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 various
abnormalities and abnormal epidermal biochemistry, immunology, and blood vessels. Psoriasis is
regarded as a primary disorder of keratinocytes. Has the form of a patch lesion demarcated
erythema with rough scaly, multi-layered and transparent with wax drip phenomenon, and the
phenomenon kobner Auspitz sign.
!
Psoriasis affects both sexes e"ually and can occur at any age, although it most commonly
appears for the first time between the ages of # and $# years. Psoriasis was first diagnosed
before age %! in %!& of patients with psoriasis.
$
Psoriasis can be classified according to the clinical picture, namely, guttate psoriasis,
erythrodermic psoriasis, napkin psoriasis, inverse psoriasis, psoriasis arthritis, psoriasis vulgaris,
pustular psoriasis and sebopsoriasis.
$
Psoriasis vulgaris is a chronic skin disease characterized by recurrent and presence of
macular erythematous, round or oval shape can be covered scaly thick, transparent or grayish
white. 'mallsingle lesion might be confluent with firm boundaries resembles a map (psoriasis
geographica).

*t may be associated with other inflammatory disorders such as psoriatic arthritis,

inflammatory bowel disease, and coronary artery disease.
+
Psoriasis vulgaris is one of the most common inflammatory skin diseases among
,aucasians worldwide. -ith its early onset . usually between the ages of $! and /! . as well as
its chronic relapsing nature, psoriasis is a lifelong disease that has a ma0or impact on affected
patients and society. Patients with psoriasis face substantial personal expense, strong
stigmatization, and social exclusion. 1anagement of psoriasis includes treatment, patient
counselling, and psychosocial support.
+
2early /!& of psoriasis patients have arthritis problems.
3he onset of the disease occurs most commonly at about the age of $! years. ! to # & of
people have psoriatic arthritis.

*n the 4nited 'tates, about + million people ($&-/& of people) have psoriasis. About
#!,!!!-$5!,!!! new cases are diagnosed each year!. 1ost people who have psoriasis of the
1
nails also have skin psoriasis (cutaneous psoriasis). 6nly #& of people with psoriasis of the nails
do not have skin psoriasis. *n people who have skin psoriasis, !&-##& have psoriasis of the
nails (also called psoriatic nail disease). About !&-$!& of people who have skin psoriasis also
have psoriatic arthritis, a specific condition in which people have symptoms of both arthritis and
psoriasis. 6f people with psoriatic arthritis, #/&-75& have affected nails, often with pitting.
Psoriasis tends to run in families. *f you have a parent or a sibling who has psoriasis, you have a
5&-$#& chance of having psoriasis, too. *f both of your parents have psoriasis, your risk is
+#&. 1ales and females are e"ually likely to have psoriasis. Psoriasis can occur in people of all
races.

Psoriasis vulgaris with incidence in -estern industrialized countries of .#& to $&. *n

more than 8!& of cases, the disease is chronic. Patients with psoriasis vulgaris have a
significantly impaired "uality of life. 9epending on its severity, the disease can lead to a
substantial burden in terms of disability or psychosocial stigmatization. *ndeed, patient surveys
have shown that the impairment in "uality of life experienced by patients with psoriasis vulgaris
is comparable to that seen in patients with type $ diabetes or chronic respiratory disease. Patients
are often dissatisfied with current therapeutic approaches, and their compliance is poor. Patient
surveys have shown that only about $#& of psoriasis patients are completely satisfied with the
success of their treatment, while over #!& indicate moderate satisfaction and $!& slight
satisfaction. 3he rate of non-compliance with systemic therapy is particularly high, ranging up to
%!&.
7
3he prevalence of psoriasis is low in certain ethnic groups such as the :apanese, and may
be absent in aboriginal Australians$ and *ndians from 'outh America.
5
,ause of psoriasis is still
unknown however, there are several factors such as ; <enetic, inherited autosomal dominant with
incomplete penentrance and is associated with human leukocyte antigen (H=A)->/, >+,
>w#+, ,w5, >$+, and ,-$. *mmunologic factors, the genetic defect is expressed on 3
lymphocytes, =angerhans cells, and keratinocytes. 'everal factors are thought to aggravate
psoriasis such as a streptococcal infected, stress, excessive alcohol consumption, and smoking.
,ertain medicines, including lithium salt and beta blockers, have been reported to trigger or
aggravate the disease. ?xcessive alcohol consumption, smoking and obesity may exacerbate
psoriasis or make the management of the condition difficult. *ndividuals suffering from the
2
advanced effects of the human immunodeficiency virus, or H*@, often exhibit psoriasis.
'ometimes food can also trigger the disease process. Aor e.g. citrus fruits, sour foods, sauces,
coffee, tea, alcohol and soft drinks.

