LP : Akut atau kronis, inflamasi dermatosis pada kulit, selaput lendir dan genitalia. Gambaran lesinya 4P (Papul, Purple, Polygonal, Pruritic).

Transkripsi

1 INFLAMASI PADA KULIT DAN KELAMIN (BUKAN KARENA INFEKSI) dr. Imam Budi Putra, MHA, SpKK DEPARTEMEN ILMU KESEHATAN KULIT DAN KELAMIN FAKULTAS KEDOKTERAN UNIVERSITAS SUMATERA UTARA RUMAH SAKIT H. ADAM MALIK MEDAN

2 LICHEN PLANUS LP : Akut atau kronis, inflamasi dermatosis pada kulit, selaput lendir dan genitalia. Gambaran lesinya 4P (Papul, Purple, Polygonal, Pruritic). - Onset : tahun - Perempuan > Laki-laki (Laki-laki = Perempuan) - Etiologi :? - Hipotesis : Virus, berdasarkan : Pada pemeriksaan hispatologis; pada epidermis menyerupai gambaran yang disebabkan oleh virus. Mikroskopik elektron : elemen-elemen virus. 2

3 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Gambaran Klinis Lesi Pertama pada LP - Mulai ditungkai dan lengan - Paling banyak : fleksor pergelangan tangan dan lengan bawah. 3

4 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Lesi Kulit Khas - Papula, poligonal, permukaan rata berkilat, pada puncaknya ditemukan cekungancekungan (Delle) - Pada permukaan papula p dapat terlihat garis-garis anyaman berwarna putih yang disebut Wickem striae. - (Tampak lebih jelas bila permukaan kulit dibersihkan dengan minyak dan diamati dengan kaca pembesar) 4

5 - Warna papula pada permukaan merah, kemudian cepat berubah menjadi ungu atau kemerahan. - Dijumpai fenomena isomorfik atau Koebner phenomena. - Lesi-lesi yang sudah menyembuh : hiperpigmentasi atau hipopigmentasi (tanda khas). - Lesi dikulit bertahan 1 2 tahun - Lesi di selaput lendir masih bertahan beberapa tahun sesudah lesi dikulit hilang. 5

6 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Lesi di selaput lendir - Lesi-lesi di selaput lendir memberi gejala khas di mukosa mulut (buccal), lidah, bibir, faring dan seluruh saluran pencernaan. 6

7 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Lesi Genitalia - Pada Pria : Penis ; papula anular atau striae putih - Pada Wanita :Vagina dan vesika urinaria :gambar retikular serupa jala yang terdiri atas garis-garis putih atau striae abu-abu. 7

8 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Kuku Adanya kelainan 10% (Samman) Kulit Kepala Papul folikuler alopesia sikatriks 8

9 Keluhan Subjektif : - Sangat gatal (LP hipertrofik) - Selaput lendir : rasa terbakar pada daerah mulut - Timbul erosi sakit 9

10 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. VARIASI GAMBARAN KLINIK I. Variasi bentuk Bentuk Anuler Pada 10% penderita LP Papula membentuk gambaran cincin Dapat juga terbentuk dari penyebaran ke pinggir, penyembuhan ditengah lesi LP khas Pada glans penis Bentuk Linier Jarang Papula papula berjejer dalam satu garis gambaran zoster 10

11 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. II. Variasi Lokalisasi Selaput Lendir Mukosa buccal, lidah, bibir, palatum, tonsil dan faring paling sering Dapat juga : Sal cerna (Lambung anus) Mukosa vagina, kandung kencing, laring, conjunctiva Efloresensi : Jaringan serat atau garis-garis putih atau abu-abu, berkelompok atau sendiri. Lesi selaput lendir 2/3 kasus 11

12 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Genitalia 25% kasus terjadi pada genitalia laki-laki yang paling sering : glans penis Papula (khas) : Anular atau linier (Putih) Di vulva dan vagina sama seperti lesi pada selaput lendir. Kuku Timbul setelah beberapa minggu lesi di kulit Permukaan kukuk kasar dan menipis, warna coklat penghancuran dan atrofi Tanda penting LP (walaupun di kulit belum ada) 12

13 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Kepala Lesi berbentuk papula folikuler alopesia sikatriks dan liken pilaris. III. Variasi Morfologi Hipertrofik Lesi plak verukosa berwarna merah coklat dan ungu cruris anterior Folikuler Papula-papulapapula seperti duri pada kulit, selaput lendir dan kulit kepala trias liken plano pilaris 13

