1
Laporan Kasus dan Telaah Telaah Jurnal Prognosis
Dermatitis Eksfoliatif dengan Underlying
Disease Dermatitis Seboroik
Oleh: Aini Mutmainah Orintya Putri Adiyusika
Pembimbing: Fitria Salim
BAGIAN/SMF ILMU KESEHATAN KULIT DAN KELAMIN FAKU FAKULT LTAS AS KEDOKTERAN KEDOKTERA N UNIVERSI UNI VERSITAS TAS SYIAH S YIAH KUALA K UALA RSUD dr. ZAINOEL ABIDIN BANDA ACEH TAHUN 2017
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KATA PENGANTAR
Segala puji syukur kehadirat Allah SWT yang telah memberikan rahmat dan karunia-Nya sehingga penulis dapat menyelesaikan laporan kasus ini. Shalawat beserta salam kita ucapkan kepada Nabi Muhammad SAW yang telah membawa kita dari zaman jahiliyah ke zaman islamiyah, serta kepada sahabat dan keluarga beliau. Ucapan terima kasih penulis sampaikan kepada dr. Fitria Salim,M.Sc, Sp.KK yang telah bersedia meluangkan waktunya untuk membimbing penulis dalam penyusunan laporan kasus yang berjudul “Dermatitis Eksfoliatif dengan
Under Under lying D i sea sease Dermatitis Seboroik ”, ”, serta para dokter di bagian/SMF Ilmu Kesehatan Kulit dan Kelamin yang telah memberikan arahan serta bimbingan hingga terselesaikannya laporan kasus ini. Tidak ada kata sempurna dalam pembuatan sebuah laporan kasus. Keterbatasan dalam penulisan maupun kajian yang dibahas merupakan beberapa penyebabnya. Oleh karena itu, penulis sangat mengharapkan masukan terhadap laporan kasus ini demi perbaikan di masa yang akan datang.
Banda Aceh, 23 Agustus 2017
Penulis
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DAFTAR ISI
Halaman HALAMAN JUDUL .......................................... ................................................................ ............................................ ......................... ...
i
KATA PENGANTAR ............................................ .................................................................. ........................................... .....................
ii
DAFTAR ISI ............................................ .................................................................. ............................................ .................................... ..............
iii
DAFTAR GAMBAR .......................................... ................................................................ ............................................ ......................... ...
iv
DAFTAR LAMPIRAN .......................................... ................................................................ ........................................... .....................
v
PENDAHULUAN........................................... ................................................................. ............................................ ............................. .......
1
LAPORAN KASUS............................................ .................................................................. ............................................ ......................... ...
3
Identitas Pasien ......................................... ............................................................... ............................................ ............................. .......
3
Anamnesis ............................................ ................................................................... ............................................. ................................ ..........
3
Pemeriksaan Fisik Kulit............................................... Kulit...................................................................... ................................ .........
4
Diagnosis Banding............................................ .................................................................. ........................................... .....................
6
Pemeriksaan Penunjang ........................................... .................................................................. .................................... .............
6
Resume .......................................... ................................................................ ............................................ ........................................ ..................
8
Diagnosa Klinis ............................................ .................................................................. ............................................ ......................... ...
8
Tatalaksana ........................................... .................................................................. ............................................. ................................ ..........
8
Edukasi ............................................. ................................................................... ............................................ .................................... ..............
9
Prognosis ........................................... ................................................................. ............................................ .................................... ..............
9
ANALISA KASUS ......................................... ............................................................... ............................................ ............................. ....... 10 DAFTAR PUSTAKA PUSTAKA ............................................. ................................................................... ........................................... ..................... 15 LAMPIRAN............................................. ................................................................... ............................................ .................................... .............. 16
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DAFTAR GAMBAR
Halaman ............................................................... ............................. .......4 4 Gambar 1. Regio thorakalis anterior . ......................................... .................................................................. ......................... .. 4 Gambar 2. Regio thorakalis posterior . ........................................... .................................................................. ............................. ...... 5 Gambar 3. Regio brachialis dextra . ........................................... ................................................................. ............................. ......5 5 Gambar 4. Regio brachialis sinistra . .......................................... ............................................................... ..................... 5 Gambar 5. Regio cruris dextra et sinistra . .......................................... ................................................................. ................................ .........5 5 Gambar 6. Regio femoris sinistra . .......................................... ................................................................ ........................................... .....................5 5 Gambar 7. Regio fascialis . .......................................... .................................................................. ........................................... .....................6 6 Gambar 8. Regio palmar . ............................................ .................................................................. ........................................... .....................6 6 Gambar 9. Regio plantar . ............................................