3he diagnosis of psoriasis vulgaris is based almost exclusively on the clinical appearance
of the lesions. AuspitzBs sign (i.e. multiple fine bleeding points when psoriatic scale is removed)
may be elicited in scaly pla"ues. *nvolvement of predilection sites and the presence of nail
psoriasis contribute to the diagnosis. 6ccasionally, psoriasis is difficult to distinguish from
nummular eczema, tinea, or cutaneous lupus. <uttate psoriasis may resemble pityriasis rosea. *n
rare cases, mycosis fungoides must be excluded. *f the skin changes are located in the
intertriginous areas, intertrigo and candidiasis must be considered. *n some cases, histological
examination of biopsies taken from the border of representative lesions is needed to confirm the
clinical diagnosis.
7
3
CASE REPORT
2.1. Identity Of Patient
2ame ; 1rs.C
'ex ; Aemale
Degistration number ; !-7+-%-#$
Age ; %! years old
Address ; 9s. >lang >intang
6ccupation ; Housewife
?xamination 9ate ; 1ay, $5th $!%
2.2. Anamnesis
3he ,hief ,omplaint ;
itching and red spots on the back of the left ear and body.
Additional ,omplaints ;
*tchy on the lesion.
History of Present *llness ;
3he patient came to the clinic with complaints of itching and red spots on the back of the
left ear and body since / years ago. *n 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 year before
she goes to polyclinic the lesion begin a red spot with the bigger pla"ue and much.
History of Previous *llness ;
3he patient admitted she had ever felt like this condition 7 year ago
History of Aamily 9isease ;
2one of her family had the same disease or complaint like her.
4
History of 3reatment;
=ast treatment on the polyclinic of dermatology dept (1ay $5th $!%)
'istemik ; ,etirizine ! mg tab x
3opical ; . Asam salisilat /& E =,9 #& E 9osoxicmetasone oint (morning-night)
$. Asam salisilat /& E 9iflucortolone valerate cream (afternoon)
/. Asam salisilat /& E @aselin album cream (night)
History of 'ocial Habits ;
3he patient experiences stress in terms of its economy. Patient difficulties in terms
of school fees of his children.
2.3. Physical Examinatin
@ital 'ign ;
. >lood pressure ; $!F7! mmHg
$. Pulse ; 7! beatsF minute
/. Despiratory Date ; 7 breathsF minute
%. 3emperature ; /5,+G,
9ermatological status ;
5
!i"#$e 2.1 On $e"i %ste$i$ th$acal!i"#$e 2.2 On $e"i ante &$acii dext$a and sinist$a
Aigure $. At regio thorax posterior,
erythematous pla"ues appeared, demarcated,
irregular edges, the size of miliary up pla"ue,
the number of multiple, over rough scaly
lesions found generalized distribution.premises.
!i"#$e 2.3 On $e"i ext$imitas infe$i$
Aigure $./ At regio extrimitas inferior,
erythematous pla"ues appeared,
demarcated, the number of multiple,
irregular edges, the size of miliary up
pla"ue, generalized distribution, and there
is a scaling on it.
2.' Res#me (
6
Aigure $.$ At regio extrimitas superior,
erythematous pla"ues appeared,
demarcated, irregular edges, the size of
miliary up pla"ue, the number of multiple
over smooth scaly lesions found
generalized distribution.premises.
3he Patient came to the clinic with complaints of itching and red spots on the back of the
left ear and body since / years ago. *n 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 year before
she goes to polyclinic the lesion begin a red spot with the bigger pla"ue and much. 6n
9ermatological status At regio thorax posterior, erythematous pla"ues appeared, demarcated,
irregular edges, the size of miliary up pla"ue, the number of multiple, over rough scaly lesions
found generalized distribution.premises. At regio extrimitas superior, erythematous pla"ues
appeared, demarcated, irregular edges, the size of miliary up pla"ue, the number of multiple over
smooth scaly lesions found generalized distribution.premises. And at regio extrimitas inferior,
erythematous pla"ues appeared, demarcated, the number of multiple, irregular edges, the size of
miliary up pla"ue, generalized distribution, and there is a scaling on it.
2.) Diffe$ential Dia"nsis (
. Psoriasis @ulgaris
$. 3inea Corporis
/. 1orbus Hansen 3ype 33
%. Pytriasis Dosea
#. ?kzema 'eborrheic
2.* Dia"nse (
Psoriasis @ulgaris pla"ue type
2.+ Plannin" (
7
S,in test (
- Kaarsvlek examination phenomen (E) ; 6n examination karsvlek phenomenon in the
hands and feet be obtained which the positive
outcome when done scraping the lesions look
like a murky color was scrapings.
- Auspitz 'ign ,hecks (E) ; 6n examination Autspitz sign positive results which when
pursued scour the lesion seen on the bleeding point.
;
- Koebner examination (E) ; 6n examination Coebner phenomenon also obtained positive
results when performed in which a healthy scratch on the skin
a few days later new lesions appear on the skin healthy.
2.. /ana"ement (
Sistemi, (
- ,etirizine! mg tab x
T%ical (
8
- 'alicylic Acid /& E =,9 #& (,arbonis 9etegens =i"uor) E @aseline Album (1orning-
2ight)
- 'alicylic Acid $& E 9esoximethasone (2ight)
2.0 Ed#catin (
. 9o not scrath the lesions
$. ,onsume the medicines according the doctor guideline
/. Ceep the lesion area remains dryH
%. 1aintain the cleanliness of the skin
#. 4se clothes made of sweet arbsorbing material
3.1 P$"nsis (
Iuo ad vitam ; dubia ad bonam
Iuo ad Aunctionam ; dubia ad bonam
Iuo ad 'anactionam ; dubia ad bonam
DISCUSSION
3he ma0or manifestation of psoriasis is chronic inflammation of the skin. *t is
characterized by disfiguring, scaling, and erythematous pla"ues that may be painful or often
severely pruritic and may cause significant. Psoriasis is a chronic disease that waxes during a
patientBs lifetime, is often modified by treatment initiation and cessation and has few
spontaneous remissions

