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1. What are the problem of the scenario?

From anamnesis Red patch in left stomach, the red scally, itchy spot getting larger to the back arms and thigh from physical examination macular eritem, herald patch, on her back there are red patch similar with christmas tree 2. What are the differensial diagnosis of the scenario? a. Ptiriasis Rosea Gibert b. Tinea Corporis c. Pitiriasis Versicolor d. Psoriasis The differensial diagnosis of the scenario is tinea korporis because the clinical characteristic is similar with pityriasis rosea. The difference in pityriasis rosea is not too itchy than tinea korporis and the scuama is smoother. Tinea korporis show positif result if we paint with KOH. Ilmu Penyakit Kulit dan Kelamin FKUI ptiriasis rosea The first is the herald patch lesions (in the body, Solitar, oval-shaped and annular, diameter of approximately 3 cm) Rash consisting of erythema and smooth on the edge skuama Subsequent lesions arise 4-10 days after the first lesion, the typical picture of the same as the first but smaller lesions, structure parallel to the ribs, until it resembles a pineapple tree In children often are Urtica, vesicles, and papules predilection: body, proximal upper arm and upper thigh terapi : treatment is symptomatic, to itch can be given sedative, while as a topical medication can be given that salicylic acid powder spiked with menthol 1/2 - 1%. Pityriasis rosea will usually go away in 6 to 8 weeks without treatment. If the rash itches, you may wish to use skin lotions. Antihistamin ,keep the are itchy cool Ilmu Penyakit Kulit dan Kelamin Edisi Keenam-FKUI Tinea

tinea capitis: abnormalities of the skin and scalp hair caused by dermatophyte species. characterized by scaly lesions, redness, alopecia, dab heavier picture called kerion. tinea pedis et manum: dermatophytosis on the feet and hands. tinea unguenum: dermatofitosis on finger and toe nails. tinea corporis: dermatofitosis on hairless skin (skin glaborous). tinea cruris: dermatophytosis in the groin, perineum, and around the anus. be acute or chronic, can even last a lifetime. skin disorders in thigh looks demarcated. on the chronic black spot with little scales. Predilection : Terapi : Topical Antifungal: cream or ointment containing miconazole, ketoconazole, clotrimazol, exonazol very powerful to eliminate phlegm, the cream is applied to the affected area of skin fungus 1-2x daily for 2-4 weeks. Systemic: penhobatan given to patients with tinea versicolor which is widespread throughout the body and which do not respond well to topical treatment, as well as the repeated recurrence: Itraconazol 4x1 with a dose of 200 mg daily for 7 days, Fluconazole at a dose of 300-400 mg single dose and can be repeated after 2 weeks ketoconazole 400mg single dose is not advised patients not to bathe for 12 hours, so that members the opportunity to accumulate the drug skin. Terbinafin and griseofulvn Ilmu Penyakit Kulit dan Kelamin Edisi Keenam-FKUI Dermatitis seboreik : oil squama, pustul Predilection : Predilection: seborrheic dermatitis can also occur in the outer ear canal, nasolabial folds, sternal region, mammary areola, under the breast crease women, interskapular, umbilicus, groin, and anogenital region. Treatment : kortikosteroid, isotretinoin Erythoderma : Erythema universal 90% part of body Predilection : whole body Treatment : kortikosteroid, metil prednison, dexametason

3. What are the cause of Pitiriasis Rosea Gibert ? a. Unknown b. Virus : Human Herpes Virus c. Weather in spring and autumn d. Drugs

The overall prevalence is approximately 0.15%.[2]

Most common in children and young adults, with 15-40 years. Occurs most often during the spring and autumn. No bacteria, virus, or fungus has been isolated as a cause but human herpes viruses 6 and 7 may play a role. Some drugs, eg bismuth, barbiturates, captopril, gold, metronidazole, Dpenicillamine and isotretinoin occasionally cause a drug-induced pityriasis rosea. Dr Colin Tidy. 2009. http://www.patient.co.uk/. Pityriasis Rosea. Diakses pada 2 Mei 2013