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DAFTAR LAMPIRAN
Halaman .................. 16 Lampiran 1. Foto Klinis Pasien setelah 6 Hari Rawatan di Rumah Sakit . ..................16
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PENDAHULUAN
Dermatitis eksfoliatif (DE) didefinisikan sebagai eritema difus dan pengelupasan kulit yang melibatkan lebih dari 90% luas permukaan kulit di seluruh tubuh. tubuh. Penyebab umum umum yang yang mendasari mendasari dermatitis eksfoliatif
adalah
psoriasis, dermatitis atopik dan penyakit kulit lainnya, reaksi hipersensitivitas obat, dan limfoma sel T kutaneous. Penyebab terjadinya dermatitis eksfoliatif masih belum diketahui (idiopatik) pada 20% kasus.(1) Beberapa penelitian telah melaporkan kejadian dermatitis eksfoliatif yang bervariasi mulai dari 0,9 sampai 71,0 per 100.000 pasien rawat jalan, den gan rasio laki-laki terhadap perempuan sekitar 2 : 1 sampai 4 : 1. Setiap kelompok usia dapat terpengaruh dan usia rata-rata onset penyakit bervariasi mulai dari usia 41 sampai 61 tahun. Dari penggabungan 18 penelitian yang sudah dipublikasikan dari berbagai negara menunjukkan bahwa dermatosis yang sudah ada sebelumnya merupakan penyebab yang paling banyak pada orang dewasa (52% dari kasus DE, dengan rentang 27% – 68%) disusul dengan reaksi hipersensitivitas obat (15%), dan limfoma sel T kutaneous atau Sindrom Serazy (5%).(1) Secara klinis, dermatitis eksfoliatif ditandai dengan peradangan yang melibatkan seluruh atau sebagian besar (> 90%) tubuh, dengan atau tanpa pengelupasan kulit.(2) Kulit memiliki fungsi untuk mengendalikan suhu tubuh, mempertahankan cairan, dan bertindak sebagai penghalang infeksi. Penderita dermatitis eksfoliatif mengalami kerusakan kulit dan kehilangan fungsi penting ini.(3) Gejalanya dapat disertai demam, menggigil, malaise, limfadenopati, distrofi kuku, alopesia, dan gagal jantung kongestif.(2) Penatalaksanaan dermatitis eksfoliatif meliputi gabungan antara pengobatan gejala dan menangani etiologi yang mendasari serta komplikasi sitemik yang dapat timbul. Rawat inap diperlukan pada kasus akut. Manajemen awal terhadap pasien dengan DE melibatkan penggantian cairan dan elektrolit, dan perbaikan nutrisi. Ketika penyebab yang mendasari DE tidak diketahui, terapi empirik dengan agen sistemik, seperti metotreksat, siklosporin, asitretin, mikofenolat
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Dermatitis
eksfoliatif
dapat
menyebabkan
serangkaian
komplikasi
metabolik dan fisiologis, termasuk ketidakseimbangan cairan dan elektrolit, gagal jantung, sindrom gangguan pernafasan akut, dan infeksi sekunder. Banyak faktor yang mempengaruhi gejala klinis dan prognosis, termasuk usia pasien, etiologi yang mendasari, kondisi medis yang menyertai, kecepatan onset eritroderma, dan waktu dimulainya terapi. Terapi suportif dan diagnosis dini penting untuk memperbaiki penyebab yang mendasarinya dan memperbaiki tingkat morbiditas dan mortalitas. Tingkat mortalitas telah dilaporkan berkisar antara 3,73% sampai 64%, tergantung pada populasi pasien yang diteliti. Kemajuan diagnosis dan pengobatan yang lebih lanjut dapat mengurangi mengurangi tingkat mortalitas.(4)
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LAPORAN KASUS
IDENTITAS PASIEN
Nama
: BM
Umur
: 65 tahun
JenisKelamin
: laki-laki
Suku
: Aceh
Agama
: Islam
Pekerjaan
: Tidak bekerja
Alamat
: Bireun
Tanggal Pemeriksaan
: 11 Agustus 2017
Nomor CM
: 1-13-83-44
ANAMNESIS Keluhan Utama
Kulit terkelupas. Keluhan Tambahan
Kaki bengkak. Riwayat Penyakit Sekarang
Pasien datang dengan keluhan kulit terkelupas diseluruh badan sejak dua bulan yang lalu. Pasien mengeluh awalnya di dada muncul seperti merah-merah tebal dan menjadi luka dan krusta, kemudian luka tersebut menyebar ke area lain.
