ORIGINAL ARTICLE

PSORIASIS IN DERMATOVENEREOLOGY CLINIC OF

DR. WAHIDIN SUDIROHUSODO GENERAL HOSPITAL MAKASSAR :
A RETROSPECTIVE STUDY IN PERIOD OF JANUARY 2006
DECEMBER 2010
Wendy Posumah, Dirmawati Kadir, Fitriyani Sennang
Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar

ABSTRACT
Background : Psoriasis is an inflammatory sk in disease that is often
found, are chronic and recurrent, are influenced by genetic and environmental factors.
Objectives : To det ermine the profile of psoriasis patients in dermatovenereology clinic of RSWS Mak assar for five years.
Methods : A retrospective study conducted in patients with ps oriasis at
the dermatovenereology clinic of RSWS based on patients medical
records from January 2006 to December 2010. Recording made on gender, age, complaint of itching, the affected part of body, the examination,
type of psoriasis and management, then presented descriptively.
Results : Obtained 80 patients, 50 (52.5%) were men and 30 (37.5%)
were women. 38 people (47.5%) in the age group of 25-44 years. 72
patients (90% ) had complaints of reddish spots or plaque, scaly sk in
with itching. 49 people (61.25%) had universalis lesions. There is a
phenomenon of wax droplets, Auspitz's sign, and Koebner phenolmenon, as well as histopat hologic examination support the diagnosis. 74
people (92.5%) is Psoriasis Vulgaris. All patients received oral antihistamines and topical combination therapy. Other therapy are systemic
corticosteroids, tar shampoos, ultraviolet light, methot rexate.
Conclusion : Psoriasis is often found in young adults, with itching and
universalis distribution of the lesion. Psoriasis vulgaris is the most
common. Therapy varies according to clinical circumstances.
Key words : Psoriasis, retrospective study.

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar :

a retrospective study in period of january 2006 december 2010

INTRODUCTION

upper dermis and the spongiform intraepidermal pustule can be found. The fully
developed lesions are characterized by
acanthosis (thickening of the epidermis),
elongated rete ridges and thinning of the
suprapapillary layers of the epidermis. The
granular layer is absent. (3-7)

Psoriasis is an inflammatory skin

disease that is often found, are chronic
and recurrent, are influenced by genetic
and environmental factors. It characterized
by circumscribed, erythematous, dry, scaling plaques of various sizes. The lesions
are usually covered by silvery white lamellar scales. The lesions have a predilection for the scalp, nails, extensor surfaces of the limbs, umbilical region and sacrum. Subjective symptoms, such as itching or burning, may be present and may
cause extreme discomfort. (1-3)

Therapy should address the different aspects of psoriatic skin lesions : it

should supress keratinocyte proliferation,
be anti-inflammtory and immunosuppressive. There are : 1) topical therapy such as
topical steroids, vitamin D analogue, tazarotene and calcineurin inhibitors, 2) phototherapy, narrrow band UVB (NB-UVB),
broad band UVB (BB-UVB), psoralen and
UVA light (PUVA) and excimer laser, 3)
systemic therapy, cyclosporine A, methotrexate, acitretine, ester fumaric acid,
hydroxyuric, 6-thioguanin, micophenolate
mophetil and sulfasalazine, and 4) biologic
therapy, alefacept, efalizumab, etanercept,
infliximab and adalimumab.(2,7-11)

The early lesions are small erythematous macules, which from the beginning are covered with dry, silvery scales.
The lesions increase in size by peripheral
extension and coalescence. The scales
are micaceous, meaning that they peel in
layers. They are looser toward the periphery and adherent centrally. When removed, bleeding points appear (Auspitzs
sign). Although plaques typically predominate, lesions may be annular or polycyclic.
Involved nails can demonstrate distal
onycholysis, random pitting, oil spots, or
salmon patches. Thick ungual hyperkeratosis may resemble onychomycosis.(1-3)

The Objectives
The objectives of this study is to
describe the profile of psoriasis patient at
the dermatovenereology departement dr.
Wahidin Sudirohusodo (RSWS) general
hospital Makassar in Januari 2006
Desember 2010 periode.