Despite years of extensive research, the cause or causes of pityriasis rosea remain unknown. However, most experts believe that the condition is caused by the body responding to a previous viral infection. http://www.nhs.uk/Conditions/pityriasis-rosea/Pages/Causes.aspx Etiology The exact etiology is unclear although some of the factors relate it to an infectious cause. Generally the condition occurs in epidemics proving that the infectious agent is present in the community. Recurrence of the infection is rare suggesting long lasting immunity to the infectious agent. More than 50% of the patients have prodromal symptoms before the onset of the herald patch. Some of them have an increase in B lymphocytes and a decrease in T lymphocytes and increase in Erythrocyte sedimentation rate. A viral etiology has been proposed 1. In electron microscopy viral changes and particles have been noticed but the antibody and polymerase chain reaction for viruses proves negative. There is a study which shows high amount of Human Herpes Virus 7 (HHV7) in these patients but further studies have not proved this 2. In addition, HHV 7 is more common in children and recurrence is very common with this. Other infective agents considered as causes are Legionella pneumoniae, Chlamydia pneumoniae and Mycoplasma pneumoniae but there is no support in the form of rise in antibody titres in subsequent studies.

The exact cause of Pityriasis Rosea remains unknown. Most recently, Pityriasis has been associated most strongly with a virus from the human herpes family called Human Herpes virus Type 6 (HHV6). Pityriasis is not caused by or known to be associated with the common types of herpes virus that cause genital or oral herpes. While the mode of transmission (how it gets passed between people) of Pityriasis Rosea is also unknown, respiratory contact has been postulated. Pityriasis does not seem to be directly or immediately contagious to close contacts or medical providers exposed to the rash. Most people with a known exposure to Pityriasis do not seem to contract the rash. http://lagunaskincenter.com/articles/pityriasis-rosea/ PR is induced by some of the Human Herpes Virus members, mainly HHV7 and HHV6. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2965909/ Studi telah menyarankan bahwa beberapa obat dapat mengakibatkan obat induced pityriasis rosea. Ini termasuk:

barbiturates (sedatif) bismut captopril (digunakan dalam tekanan darah tinggi) emas (digunakan dalam rheumatoid arthritis) metronidazole (antibiotik) D-penicillamine (chelating agen yang digunakan dalam poisonings tertentu) Isotretinoin (anti-penuaan kulit persiapan) http://www.news-medical.net/health/Pityriasis-rosea-What-is-pityriasis-rosea(Indonesian).aspx

4. What is the meaning of the macular eritem, herald patch, scuama ? Macular eritem : red lession that flat, sircumscript, and different colour with surrounding skin Herald patch (initial lession) : clinical picture of Ptiriasis Rosea initials preceded by lessions in the form of patches eritematous with a coin sized smooth skuama Scuama : the loosing of stratum corneum 5. How is the predilection about herald patch and daughter patch? Tempat predileksi pada badan, lengan atas bagian proksimal dan paha atas. lesi pertama (herald patch) umumnya dibadan, solitar, berbentuk oval dan anular. skuama halus Ruam eritem dan skuama di pinggir.

Bentuk lazimnya eritoskuama, dapat berbentuk urtika, vesikel dan papul yang sering trdapatt pada anak-anak.

6. How the Epidemiologi of Pitiriasis Rosea Gibert? pityriasis rosea was found at all ages, especially between 15-40 years, the same number of men and women Ilmu Penyakit Kulit dan Kelamin FKUI PR is observed in people of all age groups, though it is most common in persons aged 1035 years and rare in infants and elderly persons. The youngest patient reported in the literature was aged 3 months, and the oldest was aged 85 years. PR occurs slightly more often in females than in males. The female-to-male ratio is reported as 2:1 or 3:2 in the United States. http://emedicine.medscape.com/article/1107532-overview#showall 7. What are the symptoms and sign of Pitiriasis Rosea Gibert? itching lightweight skuama subtle disease begins with the first lesion (herald patch) generally dibadan, Solitar, oval-shaped and annular. Rash erythematous and skuama in baseboards. Lama anguish a few days-a few weeks selnjutnya lesions arise 4-10 days after the first lesion, lesion composition parallel to krosta that resembles inverted fir phon. The place predileksi on bodies, upper arm part the proximal and thigh upper. Shape typically eritoskuama, can shaped Urtica, vesicles and papule which often trdapatt in children-child.