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4
menggunakan selimut. Pasien juga mengeluhkan nyeri ketika BAK dan sering sakit pinggang. Riwayat penyakit dahulu
Pasien pernah didiagnosa dengan batu ginjal dan sudah dilakukan pembedahan pada tahun 2011. Pasien memiliki riwayat nyeri n yeri sendi sejak 2 tahun t ahun yang lalu. Riwayat penyakit keluarga
Tidak ada anggota keluarga yang memiliki keluhan yang sama seperti pasien. Riwayat pemakaian obat
Obat-obatan yang diberikan dari dokter kulit di RS Bireun, namun pasien tidak ingat nama obat tersebut. Dan obat untuk nyeri sendi yang dibeli di depo obat tanpa resep dokter. Riwayat kebiasaan sosial yang terkait
Pasien adalah seorang tukang becak barang yang sering terpapar sinar matahari. PEMERIKSAAN FISIK KULIT Status Dermatologis Tanggal (11 Agustus 2017)
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5
Gambar 3 Regio brachialis sinistra
Gambar 5 Regio cruris dextra et sinistra
Gambar 4 Regio brachialis dextra
Gambar 6 Regio femoris sinistra
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Regio
: Thorakalis anterior et posterior, brachii dextra et sinistra, antebrachii dextra et sinistra, femoris dextra et sinistra, cruris dextra et sinistra, dan fascialis.
Deskripsi lesi
: Tampak patch eritematous, batas tidak tegas, tepi ireguler, dengan permukaan ditutupi skuama berwarna kuning, jumlah multipel, distribusi universal.
Gambar 8 Regio palmar
Regio
: Regio palmar dan plantar
Deskripsi lesi
: Tampak deskuamasi
DIAGNOSIS BANDING
Gambar 9 Regio plantar
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7
JENIS PEMERIKSAAN PEMERIKS AAN
HASIL
NILAI RUJUKAN
SATUAN
Hemoglobin
10,7
12,0-15,0
g/dL
Hematokrit
32
37-47
%
Eritrosit
3,7
4,2-5,4
106/mm3
Leukosit
15,4
4,5-10,5
103/mm3
Trombosit
202
150-450
103/mm3
MCV
88
80-100
fL
MCH
29
27-31
Pg
MCHC
33
32-36
%
RDW
19,0
11,5-14,5
%
MPV
7,8
7,2-11,1
fL
Eosinofil
3
0-6
%
Basofil
0
0-2
%
HEMATOLOGI
Darah Rutin :
Hitung Jenis:
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8
Hati & Empedu Bilirubin total
0,40
0,3-1,2
mg/dl
Bilirubin direct
0,20
0,52
mg/dl
Bilirubin indirect
0,20
SGOT
27
< 31
U/L
SGPT
76
< 31
U/L
Protein total
5,78
6,4-8,3
g/dl
Albumin
2,94
3,5-5,2
g/dl
Globulin
2,81
g/dl
RESUME Seorang laki-laki dengan dengan inisial BM berumur 65 65 tahun datang dengan keluhan
kulit terkelupas diseluruh badan sejak 2 bulan yang lalu. Pasien mengeluh awalnya di dada muncul seperti merah-merah tebal dan menjadi luka dan krusta, kemudian luka tersebut menyebar ke area lain. Pasien sekarang merasakan kulit di seluruh tubuhnya kering dan terkelupas, ketika kulit kering pasien merasakan
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9
- Inj. Ranitidin 1 gr/12 jam - Inj. Ceftriaxon 1 gr/12 jam - Cetirizin 10 mg tab 2x1 b.