The most comon laboratory examination to confirm the clinical diagnosis

of psoriasis is a skin biopsy using hematoxylin eosin staining. Other than skin
biopsy, there are no specific laboratory
abnormalities associated with psoriasis.
Histopathologic features in early stage of
psoriasis, there are parakeratosis, irregular thickening of the epidermis, but thinning over dermal papillae with the neutrophil aggregation in the stratum corneum
formed Munros microabscesses, thinning
of the granulosum layer, dilated and
tortuous capillary loops in the dermal
papillae, with the T-lymphocyte infiltrate in

The Methods
The secondary data had been
taken from patients registration book in
dermatovenereology policlinic RSUP dr.
Wahidin Sudirohusodo Makassar from
January 2006 to December 2010. The
data had been clasified by the sex, age,
itching symptom, predilection, dermatologys sign, variant of psoriasis dan the
treatment. Then, it has been tabulated and
finally being presented in graphics.

IJDV

Vol.1 No.4 2013

The Results
The total psoriasis patients are 80 from 17.082 dermatovenereologys pa-tients
(0,47%) that came to dermato-venereologys policlinic RSUP dr.Wahidin Sudirohusodo
Makassar from January 2006 to December 2010. There are 50 males (52,5 %) and 30
females (37,5 %).
Table 1. The frequency distribution characterictics of patients by sex
Year

Male

Female

total

2006

10

18

22,5

2007

7,5

2008

10

17

21,25

2009

13

22

27,5

2010

12

17

21,25

Total

50

30

80

100

14
12
10
8

Male

Female

4
2
0
2006

2007

2008

2009

2010

Graphic 1. The frequency distribution characterictics of patients by sex Based on the age of
the patient, most case are found in the group of age 25-44 years which is 38 people
(47.5%),with the youngest patient is one year old and the oldest is 75 years old.
Table 2. The frequency distribution characterictics of patients by age
Age
< 1 year old
1 4 year old
5 14 year old
15 24 y.o.
25 44 y.o.
45 64 y.o.
>65 y.o.
Total

2006
0
1
0
2
6
8
1
18

2007
0
0
0
1
3
2
0
6

2008
0
0
0
0
6
10
1
17

2009
0
0
1
1
15
3
2
22

2010
0
0
1
2
8
5
1
17

Total
0
1
2
6
38

%
0
1,25
2,5
7,5
47,5

28
5
80

35
6,25
100

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar :

a retrospective study in period of january 2006 december 2010

16
14

1-4 years old

12
10

5-14 years old

15-24 years old

25-44 years old

45-64 years old

> 65 years old

0
2006

2007

2008

2009

2010

Graphic 2. The frequency distribution characterictics of patients by age

Most of the patients came with complaint scaly rashes associated with itchy, 72
people (90%), while another eight people (10%) came without complaint of itchy.
Table 3. The frequency distribution characterictics of patients by itching symptoms
Complaints

2006

2007 2008 2009 2010

Total

Scaly rashes, with itchy

16

16

19

15

72

90

Scaly rashes, without itchy

10

18

17

22

17

80

100

Total

20
15

Gatal

10

Tidak gatal
5

0
2006

2007

2008

2009

2010

Graphic 3. The frequency distribution characterictics of patients by itching symptoms

Obtained 80 patients, about 49 people (61.25%) had lessions on all over their body
(universal) and only one of them experienced psoriasis on nails. Nine people (11.2%) had
lessions on scalp, superior extremities, abdomen; six people (7.5 %) on scalp, facial, trunk;
five people experienced on trunk, superior et inferior extremities (6.25 5%), and four people
(5%) had lesions only on the scalp.

IJDV

Vol.1 No.4 2013

Table 4. The frequency distribution characterictics of patients by predilection

Location of lession

2006

2007

2008

Universal
Superior et inferior extremities
Scalp, superior extremities, abdomen
Scalp, facial, trunk
Trunk, superior et inferior extremities
Scalp
Total

8
3
4
3
0
0
18

5
0
0
0
0
1
6

15
0
0
0
1
1
17

2009 2010
14
1
2
2
1
2
22

7
5
1
1
3
0
17

Total

49
9
7
6
5
4
80

61,25
11,25
8,75
7,5
6,25
5
100

20

Universal

15

Superior et inferior
extremities
Scalp, superior extremities,
abdomen
Scalp, facial, trunk

10
5
0
2006

2007

2008

2009

2010

Trunkus, superior et inferior

extremities

Graphic 4. The frequency distribution characterictics of patients by predilection

The dermatology's sign that were observed are wax drop phenomenon, Auspitzs
sign, and Koebner phenomenon. From 80 patients, wax drop phenomenon gave about 16
people (20 %), six people (7,5 %) with Auspitzs sign positive and four people (5 %) with
Koebner phenomenon. For the other patients, there is no record about their examinations
have been done.
Table 5. The frequency distribution characterictics of patients by dermatologys sign
The dermatologys sign
Wax drop phenomenon