14 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Vesikulo -Bulosa Bentuk vesikobulosa >> Timbul pada tempat bekas atau sedang terdapat LP Bentuk bula <<, tegang Pada kulit normal atau pada bekas lesi LP dan selaput lendir mulut Erosif dan Ulseratif Erosif ulcus : selaput lendir Atrofi Jarang Bersama bentuk yang lain 14

15 Degenerasi Maligna Pada bentuk hipertrofik karsinoma epiderma Oleh karena iritasi menahun, trauma, pengobatan oleh arsen, sinar X. Aktinik Papul kecoklatan (menyerupai granuloma anulare) Pada usia muda, di daerah tropis, sub tropis Gejala ringan atau tanpa gejala Eritematos Papul lunak, eritem tanpa gatal Kadang-kadang g tidak ada hubungan dengan LP yang sesungguhnya, tapi pada gambaran histopatologis khas LP. 15

16 PEMERIKSAAN LABORATORIUM Pemeriksaan darah tidak banyak menunjang Jumlah leukosit dan limposit menurun PEMERIKSAAN HISTOPATOLOGI Epidermis : hiperkeratosis, akantosis tidak teratur, penebalan stratum granulosum, degenerasi mencair membrana basalis, hilangnya stratum basalis, degenerasi keratinosit (Colloid, Civatte bodies) Dermis : Sel infiltrat padat, menyerupai pita yang terdiri dari sel limfosit dan histiosit. Bentuk Bula : pemisahan antara epidermis dan dermis Bentuk Atrofi : Epidermis menipis. 16

17 Bentuk folikuler : Sel-sel infiltrat di sekitar folikel rambut menghancurkan folikel rambut Lesi di selaput lendir : Tidak hiperkeratosis atau hipergranulomatosis. Pada lesi yang lama : bagian atas dermis : melano fag >> Gambaran khas LP : pita lebar lurus yang terdiri dari fibrin dan fibrinogen pada epidermal dermal juntion Pemeriksaan immunofluorescence langsung : Deposit fibrin di junctional dan IgM, sedikit IgA, IgG dan C3 di Colloid Bodies 17

18 DIAGNOSIS Diagnosis ditegakkan berdasarkan : gambaran klinis LP atau variannya yang khas, ditunjang dengan pemeriksaan histopatologi Bahan-bahan yang dapat menimbulkan erupsi seperti ini adalah :emas, streptomisin, tetrasiklin, arsen, merkuri, yodida, quinakrin, dan klorokuin. Lichen planus liken eruption tidak dapat dibedakan secara klinis dan histopatologis, dari liken planus. 18

19 DIAGNOSIS BANDING Kulit 1. Psoriasis 2. Granuloma anulare 3. Nevus unius lateralis 4. Liken striatus Mukosa 1. Leukoplakia 2. Kandidosis oral 3. Lupuseritematosis 4. Sifilis II 19

20 Genitalia 1. Psoriasis i 2. Dermatitis seboroika 3. Skabies 4. Herpes genitalis Bentuk Hipertrofik 1. Neuro Dermatitis 2. Liken amiloidosis 3. Sarkoma kaposi Bentuk Folikuler 1. Liken spinulosis 2. Liken nitidus 20

21 Bentuk Atrofi (Kepala, Muka) 1. Lupus eritematosus 2. Folikulitis 3. Skleroderma 21

22 PENGOBATAN Topical Glucocorticoids occlusive pada lesi Intralesi triamcinolone 3 mg/ml lesi mukosa mulut dan bibir Cyclosporine dan tacrolimus solution mouthwash h (oral LP) Asam vitamin A (Asam retinoat 0,05%) Systemik Cyclosporine 5 mg/kg BB per hari kasus yang resisten dan general. Glucocorticoids : oral prednisone dosis inisial 70 mg tapering 5 mg Systemic retinoid (Acitretius) 1 mg/kg per hari (oral LP, hipertropi LP) 22

23 PUVA Photochemoterapy General LP atau kasus yang resisten it dengan obat topikal Mycophenolate mofetil, Heparin (Enoxaparin) Immunomodulator, Azathiophrine PROGNOSIS Beberapa dapat sembuh sendiri Dapat sembuh 1 2 tahun berlanjut 5 10 tahun Tergantung bentuk dan luasnya Kambuh 10 20% dari kasus Pengobatan yang cepat dan tepat dapat memberikan penyembuhan 23