Terapi Topikal: - Asam salisilat 3% + vaselin Album 30 gr 3x1 (1 jam sebelum mandi) - Asam salisilat 3% + momethason cr 2x1 (pagi dan sore dibagian wajah) - Asam salisilat 3% + Desoximethason cr 2x1 (pagi dan sore dibagian kaki) - Tyamisin 1% + Diflucortolon valerat cr 2x1 (pagi dan sore dibagian badan)
EDUKASI
-
Menjelaskan tentang penyakit pendahulu tentang pemicu dermatitis eksfoliatif yang dapat memperberat penyakit.
-
Mengurangi garukan pada lesi kulit.
-
Menggunakan pelembap untuk seluruh badan yang kering supaya lesi tidak terkelupas.
-
Memberikan makan-makanan yang bernutrisi, khususnya yang tinggi protein.
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ANALISA KASUS
Telah dilakukan pemeriksaan pada pasien laki-laki umur 65 tahun di poliklinik kulit dan kelamin RSUD dr. Zainoel Abidin. Pasien datang dengan keluhan kulit terkelupas di seluruh badan sejak 2 bulan yang lalu yang awalnya berupa bercak merah tebal dan menjadi luka dan krusta. Pasien didiagnosa dengan dermatitis eksfoliatif. Sebelumnya pasien sudah pernah dirawat di RS Bireun dengan keluhan yang sama pada bulan April 2017. Pasien juga sering mengeluhkan nyeri sendi sejak dua tahun yang lalu. Nyeri sendi yang dirasakan diatasi pasien dengan membeli obat ke apotek tanpa resep dokter. Berdasarkan teori, dermatitis eksfoliatif eksfoliatif
merupakan eritema difus dan
pengelupasan kulit yang melibatkan lebih dari 90% luas permukaan kulit di seluruh tubuh. tubuh. Dermatitis eksfoliatif lebih banyak diderita laki-laki dibandingkan dibandingkan perempuan dengan usia rata-rata 41 sampai 61 tahun.(1) Dermatitis eksfoliatif pada orang dewasa dapat disebabkan oleh dermatitis atopik, psoriasis, limfoma sel T kutaneus, dan reaksi obat. Penyebab lain yang jarang terjadi adalah dermatosis bulosa, pityriasis rubra pilaris, papuloeritroderma ofuji, dan penyakit jaringan ikat.(5)
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11
Penguapan cairan yang makin meningkat dapat menyebabkan dehidrasi. Bila suhu badan meningkat, kehilangan panas juga meningkat. Pengaturan suhu terganggu. Kehilangan
panas
menyebabkan
hipermetabolisme
dan
peningkatan
laju
metabolisme basal.(7) Kehilangan skuama pada dermatitis eksfoliatif dapat mencapai 9 gram/m2 permukaan kulit atau lebih per hari sehingga menyebabkan kehilangan protein. Hipoproteinemia dengan berkurang albumin dan peningkatan relatif globulin terutama globulin γ merupakan kelainan yang khas. Edema sering terjadi, kemungkinan disebabkan oleh pergeseran cairan ke ruang ekstravaskuler.(7) Meskipun beragam penyebabnya, dermatitis eksfoliatif memiliki beberapa ciri klinis yang umum. Pruritus, keluhan yang paling sering diamati pada 90% pasien. Gejala ini bervariasi sesuai dengan penyebab utamanya, paling sering terjadi pasien dengan dermatitis atau sindrom serazy. Selain gatal, kulit bisa menjadi menebal dan area likenifikasi terlihat pada sepertiga kasus. Pada kasus eritroderma kronis, pasien mengalami dispigmentasi, dengan hiperpigmentasi lebih
sering
terjadi
dibandingkan
hipopigmentaasi
atau
depigmentasi.