2006
2

2007
0

2008
1

2009
10

2010
3

Total
16

%
20

Auspitzs sign

7,5

Koebner phenomenon

15

wax drop phenomenon

10

Auspitz's sign
5

Fenomena Koebner

0
2006

2007

2008

2009

2010

Graphic 5. The frequency distribution characterictics of patients by dermatologys sign

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar :

a retrospective study in period of january 2006 december 2010

Histological examination on 24 patients (30 %) supporting the diagnosis of psoriasis,

while others diagnosis are still unknown.
Table 6. The frequency distribution characterictics of patients by histopathology
Histopathology

2006

2007

2008

2009

2010

Total

Supporting

24

30

Unknown

16

10

14

12

56

70

18

17

22

17

80

100

Total

20
15
supported AP result

10

Unknown

5
0
2006

2007

2008

2009

2010

Graphic 6. The frequency distribution characterictics of patients by histopathology

Obtained from 80 patients, 74 people (92,5 %) are psoriasis vulgaris, two people
(2,5%) are psoriasis gutata, two people (2,5 %) are psoriasis pustulosa and another two
people (2,5 %) are small-plaque psoriasis.
Table 7. The frequency distribution characterictics of patients by psoriasis variants
Psoriasis variants

2006

2007

2008

2009

2010

Total

Psoriasis vulgaris
Psoriasis gutata
Psoriasis pustulosa
Small-plaque psoriasis
Total

16
0
2
0
18

6
0
0
0
6

14
1
0
2
17

21
1
0
0
22

17
0
0
0
17

74
2
2
2
80

92,5
2,5
2,5
2,5
100

25
20

Psoriasis Vulgaris

15

Psoriasis Gutata

10

Psoriasis Pustulosa
Small-Plaque Psoriasis

5
0

2006

2007

2008

2009

2010

Graphic 7. The frequency distribution characterictics of patients by psoriasis variants

6

IJDV

Vol.1 No.4 2013

The patients are treated with oral antihistamin and topical combination therapy. Most
of the topical combination therapy that have been used to 20 patients (25 %) are
cortikosteroid (CS) + salicylic acid (SA) 3 5 % + liquor carbones detergent (LCD) 2 %.
About 10 patients (12,5 %) are systemic corticosteroid. Nine patients (11,25 %) are given ter
shampoo, six patients (7,5 %) get ultraviolet therapy (narrowband ultraviolet/NB-UVB), and
14 patients (17,5 %) are treated with methotrexate (MTX).
Table 8. The frequency distribution characterictics of patients by treatment
Treatment
Oral antihistamines
Systemic corticosteroids
Topical combination
Topical corticosteroids
Ter shampoo
NB - UVB
Methotrexate

2006 2007
18
6
2
0
18
6
5
1
7
2
0
3
2
2

2008 2009 2010

17
22
17
1
5
2
17
22
17
4
10
8
0
0
0
3
0
0
1
8
1

Total
80
10
80

%
100
12,5
100

28
9
6
14

35
11,25
7,5
17,5

25

Oral Antihistamin

20

Systemic cortikosteroid
15

Topical combination
Tropical cortikosteroid

10

Ter Shampoo
NB - UVB

Methotrexate

2006

2007

2008

2009

2010

Graphic 8. The frequency distribution characterictics of patients by treatment

Table 9. The frequency distribution characterictics of patients by topical combination
Type of Topical combination

2006

2007

2008

2009

2010

Total

CS +SA 3-5% + LCD 2%

20

25

CS + SA 3-5% + Lanolin 2-5%

17

21,25

CS + Lanolin 2-5%

14

17,5

CS + SA 3-5% + LCD 2% + Lanolin 2-5%

13

16,25

CS + SA 3-5% + Sulfur pp 5%

7,5

CS + SA 3-5%

6,25

CS + SA 3-5% + LCD 2% + Sulfur pp 5%

6,25

18

17

22

17

80

100

Total

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar :

a retrospective study in period of january 2006 december 2010

KS + AS 3-5% + LCD 2%

KS + AS 3-5% + Lanolin 2-5%

6
5

KS + Lanolin 2-5%

KS + AS 3-5% + LCD 2% + Lanolin

2-5%

KS + AS 3-5% + Sulfur PP 5%

KS + AS 3-5%

0
2006

2007

2008

2009

2010

KS + AS 3-5% + LCD2% + Sulfur PP

5%

Graphic 9. The frequency distribution characterictics of patients by topical combination

