kulit jamilah - english

7/28/2019 Kulit Jamilah - English

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CUTANEOUS NEUROSES

Under the heading of functional disorders and psychosomatic dermatoses are include

a great many diseases. Many have studied the influence of the psyche on the skin and the

influence of the skin on the psyche. There are those dermatoses that are purely psychic in

origin, such as acrophobia, parasitophobia, neurotic excoriations, and trichotillomania. In

other dermatoses psychic factors have a more or less prominent role. Dermatitis factitia,

psychogenic pruritus, neurodermatitis, exudative chronic discoid and lichenoid dermatitis,

and hyperhidrosis are included in this group in which stress, tension, and anxiety are essential

factors.

LICHEN1F1CATION

As a result of long-continued rubbing and scratching, more vigorously than a normal

pain threshold would permit, the skin becomes thickened and leathery. The normal markings

of the skin become exaggerated, so that the striae form a criss-cross pattern, and between

them there is produced a mosaic composed of flat-topped, shiny, smooth, quadrilateral facets.

This change, known as lichenification, may originate upon seemingly normal skin, or may

develop upon skin that is the site of another disease, such as eczema or ringworm.

Paroxysmal pruritus is the main symptom. This is known as iichen simplex cronicus(neurodermatitis circumscripta)

Lichen Simplex Chronicus

CLINICAL FEATURES. Also known as neurodermatitis circumscripta, this

circumscribed, lichenified, pruritic patch may develop on any part of the body. However, the

disease has a predilection for the back and sides of the neck, and the extremitiesespecially

the wrists and ankles. At times the eruption is decidedly papular, resembling lichen planus; in

other instances the patches are excoriated, slightly scaly or moist, and rarely nodular.

Several distinctive types are recognized. Lichen simplex nuchae occurs on the back of

the neck. It is not unusual to find this area excoriated and bleeding.

Nodular neurodermatitis of the scalp of Ayres consists of multiple pruritic and

excoriated papules. It may be called prurigo of the scalp. The nodules or papules may ooze

and form crusts and scales.


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The vulva, the scrotum, and the anal area can be sites of severe neurodermatitis.

Seldom, however, as Rees has pointed out, are genital and anal areas involved at the same

time. An upper eyelid, the orifice of one or both ears, or a palm or sols may also be involved,

and the ankle flexure is a favorite site as well.

It is not known by what mechanism the act of tearing through the epidermis with the

fingernails, or burning the skin with painfully hot water, is made not merely painless but

exquisitely and irresistibly pleasurable. But that is what happens, and virtually every patient

with the disorder experiences this mysterious hallucination. The same phenomenon is

encountered in atopic dermatitis, dermatitis herpetiformis, and prurigo nodularis.

ETIOLOGY. To what extent mechanical trauma plays a role in producing the original

irritation is not known. The onset of this dermatosis is usually insidious, developing

gradually. Scratching of a localized area on a chronic basis is a response to unknown factors;

however, stress and anxiety have long been thought important.

TREATMENT. The primary consideration is the control of the pruritus, which is

accomplished by no other means so effectively as by intralesional injections of triamcinolone

suspension, using a concentration of 5 or (with caution) 10 mg per ml. Superficial injection

invites the twin risks of epidermal and dermal atrophy and depigmentation, which may last

for many months. Injection should not be made into infected or even excoriated or eroded

lesions, for fear of causing abscesses. In such cases it is better to give 40 to 60 mg of

triamcinolone acetonide intramuscularly instead initially to gain control, and perform the

intralesional injections later, when the lesions first recur.

Superficial x-ray or even grenz ray therapy, though effective, has been virtually

completely superseded by therapy with topically applied corticosteroids. These are today the

mainstay of therapy. High potency agents such as clobetasol propionate (Temovate) or

betamethasone dipropiortate (Diprolene) cream or ointment should be used initially, but not

indefinitely; within weeks to months, they may cause epidermal and even dermal atrophy,

with hypopigmentation, and before this a milder steroid should be substituted for them.

Occlusion may rarely be, required. If lichenification is well established, it is better not to

waste time with topical applications but to resort immediately to intralesional triamcinolone

injections.


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Essentially, cessation of pruritus is the goal. Recurrences are frequent even after most

thorough treatment. There are instances when the clearance of one lesion will see the onset of

another elsewhere.

