related with the literature, she have a "=I A&) that
condition show she get a obesity.
#ombination of topical therapies 3ince all topical medications for the
treatment of psoriasis have limitations, combination regimens, utilizing
medications from different categories, have been studied and shown to be
potentially beneficial.
(
#orticosteroids and salicylic acid The combination of
topical corticosteroids and salicylic acid may be valuable because of the ability of
salicylic acid to enhance the efficacy of corticosteroids by increasing penetration.
To ensure that there is not an increase in steroid toicities when adding salicylic
acid to topical corticosteroid preparations, it is recommended that this
combination belimited to no more than medium$potency 9class &$': topical
corticosteroids. The strength of recommendations for the treatment of psoriasis
using topical corticosteroids and salicylic acid.
0
#orticosteroids and vitamin 5
analogues The combination of topical corticosteroids and vitamin 5 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 9please also see prior section
on combination calcipotriene6betamethasone ointment:. The strength of
recommendations for the treatment of psoriasis using topical corticosteroids and
vitamin 5 analogues.
(,7

#orticosteroids and tazarotene 8wing 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$potency topical corticosteroid is more effective
than therapy with tazarotene aloneB however, this study did not determine if
tazarotene plus topical steroid is superior to topical corticosteroid alone. There
may be a synergistic effect between tazarotene and topical corticosteroids as a
clinical trial comparing tazarotene gel plus mometasone cream to mometasone
cream alone showed superior efficacy of the combination over mometasone cream
used alone both for efficacy during the therapy and for the duration of therapeutic
effect. #ombination therapy may increase the duration of treatment benefit as well
as length of remission. .nother potential advantage of using combination
(
tazarotene and topical corticosteroid is potential decrease in steroid$induced
atrophy. The strength of recommendations for the treatment of psoriasis using
topical corticosteroids and tazarotene.
0,7
in that case we find the

Patients received
systemic and topical therapy when she get on the polyclinic of dermatology
C3<D. "anda .ceh.
0
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