years old, and more often appears at the
ages of 15 to 40 years. (2.5)
Most of the patients present with
scaly red patches with itching, which is 72
people (90%), while eight people (10%)
did not have any complaints of itching
(Table 3). This is consistent with the references that psoriasis lesions are demarcated, elevated, in the form of patches
or plaques reddish with white scaly
surface. (1,2,3,5) According to the references,
two-thirds of psoriasis patients have
complaint of itching.(11) In this study, most
of the patients have complaints of itchy.

DISCUSSION
During the periode January 2006 December 2010, the number of psoriasis
patient are 80 people out of 17 082
patients (0.47%) who came for treatment
at the clinic of dermato genitalia department in RSUP dr. Wahidin Sudirohusodo
Makassar. The prevalence of psoriasis in
varies populations is from 0.1% to 11.8%.
(2)
Worldwide epidemiologic study of psoriasis estimated the prevalence is 0.6% to
4.8%. (12) The prevalence of psoriasis in 10
teaching hospitals in Indonesia are varies
between 0.59% to 0.92%. (13) In this study,
the prevalence is slightly lower.

Most of them had lesions on all

over the body (universal) in 49 people
(61.25%) and only one of them who also
have psoriasis of the nails (Table 4). The
other patients had lesions on the superior
et inferior extremities (11.25%), scalp,
superior extremities and abdomen superior (8.75%), scalp, facial, trunk (7.5%),
trunk, superior et inferior extremities (6.25
5%), scalp (5%). According to the reference, patients with psoriasis commonly
have lesions on the extensor surfaces of
elbows and knees, scalp, anterior and
posterior trunk, sacral region, and genitalia. At the area around the umbilicus and

From 80 patients with psoriasis,

50 people (52.5%) are male and 30
(37.5%) are female (Table 1). According to
references, women and men have equal
chances to get psoriasis. (1 to 3.14) Some
studies suggest that psoriasis may be
slightly more common among men than
women. (11)
Most of the case are found in the
age of 25-44 years is 38 people (47.5%)
(Table 2). This is corresponding with the
references that psoriasis can occur at any
age, but is rarely found in less than 10
8

IJDV

Vol.1 No.4 2013

intergluteal also be affected. The affected

part of the body are varies from one
patient to another patient.(1- 3,6,11) Nail
changes usually happen in psoriasis,
about 40 percent of patients are found,
and rarely occurs in the absence of skin
disease with an image of "pitting" onycholysis and sometimes subungual hyperkeratosis. (2.5) In this study, patients with
nail psoriasis also have psoriatic lesions
on other parts of the body.

ridges, Munro abscesses, hypogranulosis,

suprapapilary plate thinning, dilating blood
vessels and papillary dermis contains
erythrocytes, and infiltration of lymphocytes. Based on references, although histopathological examination is rarely necessary to make a diagnosis, but it can be
helpful in difficult cases. Histopathological
view that supports the existence of parakeratosis, hyperkeratosis, elongated rete
ridges, decreased or loss granulosum
layers, Munro abscesses, suprapapilary
plate thinned, dilated capillaries and winding, and there is infiltration of lymphocytes. (2,5,15)
Obtained from 80 patients that
suffering from psoriasis vulgaris were 74
people (92.5%), while other patients are
guttate psoriasis, psoriasis pustulosa,
small-plaque psoriasis (Table 7). This is
consistent with the references which state
that psoriasis vulgaris is the most common
form of psoriasis, seen in about 90 percent
of patients. (2,11,14)
All patients treated with oral antihistamines and topical therapy combinations. Other than that, there are also patent who treated with systemic corticosteroids, tar shampoo, ultraviolet light therapy
(narrowband ultraviolet / NB-UVB), and
some treated with methotrexate (MTX).
According some resources, there are
many psoriasis treatment that is safe and
effective. The treatment is to improve skin
condition and reduce complaints of itch. (14)
Antihistamines are given in psoriasis treatment because in psoriasis actually mast
cells release the histamine. (16) In addition,
the sedative effects from antihistamines is
to reduce the itching sensation that
experienced by patients. ( 1 7) For a topical
combination therapy, generally consists of
corticosteroids and salicylic acid 3-5%,
then there is LCD 2%, lanolin 2-5% and 25% sulfur pp added. According to some