Distinctive Exudative Discoid and Lichenoid Dermatitis (DEDLE)

Sulzberger and Garbe in 1937 reported a psychosomatic disease encountered mostly

in middle-aged or older patients of Jewish heritage, commonly called "oid-oid" disease. Since

then it has been seen frequently by some observers (Knox) and not at all by others (Arnold),

and its existence has been questioned. Recently two cases were reported in one issue of the

International journal of Dermatology, and Frank discussed its checkered career.

CLINICAL FEATURES. The eruption often begins on the penis or the bridge of the

nose and persists there after other manifestations have disappeared. The onset is usually

sudden, with a severely itching discoid plaque that later becomes a widespread dermatitis.

Intractable and uncontrollable itching, with nocturnal accentuation and frequent crises, is the

outstanding symptom. The lesions are sharply demarcated oval and discoid plaques showing

rapid variations in consistency and appearance; they are at times flat and scaly, elevated, and

edematous or oozing and crusting, and pass speedily through many of the clinical stages

considered characteristic of eczematous lesions. Distinct clinical vesiculation and trueherpetiform lesions are uniformly absent. The general lack of distinct and persistent vesicles

and complete absence of bullae are emphasized, for these are important points in

differentiating the findings in this dermatosis from characteristic findings in dermatitis

herpetiformis, dermatophytids, and acute contact dermatitis. Sulzberger emphasized the

constancy of penile involvement as an essential diagnostic criterion.

The significant histologic findings are a dilatation and thickening of the arterioles and

a swelling of the nuclei in the intima. The entire dermis is edematous. An infiltrate of

polymorph nuclear leukocytes, eosinophils, and many plasma cells forms a mantle about the

blood vessels. Epidermal changes are variable degrees of acanthosis. Direct

immunofluorescence has only very rarely been performed.

TREATMENT. The disease is usually refractory to treatment, most patients requiring

prolonged care. Rest in the sunshine of warm southern climates with salt-water bathing was

reported to be helpful.


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The disease is benefited by corticosteroids. Intralesional injections of triamcinolone

suspension have been the most effective treatment. Tranquilizers and the antihistaminic have

a definite place in treatment of this disease. Cyproheptadine is frequently helpful. Tar baths

are useful. The disease may have a self-limited course; however, usually it has been a

persistent problem, affected mainly by the emotional status of the patient.

PRURIGO NODULARIS

SIGNS AND SYMPTOMS. Prurigo nodularis is a disease with multiple itching

nodules situated chiefly on the extremities, especially on the anterior surfaces of the thighs

and legs. A linear arrangement is common. The individual lesions are pea-sized or larger,

firm, and erythematous or brownish. When fully developed they become verrucous, or

fissured. The course of the disease is chronic and the lesions evolve slowly. Itching is always

severe but is confined to the lesions themselves. Bouts of extreme pruritus occur when these

patients are under stress. Prurigo nodularis is one of the disorders in which the pruritus is

characteristically paroxysmal: intermittent, unbearably severe, and only relieved by

scratching to the point of damaging the skin, usually inducing bleeding and often scarring.

King et al reported a case in which unilateral pruritus and prurigo nodularis also

unilateral associated with diminished touch, pain, temperature and position, followedsurgical repair of a cerebral aneurysm.

ETIOLOGY. The etiology is unknown. The disease is regarded as an atypical nodular

form of neurodermatitis circumscripta.

Some clinical resemblance to dermatitis herpetiformis is by no means rarewith

similarly severe and paroxysmal pruritus, similar hyperpigmentation, and similar remissions

and recurrences. Occasionally pemphigoid may present as the so-called prurigo nodularis

variant, which was reviewed by Roenigk et al. Half of 46 patients reviewed by Payne et al

had potential metabolic causes of pruritus, and an additional 37 per cent had focal causes.

Psychosocial factors were considered relevant in one-third of the cases.

HISTOPATHOLOGY. The histologic findings are irregular acanthosis and abundant

hyperkeratosis, degenerated nerve fibers and hyperplasia of Schwann cells, and dilated blood

vessels surrounded by lymphocytes and occasional mast cells.


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TREATMENT. The lesions respond readily if only temporarily to intraIesional

injections of triamcinolone. Thalidomide was tried successfully in 1979 by van den Broek,

and its effectiveness was confirmed by Winkelmann et al in 1984. The dose was 100 mg

twice a day Relief was noted in two or three weeks, and treatment continued for three

months. The safety of thalidomide is still in doubt; chronic neuropathy has been observed

after long use.

Cryotherapy has also been used successfully, as reported by Waldinger et al.

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