24 LICHEN SCLEROSUS (Lichen Sclerosus et atrophicus) Kelainan kulit Anogenital, chronis, atrophic Etio :? DNA : Borrelia Spp (Jerman, Jepang) PNA :Sporochetes (USA) Perempuan >> 10x dari laki-laki Dewasa >> (Anak 1 13 tahun) 24

25 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Gambaran Klinis : Papul berwarna putih ivory atau putih porceline Permukaan meninggi atau datar, verocous Papul dapat berkonfluen membentuk plaque Pada lesi yang sudah lama depressed Dilatasi pilosebaceous atau kelenjar keringat (Keratin plugs / delle) Gambaran karakteristik : Bula, erosi, purpura, tellangiectasia. 25

26 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Pada vulva; plaque hyperkeratotic erosi maserasi vulva atropi khususnya clitoris dan labia minora ukuran introitus vagina berkurang (mengecil) Terjadi fusi labia minora dan mayora 26

27 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Pada laki-laki yang tidak sirkumsisi di daerah preputium/frenulum papul-papul konfluen warna putih ivory sclerotic Glans :putih ivory atau putih porceline, purpura hemoragic 27

28 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Lesi pada vulva menjadi sensitif ketika berjalan : pruritus, sakit (erosi), dysuria, dyspareunia Pada laki-laki : rekuren phimosis balanitis, Acquired 28

29 Pada perempuan yang lebih muda dapat terjadi resolusi Pada perempuan p yang lebih tua atropi vulva Pada laki-laki phimosis Vulva dan penis squamous cell carcinoma 29

30 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Histopatologi : infiltrasi lymphocytic, atropic epidermis dermis. Sebahagian epidermis edematous, sub epidermal zone tidak terstruktur Adanya serabut kolagen yang homogen pada papiladermis 30

31 Pengobatan : Tidak ada pilihan terapi khusus Topikal :- Poten glucocorticoids (Clobetasol Propionate) 6 8 minggu - Monitor tanda-tanda glucocorticoid induced atrophy - Pimekrolimus atau takrolimus - Topical androgen << (Hypertrophy clitoris) i Systemik : - Hydrochloroquine : mg/hari untuk beberapa minggu bulan (monitor efek samping pada mata) Pada laki-laki : sirkumsisi 31

32 GRANULOMA ANNULARE GA : Self limited, asymtomatic, chronis pada dermis (lokal : tidak ada tanda-tanda kelainan secara internal diseases) papul-papul annulare Pada dorsum manus, kaki, siku, kadang-kadang bisa generalisata. Pada anak dan dewasa muda Perempuan : laki-laki = 2 : 1 dan lutut Etiologi :? Immunologios : Mediated necrotizing inflammation pada pembuluh darah 32

33 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Gambaran Klinis : Papul dan plaques (1 5cm), annular, arciform plaques dan penekanan di tengah Seperti warna kulit, violaceous, erytematous Subcutaneous GA (jarang) : tidak sakit, seperti warna kulit, soliter atau multiple nodulus, deep dermal atau subcutaneous. 33

34 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Distribusi : Lesi tunggal : Dorsum manus 34

35 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Lesi multiple : Ekstremitas dan punggung atau generalisata Lesi subcutaneous : dekat sendi, telapak tangan dan telapak kaki 35

36 Variasi Klinis : Lesi perforasi GA dengan nekrobiosis dengan lipoidica GA fascia, tendon sclerosis GA generalisata bersamaan dengan DM Differential Diagnosis : Lesi Papula dan plaques Lichen planus Papular sarcoid Necrobiosis lipoidica Lymphocytic infiltrate of Jessner 36

37 Subcutaneous Nodules Reumatoid Noduls Atau yang mempunyai kemiripan pada pemeriksaan patologi dari GA, rheumatic nodul atau rhematoid nodul Lesi Anular Tinea (T. corporis), i) Erythema migrans (cutaneous larva migrans), sarkoid, lichen planus. 37

38 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. Pemeriksaan Laboratorium : Histopatologi : Focal chronic inflamasi dan histiocytic infiltrasi pada superfisial dan mid dermis dengan necrobiosis dari connective tissue yang dikelilingi oleh dinding pallisade histiocytes dan multi nucleated giant cells. 38

39 Pengobatan : Topical glucocorticoid occlusif Injeksi Intralesi triamsinolon : 3 mg/ml Cryospray PUVA photochemoteraphy GA generalisata 39

40 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. TERIMA KASIH 40