Physical examination that had

been done are wax droplets phenomenon,
Auspitz's sign, and Koebner phenomenon.
From the 80 patients, the wax drop
phenomenon are 16 people (20%), positive Auspitz's sign in six people (7.5%) and
Koebner phenomenon is four people (5%).
The other patients is unknown whether the
examination had been done or not (Table
5). This is consistent with the references,
that the scaly layered shows by a long
way, known as the scratch grattage
methodique which is scratching the scaly
with a scalpel or nails until uneven white
and wrinkled appear (looks like scratched
wax drop). (14) Under the scaly, the skin
looks erythema homogenous and shiny
and bleeding spots will appear when the
scale is taken out and the dilated capillaries will injured (Auspitz sign). Koebner
phenomenon (also called isomorphic response) is psoriasis lesions that induced by
trauma that occurs to the skin without lesions. Koebner phenomenon is not specific to psoriasis but can assist in establishing the diagnosis when found. (1-3)
Histopathological examination in
24 patients (30%) supported the diagnosis
of psoriasis, whereas in other patients is
unknown whether or not the histopathologic examination had been done (Table 6).
Histopathologic view seen in psoriasis patients is psoriasiform hyperplasia, hyperkeratosis, parakeratosis, elongated rete
9

Wendy Posumah

P soriasis in dermatovenereology clinic of dr. Wahidin Sudirohusodo general Hospital Makassar :

a retrospective study in period of january 2006 december 2010

sources, topical therapy has been and

remains a major therapeutic option for the
treatment of psoriasis on the skin as it
provides a potential therapeutic efficacy
and limited treatment effects on target
tissues. Topical corticosteroids have long
been the mainstay of therapy for mild to
moderate psoriasis and can be used alone
or in combination with other topical
treatments. (8) Additional salicylic acid is
efficacious in treating psoriasis because it
can reduce the scaly and fine lesions.
Salicylic acid is proven to increase the
efficacy of steroids by increases its
penetration when given with steroids. (8.18)
LCD (liquid detergent carbonis) is a coal
ter preparations that used to treat mild,
moderate or severe psoriasis but the
efficacy of antipsoriatic is weak. (19) LCD is
often combined with salicylic acid 2-5%
with its keratotic effect that helping in
absorption of LCD. (2) Lanolin is vehikulum
that is charecterize as emollient. ( 20) In
psoriasis skin care should be done using
emollients to prevent dryness. Emollients
can reduce the scaly, prevent the
formation of fissures that are painful and
can help in pruritus controling. (2)

ding erythrodermic psoriatika and pustular

psoriasis. (2)
Conclusion
Psoriasis is an inflammatory skin
disease that is chronic and residif, but not
contagious. Clinical knowledge and severity assessment of psoriasis should be
understood to determine the type of treatment that can be given. Although there are
many treatment options but until now there
is no cure for psoriasis. The existing therapies only use to reduce the symptoms and
lesions of psoriasis for just a while.
Patient's lifestyle is also an important
factor. In making the patients medical
records, should include the history of the
disease, presence / absence of other
family member with the same complain
like this, a history of smoking or alcohol
consumption, history of drugs taking,
stress and disease history of previous
infection.
REFERENCES

Systemic steroids should not be

used as routine treatment for psoriasis
patients. However, systemic steroids can
be given to persistent psoriasis, uncontrollable, erythrodermic and generalized pustular psoriasis that are fulminating, if other
treatments are not effective. (2) Ter
shampoos used to treat psoriasis on the
head. (1 9) For moderate psoriasis or severe
psoriasis that are unresponsive to topical
treatment, ultraviolet rays treatment can
be used. The most often type used today
is a short spectrum ultraviolet B (narrowband UVB / NB-UVB). (9.11) Methotrexate
(MTX) is effective for chronic plaque psoriasis and is also indicated for the longterm treatment of severe psoriasis, inclu10

1.

James W, Berger T, Elston D. Psoriasis.

In: James W, Berger T, Elston D, editors.
Andrews diseases of the skin clinical
dermatology. 10th ed. Canada: Elsevier
Saunders; 2006. p. 193-201.

2.

Gudjonsson J, Elder J. Psoriasis. In: Wolf

K, Katz S, Gilchrest B, Paller A, Leffel D,
editors. Fitzpatrickss dermatology in
general medicine 7th ed. New York:
McGraw-Hill; 2008. p. 169-88.

