This document discusses papulosquamous disorders, which are characterized by scaly, erythematous papules and plaques. It begins by defining papulosquamous disorders and providing a morphological classification. It then discusses specific disorders like psoriasis, parapsoriasis, and pityriasis rosea. For each disorder, it describes clinical features, pathogenesis, histopathology, and management approaches. The document aims to comprehensively cover papulosquamous disorders through classification, descriptions of individual disorders, and inclusion of relevant images and diagrams.

1. PAPULOSQUAMOUS
DISORDERS
Peter Nugraha Soekmadji
Department of Dermatovenereology
Faculty of Medicine
Maranatha Christian University
Bandung

2. What is
papulosquamous disorders?
• Referred as erythrosquamous disorders or
erythropapulosquamous disorders (EPS)
• Morphological classification
• Characterized by scaly, erythematous
papules/plaques
• Little in common, but most often
inflammatory in nature
Clinical dermatology. Edisi ke-5. London: Elsevier; 2010. hlm. 264-334.
Dermatology secrets plus. Edisi ke-4. London: Elsevier; 2011. hlm 50-6.

3. CLASSIFICATION (ICD 10)
L40 Psoriasis
L41 Parapsoriasis
L41.0 Pityriasis lichenoides
et varioliformis acuta
L41.1 Pityriasis lichenoides
chronica
L41.3 Small plaque
parapsoriasis
L41.4 Large plaque
parapsoriasis
L42 Pityriasis rosea
L43 Lichen planus
L44 Other papulosquamous
disorders
L44.0 Pityriasis rubra pilaris
L44.1 Lichen nitidus
L44.2 Lichen striatus
ICD 10
L40-L45 Papulosquamous disorders

4. What about
other diseases that exhibit
papulosquamous lesions?
• Sometimes referred as ‘false’ EPS, and known
as the great immitators in skin diseases
• Example:
– Syphilis
– Leprosy
– Dermatophytosis
– Pityriasis versicolor
– Scabies
– Atopic dermatitis
– Drug eruption
– Lupus erythematosus
– Cutaneous T-cell
lymphoma

5. PSORIASIS
Chronic, recurrent
dermatosis
T-cell mediated
inflammation
Epidermal
hyperproliferation
Putative self-
antigen
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-6. Stuttgart: Thieme; 2006. hlm 262-89.

6. EPIDEMIOLOGY
• Prevalence: 0,1 – 11.8%
• Age of onset: 15 – 30 yo
• ♂ = ♀
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

7. TRIGGER FACTORS
• Trauma
• Infections, eg: streptococcal pharyngitis, HIV
infection
• Medications, eg: lithium, beta-blocker, oral CS
taper, antimalarials, interferon
• Psychogenic stress
• Alcohol consumption, smoking
• Obesity
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

8. SYSTEMIC ASSOCIATIONS
• Psoriatic arthritis
• Rheumatoid arthritis
• Metabolic syndrome
• Inflammatory bowel disease
• Depression & anxiety
• Lymphoma
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

9. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Normal skin (healthy
individual): Langerhans cells
(L), immature dendritic cells
(D), memory T cells (T)
Normal-appearing psoriatic
skin: slight capillary dilatation
& curvature, mononuclear
cells & mast cells (M),
epidermal thickness ↑

10. Developing lesion:
Dermis: capillary dilatation &
tortuosity, macrophages (MP), T &
M degranulation (small arrows) ↑↑↑
Epidermis: thickness ↑, prominent
rete pegs, spotty loss of the
granular layer & parakeratosis. L
begin to exit the epidermis,
inflammatory dendritic epidermal
cells (I) & CD8+ T cells (8) begin to
enter the epidermis
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

11. Fully developed lesion:
Dermis: 10-fold increase in blood
flow, M under the basement
membrane & dermal T (mainly
CD4+) making contact with
maturing D ↑
Epidermis: 10-fold keratinocyte
hyperproliferation, loss of the
granular layer, overlying
parakeratosis, CD8+ T cells ↑,
Munro’s microabscesses
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

12. Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
Psoriasis. Nestle FO, Kaplan DH, Barker J. N Engl J Med 2009; 361:496-509July 30, 2009. DOI: 10.1056/NEJMra0804595

13. 1. Self-DNA & RNA from
stressed keratinocytes form
complexes w/ cathelicidin LL-37
2. Plasmacytoid dendritic cell
(pDC) produce IFNα to activate
dermal DC
3. dDC promote differentiation
of naïve T cells to Th1, Th17 &
Th22 in lymph nodes

14. 1. Th1 activate inflammation on
DC & keratinocytes
2. Th17 & Th22 stimulate
keratinocyte proliferation &
activation
4. Neutrophils secrete reactive
oxygen species & AMP
3. Keratinocytes produce
chemokines & antimicrobial
peptides (AMP)

15. 6. Keratinocytes promote
neoangiogenesis
7. Tc1 secretes Th1 & Th17
cytokines
5. Macrophages promotes
clustering of Th cells

16. Psoriasis. Nestle FO, Kaplan DH, Barker J. N Engl J Med 2009; 361:496-509July 30, 2009. DOI: 10.1056/NEJMra0804595

17. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

18. Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

19. • 90% patients
• Typical lesion: well-demarcated, erythematous
plaque with silvery scale
• Often symmetric, may be generalized
• Variant: annular, rupioid, ostraceous, elephantine
• Woronoff’s ring: peripheral, blanching ring,
associated w/ treatment
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
PSORIASIS VULGARIS
Plaque-type Psoriasis, Stationary Psoriasis

20. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

21. Koebner Phenomenon
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
Isomorphic Response

22. Candle Wax Phenomenon
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
”Signe de la tache de bougie”

23. Auspitz Sign
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

24. • Generalized, small papules/plaques (3-15
mm) with adherent scales
• Children > adults
• Often preceded by streptococcal pharyngitis
(antibiotics are not beneficial)
• May have spontaneous remission in children
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
GUTTATE PSORIASIS
Eruptive Psoriasis

25. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

26. INVERSE PSORIASIS
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
Flexural Psoriasis
• Located on major skin folds
• Scaling: minimal/absent!!!

27. SEBOPSORIASIS
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
• Common
• Located on seborrheic areas

28. PSORIATIC ERYTHRODERMA
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Cause:
• Worsening of
psoriasis
vulgaris
• Generalized
Koebner
phenomenon
• Pustular
psoriasis
• Discontinuation
of oral CS

29. • Generalized (von Zumbusch): lake of pus,
fever, life-threatening
• Exanthematic: after viral infection, no
constitutional symptoms, no recurrence
• Annular: rare
• Localized: within plaques
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
PUSTULAR PSORIASIS

30. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

31. Palmoplantar Pustulosis
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
• Now considered to be
different entities w/ psoriasis
• Associated w/ smoking,
tonsilitis & gluten sensitivity

32. Acrodermatitis Continua
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
• Rare
• Pustular eruptions of the tips of the fingers &
toes, slowly extends proximally
• Nail destruction & distal phalanx atrophy
of Hallopeau

33. NAIL PSORIASIS
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.
• 40% patients
• Pitting nail, oil spot, salmon patch, splinter
hemorrhage, subungual hyperkeratosis,
onycholysis

34. GEOGRAPHIC TONGUE
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.
• Relatively common in normal individuals
• Local loss of filiform papillae
Benign Migratory Glossitis

35. PSORIATIC ARTHRITIS
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

36. HISTOPATHOLOGIC FINDINGS
•Parakeratosis
•Microabscess of Munro
(neutrophils on stratum
corneum)
•Hypogranulosis
•Acanthosis
•Dilated blood vessels
•Spongiform pustules of
Kogoj (neutrophils on
stratum spinosum)
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

37. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

38. Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

39. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

40. TOPICAL TREATMENTS
• Absorption: ointment > cream
• Corticosteroids (CS): 1st line, long-term use may
cause tachyphylaxis & many side effects
• Vitamin D analogs: no tachyphylaxis, often used
alternately/combined w/ CS
• Coal tar: often combined with salicylic acid,
irritating, stains clothing, carcinogenic
• Salicylic acid: keratolytic agent, enhances
absorption
• Emollients
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 197-232.

41. Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 135-56.

42. PARAPSORIASIS
Chronic,
asymptomatic,
erythematous scaly
patches in adults
Favors nonsun-
exposed skin (bathing
suit), cigarette paper
wrinkling
Small (< 5 cm) plaque
(variant: digitate
dermatosis)
Large (> 5 cm) plaque
(variant: retiform) →
malignancy (mycosis
fungoides)!
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.
Dermatology. Edisi ke-6. Stuttgart: Thieme; 2006. hlm 262-89.
Parapsoriasis en plaques

43. Small Plaque Parapsoriasis
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

44. Large Plaque Parapsoriasis
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

45. Management
• SPP: emollient, topical CS/tar, phototherapy,
reexamination every 3-6 months
• LPP: high-potency topical CS w/ phototherapy,
reexamination every 3-6 months, repeated
multiple biopsies
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.

46. PITYRIASIS LICHENOIDES
Continuum:
PLEVA (et varioliformis
acuta) - PLC (chronica)
Recurrent,
spontaneously regressing
erythematous papules
on trunk & proximal
extremities
PLEVA: develop crusts,
vesicles, or pustules
PLC: scaly lesions
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

47. PLEVA
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.

48. PLC
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

49. Management
• Topical CS
• Antibiotics (erythromycin, azithromycin,
tetracycline, minocycline)
• Phototherapy
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 285-96.

50. PITYRIASIS ROSEA
Self-limiting,
moderately pruritic
eruption on
adolescents-young
adults
Cause: reactivation of
HHV-6 & HHV-7?
(occasionally flu-like
symptoms)
Herald patch: 2-4 cm,
oval/round
erythematous macule,
collarette scale
2nd eruption in 2 weeks
Bathing suit
distribution, X-mas tree
pattern
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 458-63.

51. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 458-63.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

52. Management
• Symptomatic: mid-potency topical CS for
pruritus
• Complicated cases (flu-like
symptoms/extensive skin disease): high-dose
acyclovir
• Erythromycin?
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 458-63.

53. ERYTHRODERMA
Skin failure:
presentation of a
variety of diseases
Diffuse erythema &
scaling, > 90% BSA
Life-threatening
complications
Management:
symptomatic relief,
address the etiology
& complications
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 266-79.
Exfoliative Dermatitis

54. Etiology
23
20
9
15
5
20
18
0
10
20
30
40
50
60
Dermatosis Drugs Malignancy Idiopathic Other
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 266-79.
Psoriasis
Dermatitis

55. Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 171-82.

56. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 266-79.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 171-82.

57. Complications
• Fluid & electrolyte imbalance
• Thermoregulatory disturbance
• High-output cardiac failure
• Hypoalbuminemia
• Septicemia
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 266-79.

58. Management
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 266-79.

59. LICHEN PLANUS
Idiopathic inflammation in
middle-aged adults
Widespread distribution,
flexural predilection:
wrists, forearms, genitalia,
distal lower extremities,
presacral area
Symmetric, grouped, flat-
topped erythematous-
violaceous papules
Wickham striae, Koebner
phenomenon
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 296-312.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 183-202.

60. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 296-312.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 183-202.

61. Management
• Topical, intralesional, or systemic CS
• Topical calcineurin inhibitors
• Phototherapy
• Systemic retinoids
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm. 296-312.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 183-202.

62. LICHEN NITIDUS
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 312-6.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 183-202.

63. LICHEN STRIATUS
Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 1319-37.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 183-202.

64. PITYRIASIS RUBRA PILARIS
Orange-red
follicular papules
Coalescence of
plaques, islands of
sparing, progress
to erythroderma
Orange-red waxy
keratoderma
Adult & juvenile
onset
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

65. Fitzpatrick's dermatology in general medicine. Edisi ke-8. New York: McGraw-Hill; 2012. hlm 279-85.
Dermatology. Edisi ke-3. London: Elsevier; 2012. hlm 157-70.

67. REFERENCES