*nverse psoriasis is characterized by lesions in the skin folds. >ecause of
the moist nature of these areas, the lesions tend to be erythematous pla"ues with minimal scale.
9
,ommon locations include the axil-lary, genital, perineal, intergluteal, and inframammary areas.
Alexural surfaces such as the antecubital fossae can exhibit similar lesions.
/
*n case we find the patient with chief complaint *tch and red spots on the back of the left
ear and body. *n 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 pla"ue. 3he patient admitted she had ever felt like this
condition / year ago.
Psoriasis is universal in occurrence however different population varies from !. percent
to .7 percent. Psoriasis may begin at any age, but is uncommon under age ! years. *t most
likely appears #-/! years. *t certain H=-A ,-5 antigen carier from family. Psoriasis is a
chronic inflammation skin deases with a strong genetic basic characteristic by complex dermal
growth epidermal diferentation and multiple biochemical, immunologic, vascular abnormality. *t
caused poor keratinocyte.
%
in case we find the lesion At regio thorax posterior, erythematous
pla"ues appeared, demarcated, irregular edges, the size of miliary up pla"ue, the number of
multiple, over rough scaly lesions found generalized distribution.premises and on regio
extrimitas superior, erythematous pla"ues appeared, demarcated, irregular edges, the size of
miliary up pla"ue, the number of multiple over smooth scaly lesions found generalized
distribution premises and on regio extrimitas inferior, erythematous pla"ues appeared,
demarcated, the number of multiple, irregular edges, the size of miliary up pla"ue, generalized
distribution, and there is a scaling on it.
*nitial 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
10
Aigure /.. 3ype the lesion of psoriasis
with the focal loss of the granular layyer.
#
Pla"ue psoriasis is the most common form, affect-ing
approximately 7!& to 8!& of patients. 3he vast ma0ority of all high-"uality and regulatory
clinical trials in psoriasis have been conducted on patients with this form of psoriasis. Pla"ue
psoriasis manifests as well-defined, sharply demarcated, erythematous pla"ues varying in size
from cm to several centi-meters 3hese 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 expanded dermal papillary vasculature. Patients may have involvement ranging
from only a few pla"ues to numerous lesions covering almost the entire body surface. 3he
pla"ues are irregular, round to oval in shape, and most often located on the thorax posterior,
extrimitas superior and extrimitas inferior.
/,#
11
Aigure /.$ Picture of pathogenesis lesion on
psoriasis
#
clarification
1.,apillary dilatation increased
the numbered of dermal
mononuclear cells and mast
cell. 3he process increase in
epidermal thicknes
$.mast cell, macrophages, 3
cell (the component mediator
inflamation)
/. lagerhan cell begin exit the
idermis and inflamtory
dendritic cell, cd7E t cell begin
to epidermal cell
9epressionF suicide Psoriasis is associated with lack of self esteem and increased
prevalence of mood disorders including depression. 3he prevalence of depression in patients
with psoriasis may be as high as 5!&. 9epression may be severe enough that some patients will
contemplate suicide. *n one study of $+ patients with psoriasis, almost !& reported a wish to
be dead and #& reported active suicidal ideation. 3reatments for psoriasis may affect depression.
6ne study demonstrated that patients with psoriasis treated with etanercept had a significant