Keratoderma palmoplantar terjadi pada 30% kasus, dan ini sering merupakan tanda awal pada pityriasis rubra pilaris. Keratoderma dengan krusta bisa
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12
-
Splenomegali juga jarang dilaporkan, dan paling sering dikaitkan dengan limfoma
-
Edema tungkai dapat terjadi pada 54% pasien dermatitis eksfoliatif dan edema wajah dapat terjadi pada kasus dermatitis eksfoliatif karena reaksi obat namun jarang terjadi.(1) Pemeriksaan penunjang yang telah dilakukan pada pasien berupa
pemeriksaan laboratorium dan didapatkan hasil anemia, hematokrit menurun, leukositosis, SGPT meningkat, dan hipoalbumin. Berdasarkan teori, pemeriksaan laboratorium pada dermatitis eksfoliatif tidak spesifik untuk menegakkan diagnosa. Kelainan laboratorium yang sering ditemukan pada pasien dermatitis eksfoliatif meliputi
anemia, leukositosis, limfositosis, eosinofilia, peningkatan
IgE, penurunan albumin serum dan LED meningkat. Kehilangan cairan dapat
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yang dapat dideteksi. Kelompok ini terutama terdiri dari pria lanjut usia dengan riwayat eritroderma pruritic pruritic yang kambuh sehubungan dengan limfadenopati dermatopati dan keratoderma palmoplantar yang luas. Ketika kelompok ini dibandingkan dengan keseluruhan kelompok pasien dermatitis eksfoliatif, limfadenopati dan edema perifer ternyata lebih sering ditemukan dibandingkan pada
penyebab
lainnya,
dan
hipotermia
lebih
sering
terjadi
daripada
hipertermia.(8) Pada pasien ini diberikan diberikan obat antihistamin berupa cetirizin 10 mg diminum diminum dua kali sehari dan antibiotik berupa seftriakson yang diberikan melalui intravena per 12 jam. Antihistamin berguna karena kar ena bisa mengurangi gatal saat kambuh.(4) Antihistamin dapat diberikan untuk efek sedasi dan antipruritik. Antibiotik sistemik diperlukan untuk pasien dengan bukti infeksi sekunder lokal dan
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14
kortikosteroid sistemik berupa injeksi metilprednisolon 62,5 gram per 12 jam. Untuk efek samping dari kortikosteroid tersebut diberikan ranitidin secara intravena per 12 jam. Berdasarkan teori, pasien dermatitis eksfoliatif harus dirawat di tempat yang hangat (30°C - 32°C) dan lingkungan lembab untuk kenyamanan dan kelembaban kulit, serta untuk mencegah hipotermia. Perawatan kulit lokal yang lembut, termasuk mandi oatmeal dan dressing basah pada lesi yang basah atau krusta, pemberian emolien, dan steroid topikal dengan potensi rendah harus dimulai.(1) Pada dermatitis eksfoliatif akibat perluasan penyakit kulit juga diberikan kortikosteroid sistemik. Jika setelah beberapa hari tidak tampak perbaikan dosis dapat dinaikkan. Setelah tampak perbaikan, dosis diturunkan perlahan-lahan. Pada pengobatan dengan kortikosteroid jangka panjang (long term), term), yakni jika melebihi 1 bulan lebih baik digunakan
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DAFTAR PUSTAKA
1.
2. 3. 4.
5.
Grant-Kels JM, Fedeles F, Rothe MJ. Exfoliative Dermatitis. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, Wolff K, editors. Fitzpatrick’s Dermatology in General Medicine (Volume 1). 8th ed. United States: McGraw Hill Companies; 2012. p. 266 – 79. 79. Egeberg A, Thyssen JP, Gislason Gislason GH, Skov L. Prognosis after Hospitalization for Erythroderma. Acta Derm Venereol. 2016;96(7):959 – 62. 62. Dobson JS, Levell NJ. Erythroderma. Medicine (Baltimore). 2017;45(7):417 – 21. 21. Mistry N, Gupta A, Alavi A, Sibbald G. A Review of the Diagnosis and Management of Erythroderma ( Generalized Red Skin ). Adv Skin Wound Care. 2015;28(5):228 – 36. 36. Thomson MA, Berth-Jones J. Erythroderma and Exfoliative Dermatitis. In: Revuz J, Roujeau J-C, Kerdel FA, Valeyrie-Allanore L, editors. LifeThreatening Dermatoses and Emergencies in Dermatology. Berlin: Springer Berlin Heidelberg; 2009. p. 79 – 79 – 87. 87.
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Lampiran 1. Foto Klinis Pasien setelah 6 Hari Rawatan di Rumah Sakit
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