Ilmu Penyakit Kulit dan Kelamin, Edisi Keenam. Fakultas kedokteran universitas indonesia There may be prodromal symptoms, eg malaise, nausea, anorexia, fever, joint pain, lymph node swelling, headache, that precede the appearance of the herald patch. Pruritus (may be intense) occurs in the majority of patients. The herald patch measures 1-2 cm in diameter and is oval or round with a central, wrinkled, salmon-coloured area, separated from a dark red peripheral zone by fine scales. The herald patch is usually located on the trunk but may be seen on the neck or extremities. The secondary rash is symmetrical and localised, predominantly to the trunk, neck and proximal extremities. The lesions of the secondary rash are small versions of the herald patch, with the two red zones separated by a scaling ring. They are distributed in a Christmas tree pattern. In a minority of patients, the herald patch is either absent or confluent with the other lesions. Variant presentations include peripheral distribution of the rash, and facial involvement may be seen in children. Skin lesions may also be large, urticarial, vesicular, pustular, purpuric, and resemble erythema multiforme. Hypopigmentation and hyperpigmentation of affected skin may follow the inflammatory stage. Hyperpigmentation is more common In patients with black skin. Oral lesions are rare but may occur, eg erythematous plaques and ulcers. http://www.patient.co.uk/doctor/pityriasis-rosea 8. What are the supportive examination for Pitiriasis Rosea Gibert? Biopsi kulit diperlukan untuk mengkonfirmasi atau mengubah diagnosis. serologi sifilis,diperlukan untuk menyingkirkan diagnosis lain. http://www.patient.co.uk/doctor/pityriasis-rosea KOH painting : to confirm about dermatophyta disease Tests to rule out other causes of rashes that may mimic Pityriasis Rosea: Potassium hydroxide KOH- fungal prep of skin Blood test : Rapid Plasma Reagent RPR- to exclude secondary Syphilis Skin biopsy

9. What are the therapy of Pitiriasis Rosea Gibert?


Medications (to relieve itching and inflammation) Antihistamine pills Steroid pills Steroid creams or ointments Calamine lotion

Other treatment Avoid physical activities that can raise your body temperature. Avoid hot baths or showers. Oatmeal baths may also soothe the itching. Sunlight or medical treatment with artificial ultraviolet light may speed the healing process. Be careful to avoid sunburn. Marjorie Montemayor-Quellenberg, MA. 2013. http://keckmedicalcenterofusc.org/. Pityriasis Rosea. Diakses pada 2 Mei 2013

To date, it has been seen that only high doses of acyclovir have had a suppressing effect on HHV-6 and the same is correct about HHV-7. In fact HHV-7 is less sensitive to acyclovir than HHV-6. These studies have shown that antiviral drugs such as Cidofovir and Foscarnet may be more effective against HHV-6, 7. Considering the high rate of side-effects of these drugs and according to the selflimiting nature of PR, in many cases we preferred to use high-dose acyclovir as a safer alternative, to evaluate its effects on relieving the symptoms of PR. Considering the high rate of side-effects of these drugs and according to the selflimiting nature of PR, in many cases we preferred to use high-dose acyclovir as a safer alternative, to evaluate its effects on relieving the symptoms of PR.
http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2965909/

10. How the prognosis of Pitiriasis Rosea Gibert? There are 4 prognosis : bonam, dubia ad bonam, dubia ad malam, malam The general prognosis for Pityriasis is excellent as most cases clear even without treatment by 6-8 weeks. Pityriasis Rosea will in nearly all cases clear completely on its own, with or without medical treatment. It typically leaves no long-lasting scars, although some mild, temporary skin discoloration called post inflammatory hypopigmentation or hyperpigmentation can occur in people with darker skin. It has no known long-lasting side effects and has not been associated with any other diseases. Symptoms may be reduced with topical treatment or taking extra precaution to prevent overheating, and the rash will usually clear on its own in 6-8 weeks. Once a person has Pityriasis Rosea, they generally have lifelong immunity.
http://lagunaskincenter.com/articles/pityriasis-rosea/

11. How can we cure the symptoms of the diagnosis? - Same with number 9

Concept Mapping

Red patch and itchy

Herald patch, macular eritem, saclly, christmas tree, scuama

Hypopigmentasi, scuama, macula

Scuama, eritem, macula

Hiperpigmentasi, skuaama, eritem

Pitiriasis Rosea Gibert

Pitiriasis Versicolor

Psoriasis

Tinea korporis