decrease in their depression scores when compared with control sub0ects. However, clinically
diagnosed depression was an exclusionary criterion for entry into this study.
/
3herefore,
treatment of psoriasis with etanercept lessened symptoms of depression in patients without overt
clinical depression. *ncreased rates of depression in patients with psoriasis may be another factor
leading to increased risk of cardiovascular disease. Although there is some suggestive evidence
that treatment of depression with selective serotonin reuptake inhibitors may reduce
cardiovascular events.
/
*n case the patient experiences stress in terms of its economy. Patient
difficulties in terms of school fees of his children. And when he getting start to remember she
difficulties in terms of school fees of his children always feel the symptom going severe, like itch
and red spot, in that case related with the literatur.
6besity has become an epidemic within the 4nited 'tates. A body mass index (>1*) of
more than /! is defined as obese with overweight being defined as a >1* between $# and /!. *n
the 4nited 'tates, 5#& of people older than $! years are either overweight or obese. 6besity has
serious health conse"uences including hypertension, vascular dis-ease, and type $ diabetes
mellitus. Psoriasis was first associated with obesity in several large, ?uropean epidemiologic
studies. 'tudies from the 4nited 'tates also show an elevated >1* in patients with psoriasis.
3hese analyses of >1* compared sub0ects with and without psoriasis while controlling for age,
sex, and race. Analysis of data from the 4tah Psoriasis *nitiative revealed that patients with
psoriasis had a significantly higher >1* than control sub0ects in the general 4tah population.
/
3he 2urses Health 'tudy **, which contains prospective data from +7,5$5 women followed up
during a %-year period, indi-cates that obesity and weight gain are strong risk factors for the
development of psoriasis in women. *n this study, multiple measures of obesity, including >1*,
waist and hip circumference, waist-hip ratio and change in adiposity as assessed by weight gain
since the age of 7 years, were substantial risk factors for the development of psoriasis.
1ultivariate anal-ysis demonstrated that the relative risk of developing psoriasis was highest in
12
those with the highest >1*s. *n contrast, a low >1* ($) was associated with a lower risk of
psoriasis, further supporting these findings. Aurthermore, the average weights of pa-tients with
psoriasis in the large clinical trials of the biologic agents have been in the 8!- to 8#-kg range
(although these clinical trials all enrolled more men than women) whereas the average body
weight for the 4' population from the 2HA2?' database from888 to $!!$ was 75 kg. An
association between psoriasis and elevated >1* 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 >1* J/! that condition show she
get a obesity.
Arom the history, physical examination, and investigation in this case , it can be enforced,
namely diagnosis of psoriasis vulgaris. 6f history with the patient, obtained information which
led to the suspicion that the complaint psoriasis vulgaris lesions on the back of the left ear and
body since / years ago. =esion area itchy and painful sometimes. Picture of psoriasis vulgarisis
characterized by slight itching, feels like summer. 3he most commonly affected areas are the
scalp, fingers and feet, palms of the hands, soles of the feet, umbilicus, gluteal, under the breasts
and genitals, elbows, knees, shins and sacrum. 3his disease is chronic in nature with a tendency
to relapse.