3.

Griffiths C, Barker J. Psoriasis. In: Burns

T, Breathnach S, Cox N, Griffiths C,
editors. Rooks textbook of dermatology
8th ed. Ox ford: Blackwell P ublishing Ltd;
2010.p. 20.1-58.

4.

Vavricka B, Guitart J. Diagnostic

evaluation. In: Gordon K, Ruderman E,
editors. Psoriasis and psoriatic arthritis an
integrated approach. Germany: Springer
Verlag Berlin Heldelberg; 2005. p. 83-91.

IJDV

Vol.1 No.4 2013

5.

Hunt er J, Savin J, Dahl M. Psoriasis. In:

Hunt er J, Savin J, Dahl M, editors. Clinical
dermatology 3rd ed. Ox ford: Blackwell
science Ltd; 2003. p. 48-62.

6.

Buxton P. Psoriasis. In: B uxton P, editor.

ABC of dermatology 4t h ed. London: BMJ
Publishing; 2003. p. 8-12.

7.

8.

9.

15. Tjarta A. Psoriasis, gambaran histopatologis. In: Tjarta A, Sularsito S, dkk, editors. Metode diagnostik dan P enatalaksanaan psoriasis dan dermatitis seboroik.
Jakarta: Balai Penerbit FKUI; 2003. p. 1722.
16. Krogstad A, Lonnroth P, Larson G, Wallin
B. Increased interstitial histamine concentration in the psoriatic plaque. J Invest
Dermatol.1997; 109: 632-5.

Prinz J. Psoriasis vulgaris and arthopathica. In: Hertl M, editor. Autoimmune

diseases of t he skin. New Y ork: Springer
Wien; 2005. p. 291-304.

17. Limb S, Wood R. Antihistamines. In: Wolf

K, Katz S, Gilchrest B, Paller A, Leffel D,
editors. Fitzpatrickss dermatology in general medicine 7th ed. New York:
McGraw-Hill; 2008. p. 2168-93.

Quinby R. Topical therapy. In: Gordon K,

Ruderman E, editors. Psoriasis and
psoriatic arthritis an integrat ed approach.
Germany: Springer V erlag Berlin
Heldelberg; 2005. p. 134-41.

18. Afifi T, Gannes G, Huang C, Zhou Y.

Topical therapies for psoriasis. Can Fam
Physician. 2005;51: 519-25.

Dempsey J, Zanolli M. Phototherapy. In:

Gordon K, Ruderman E, editors. Psoriasis
and psoriatic arthritis an integrated approach. Germany: Springer Verlag
Berlin Heldelberg; 2005. p. 145-57.

19. Wiryadi BE. Psoriasis, penat alaksanaan.

In: Tjarta A, Sularsito S, dkk, editors.
Metode diagnostik dan penatalaksanaan
psoriasis dan dermatitis seboroik. Jakarta:
Balai Penerbit FKUI; 2003. p. 32-51.

10. J, Menter A. Methotrexate and cyclosporine. In: Gordon K, Ruderman E, editors. Psoriasis and ps oriatic arthritis an
integrated approach. Germany: Springer
Verlag Berlin Heldelberg; 2005. p. 172-81.

20. Bergstrom K, Strober B. Principles of

topical therapy. In: Wolf K, Katz S,
Gilchrest B, Paller A, Leffel D, editors.
Fitzpatrickss dermatology in general
medicine 7th ed. New York: McGraw-Hill;
2008. p. 2091-6.

11. Mrowitz U, Rech K. Psoriasis-new insights

into pathogenesis and treatment. Dtsch
Arztebl Int. 2009;106(1-2):11-9.
12. Neimann AL, Port er SB, Gelfand JM. The
epidemiology of psoriasis. Expert Rev.
Dermatol. 2006;1(1):63-75.
13. Marlia L, Sutedja E, Muljaningsih S, Supriyadi R. Penurunan k adar soluble tumor
necrosis factor receptor type I (s TNFRI)
dalam serum penderita psoriasis vulgaris
setelah di terapi dengan krim klobetasol
propionat 0,05%. MKB.2008; XI(1): 24-8.
14. Jacoeb T. Psoriasis, gambaran klinis dan
penilaian keparahan. In: Tjarta A, Sularsito S, dkk, editors. Metode diagnostik
dan penatalaksanaan psoriasis dan dermatitis seboroik. Jakarta: Balai Penerbit
FKUI; 2003. p. 1-12.

11