IMPROVEMENT OF PSORIASIS AREA AND SEVERITY
INDEX SCORE IN PSORIASIS VULGARIS TREATED WITH
TOPICAL DESOXYMETHASONE 0,25% OINTMENT
Elfa Wirdani Fitri1, Wiwiek Dewiyanti1, Dirmawati Kadir1, Fitriyani Sennang1,
Safruddin Amin1, Dianawaty Amiruddin2, Alwi A. Mappiasse1, Andi Muhammad
Adam1, Muhammad Dali Amiruddin1
1Dermatovenereology
Department, Medical Faculty Hasanuddin University/ Dr.
Wahidin Sudirohusodo General Hospital, Makassar, Indonesia
2Dermatovenereology Department, Akademis Hospital, Makassar, Indonesia
INTRODUCTION
• Psoriasis is a chronic recurrent inflammatory skin
diseases with typical lesions form of patches and
demarcated erythema, scale covered by thick layers
of shiny white mica
• Prevalence : 0,8-11,8% world population
• Can occur at any age
• Based on a study in the U.S. population, the
incidence of psoriasis is highest in the age group of 5
to 6 decades
2
Psoriasis Varian
• Plaque psoriasis
• Pustular psoriasis
• Guttate psoriasis
• Inverse psoriasis
• Eritroderma psoriasis
• Psoriatic arthritis
3
PSORIASIS VARIAN
• Plaque psoriasis  skin lesions are red at the
base and covered by silvery scales
• Pustular psoriasis  blisters of non infectious
pus appear on the skin. Attacks of pustular
psoriasis may be triggered by medications,
infections, stress, or exposure to certain
chemical
4
PSORIASIS VARIAN
• Psoriasis guttata  small, drop shaped
lessions appear on the trunk, limbs, and scalp.
Guttate psoriasis is most often triggered by
upper respiratory infections
• Inverse psoriasis  smooth, red patches occur
in the folds of the skin near the genitals, under
the breast, or in the armpits. The symptoms
may be worsened by friction and sweating
5
PSORIASIS VARIAN
• Erythrodermic psoriasis  widespread
reddening and scalling of the skin may be a
reaction to severe sunburn or to taking
corticosteroids or other medications
• Psoriatic arthritis  joint inflammation that
produces symptoms of arthritis in patients
who have or will develop psoriasis.
6
The cause
of psoriasis
is unknown,
Genetic factors
may influence the
onset of the
disease.
stress, alcohol consumption,
smoking, presence of systemic
diseases such as streptococcal
infection, HIV, endocrine factors, as
well as the discontinuation of
corticosteroid therapy abruptly
factors
as
trigger
7
• To measure the severity of psoriasis, use the
calculation of body surface area (BSA)
involved and the psoriasis area and severity
index (PASI). Objective scale or PASI and BSA
can be used as a reference for the selection of
drug therapy and to assess the response given
8
PASI SCORE
I.
INTENSITY
Redness, Thickness , Scalling
(none (0), mild (1), moderate (2), severe (3) or very severe (4)
Then add for each region of body A1 as Head and Neck, A2 as
Upper limb, A3 Trunk, A4 lower limb
•
•
•
•
A1 x 0.1 gives B1
A2 x 0.2 gives B2
A3 x 0.3 gives B3
A4 x 0.4 gives B4
9
II. Area
The percentage area affected by psoriasis is evaluated in the four
regions of the body. In each region, the area is expressed as
none (0), 1-9% (1), 13-29% (2), 30-49% (3), 50-69% (4), 7089% (5) or 90-100% (6)
•
•
•
•
B1 x (0 to 6)= C1
B2 x (0 to 6)= C2
B3 x (0 to 6)= C3
B4 x (0 to 6)= C4
The PASI score is C1 + C2 + C3 + C4
10
CASE REPORT
• A 80-year-old man, came with reddish scaly patches, looked
dry on the chest, abdomen, back, arms and thighs,
accompanied by intense itching. The disorder is experienced
since more than 3 years ago. Patients did not remember the
initial shape and in which lesions first appear
• Patients often went to the doctor and was given ointment
(unknown), but the symptoms of redness and itching did not
dissapear. Family history was denied. The patient did not
complain of pain in the joints. The patient did not smoke and
did not consume alcohol
11
• Results of physical examination showed good general
condition, awareness compos mentis, and vital signs
within normal limits.
• Dermatological status of the chest, abdomen, back,
arms and thighs, scaly erythematous plaques
effloresence demarcated by the shape varies with
the size of nummular - plaque. Wax phenomenon
and Auspitz sign were positive. PASI score (Psoriasis
Area and Severity Index) was 9.6
12
PASI SCORE BEFORE THERAPY
I.