Psoriasis vulgaris is a chronic skin disease characterized by recurrent and presence of

macular erythematous, round or oval shape can be covered scaly thick, transparent or grayish
white. Psoriasis vulgaris is recognized as the most common autoimmune diseases are caused by
the activation of the cellular immune system.
+
Psoriasis affects both sexes e"ually and can occur at any age, although it most commonly
appears for the first time between the ages of # and $# years. Psoriasis was first diagnosed
before age %! in %!& of patients with psoriasis.
7
6btained from physical examination results reinforce pla"ue psoriasis vulgaris is looked
eriteumatous, demarcated, the number of multiple, irregular edges, pla"ue size, distribution and
generalized scaling above are his. >ased on literature psoriasis is a chronic skin disease that is
characterized by recurrent and has patches demarcated lesions with erythematous scaly rough,
round or oval can be covered scaly thick, transparent or grayish white.
7
13
3he diagnosis of psoriasis vulgaris can be strengthened by the results of investigations
Carsvlek phenomenonF phenomena spots where the wax when done scraping at the skin lesion
looks like a murky color wax scrapings. then forwarded scrapings and visible point on the lesions
that indicate bleeding 'ign Auspitz positive. 3hen on healthy skin lesions arises when new
etching done the next day that signifies positive Coebner phenomenon.
>y -ollf C $!$ investigation for the diagnosis of psoriasis vulgaris is a skin test that
consists of examination Carsvlek phenomenon (a phenomenon wax spots) are scaly psoriasis
when scraped muddy color will look like wax scrapings, Austpitz sign is when the way was for
warded to scrape visible point-point because of papillary dermis bleeding at the ends
ofelongated.
Aigure /./. ?xamination Austptiz 'ign
$
Coebner phenomenon, namely when the skin is exposed to trauma or scratching normally
will give rise to new lesions that are similar to those already existing.
Aigure /.%. Coebner phenomenon
%
14
6ther investigations such as histology, histologically, psoriasis has a marked thickening of
the epidermis appearance, due to the increased proliferation of keratinocytes in the epidermis and
undulations epidermal interfolikular into form very long, thin pro0ections decline into the dermis.
Aigure /.# Psoriasis Preview Histopathology @ulgaris
$
1ikroskoipic examination of psoriasis vulgaris

. Parakeratosis or hyperkeratosis,
$. 2eutrophils in the stratum corneum or epidermis,
/. >enign epidermal,
%. 9ilatation of the veins,
#. ?longation and enlargement of Paila dermis,
5. 3hinning to loss granulalosum layer,
+. 1unro 1icroabscess, an increase in the number of neutrophils in the stratum corneum cells.
*n this case differential diagnosis of psoriasis vulgaris in this case are 3inea ,orporis,
1orbus Hansen, Pytiriasis Dosea and ?kzema 'eborrheic.because in terms of colored macular
erythematous lesions and have clinical symptoms of itching.
15
1anagement given to the patient in this case is cetirizine, salicylic acid $& E
desoximethasone, salicylic acid /& E =,9 #& (=i"uor ,arbonis 9etegens) E @aseline album.
3herapy that can be administered in the form of topical treatment of psoriasis vulgaris as
corticosteroids once a day, plus vitamin 9 is applied once a day (applied separately, one in the
morning and the other in the evening) for up to % weeks as initial treatment for mild psoriasis.
Phototherapy, can use a narrow band ultraviolet > (4@>). Phototherapy is used for moderate or
severe psoriasis and people with pla"ue psoriasis or guttate-pattern resistant to topical treatment.
treatment with narrow band 4@> phototherapy can be given / or $ times a week.
7
*f the topical treatment and phototherapy cannot be resolved and in severe psoriasis can
be given systemic treatment such as methotrexate, cyclosporine.
+
*n this case given drugs such as cetirizine antihistamine to relieve itching. 'alicylic acid
is given because it has keratolytic substances which have the effect of reducing the proliferation
of epithelial and keratolinisasi normalize impaired and at a concentration of /& is used for
conditions keratolytic and hyperkeratotic dermatoses, desoximethasone given to patients with
psoriasis because it has anti-inflammatory and antiproliferative effects. =,9 is one type of pitch
that functions as an anti-pruritic and increases keratinization normal.serta vaseline given to these
patients as a base for ointments.
16
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*l#n#*al "ermatolog+. 11
t(
e". ,(#la"el-(#a!WB .a/n"er
0o12011.-.62287.
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th
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1akasar.
17
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18