INTENSITY
Redness, Thickness , Scalling
(none (0), mild (1), moderate (2), severe (3) or very severe (4)
Then add for each region of body A1 as Head and Neck, A2 as
Upper limb, A3 Trunk, A4 lower limb
•
•
•
•
A1 x 0.1 gives B1  0 x 0,1 : 0
A2 x 0.2 gives B2  3 x 0,2 : 0,6
A3 x 0.3 gives B3  4 x 0,3 : 1,2
A4 x 0.4 gives B4  3 x 0,4 : 1,2
13
II. Area
The percentage area affected by psoriasis is evaluated in the four
regions of the body. In each region, the area is expressed as
none (0), 1-9% (1), 13-29% (2), 30-49% (3), 50-69% (4), 7089% (5) or 90-100% (6)
•
•
•
•
B1 x (0 to 6)= C1  0
B2 x (0 to 6)= C2  0,6 x 4 : 2,4
B3 x (0 to 6)= C3  1,2 x 4 : 4,8
B4 x (0 to 6)= C4  1,2 x 2 : 2,4
The PASI score is C1 + C2 + C3 + C4  0 + 2,4 + 4,8 + 2,4 : 9,6
14
Day 1
Dermatological status of the chest, abdomen, back, arms and
thighs, scaly erythematous plaques effloresence demarcated by
the shape varies with the size of nummular - plaque. Found wax
15
phenomenon is positive, the Auspitz sign positive
Day 1
Dermatological status of the chest, abdomen, back, arms and thighs, scaly
erythematous plaques effloresence demarcated by the shape varies with the
size of nummular - plaque. Found wax phenomenon is positive, the Auspitz
sign positive
16
• Laboratory results (CBC, blood sugar) within normal
limits. Liver function within normal limits, creatinine
renal function in the upper threshold of normal value
• The differential diagnosis of this disease is seborrheic
dermatitis and pityriasis rubra pilaris, the working
diagnosis was psoriasis vulgaris
• Results of histopathological examination showed
support a conclusion of psoriasis vulgaris
17
Therapy
Desoximetasone ointment 0,25%+salisil acid 3 %+LCD 3
% : 2x / day
Simptomatic therapy: mebhydrolin napadisylate 2x50
mg / day and neuroroboransia 2x/day
biopsy: eritromisin 3x500 mg / day dan mefenamic acid
3x500 mg/ day
18
DAY 15
The patient showed improvement in the form of plaque
thinning, reduced erythema and scaling and itching
reduced
19
PASI score 2,3  Topical therapy is continued, the patient
is recommended to control regularly
20
PASI SCORE AFTER THERAPY
I.
INTENSITY
Redness, Thickness , Scalling
(none (0), mild (1), moderate (2), severe (3) or very severe (4)
Then add for each region of body A1 as Head and Neck, A2 as
Upper limb, A3 Trunk, A4 lower limb
•
•
•
•
A1 x 0.1 gives B1  0 x 0,1 : 0
A2 x 0.2 gives B2  1 x 0,2 : 0,2
A3 x 0.3 gives B3  1 x 0,3 : 0,3
A4 x 0.4 gives B4  2 x 0,4 : 0,8
21
II. Area
The percentage area affected by psoriasis is evaluated in the four
regions of the body. In each region, the area is expressed as
none (0), 1-9% (1), 13-29% (2), 30-49% (3), 50-69% (4), 7089% (5) or 90-100% (6)
•
•
•
•
B1 x (0 to 6)= C1  0
B2 x (0 to 6)= C2  0,2 x 4 : 0,8
B3 x (0 to 6)= C3  0,3 x 1 : 0,3
B4 x (0 to 6)= C4  0,8 x 2 : 1,6
The PASI score is C1 + C2 + C3 + C4  0 + 0,8 + 0,3 + 1,6 : 2,3
22
Discussion
• Most people never reach a state of remission-free therapy
• Patients with psoriasis (2/3 cases) reported experiencing
itching. Characteristic plaques of psoriasis vulgaris in the form
of hyperkeratosis, itchy and sometimes sore.
• This sensation occurs due to changes in the structure of the
epidermis dry and broken in layers that trigger inflammatory
• Histopathological picture of psoriasis vulgaris varies,
depending on the stage of the lesion is the initial lesions,
lesions that developed, and advanced lesions.
23
Discussion
• To initiate therapy may use a reference PASI score.
PASI score calculation method is to assess the
intensity of erythema, thickness and scaling lesions.
• Topical corticosteroids have become the primary
therapy for many years. Corticosteroids have antiinflammatory, anti-proliferative, immunosuppressive
and vasoconstrictor.
24
Discussion
• Topical corticosteroids can be used in combination
with other topical therapies to increase effectiveness
and reduce side effects.
• The combination of topical corticosteroids with
salicylic acid 3-10% aiming to increase the
penetration of corticosteroids, thereby increasing
therapeutic efficacy.
25
Discussion
• Liquor carbonis detergent (LCD) 2-5% is a distillation of coal is
most often used in the treatment of inflammatory skin
disease that has been used since long, was originally used for
the treatment of psoriasis.
• LCD inhibits DNA synthesis and mitosis in epidermal cells, also
an antipruritic, anti-inflammatory, antiakantosis keratoplastic,
and the photosensitizing effect vasokonstriktif
• Reduction of PASI score (Psoriasis Activity and Severity Index)>
50% showed clinically meaningful improvement
26
CONCLUSION
• The use of objective scales such as psoriasis area and
severity index (PASI) is essential for assassing disease
severity before starting therapy and to fascilitate
subsequent assessment of response to treatment.
• Psoriasis is a complex disease to manage. Although
no modality of therapies can cure the disease,
several topical therapies can minimize the disease.
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Case
Reference
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