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NEURODERMATITIS (LICHEN SIMPLEX CHRONIC) By : Yusran Ady Fitrah Filianmi Dyospama Patandianan Setiawan Winarso Advisor : dr.Regina Mihardja Supervisor : Dr. dr. Khairuddin Djawad, SpKK(K) DERMATOVENEROLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY

Neuro Dermatitis

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NEURODERMATITIS (LICHEN SIMPLEX CHRONIC)

NEURODERMATITIS (LICHEN SIMPLEX CHRONIC) By :Yusran Ady FitrahFilianmi Dyospama PatandiananSetiawan WinarsoAdvisor :dr.Regina Mihardja

Supervisor :Dr. dr. Khairuddin Djawad, SpKK(K)

DERMATOVENEROLOGY DEPARTMENTFACULTY OF MEDICINEHASANUDDIN UNIVERSITY

Definition A chronic, severely pruritic disorder characterized by one or more lichenified plaques.Most common sites of involvement are scalp, nape of neck, extensor aspects of extremities, ankles, and anogenital area.Epidemiology Lichen simplex chronicus affects adults, predominantly from ages 30 to 50. Females are affected more commonly than males.

Etiology Pruritus can be caused by the by various factors which are not understood well.There is association between neurodermatitis and atopic disorders.Enviromental factors: heat, sweat, and irritationEmotional and psychological factorsPathomechanismLichen simplex chronicus is induced by rubbing and scratching secondary to itch. Various factors incite itch in both disorders and not all are well understood.Clinical manifestationItchingFirst lession can be eritomatous plaqueLater became edema, erythema disappeared, scaly and thickened, lichenification and excoriationAround the lesion can be hyperpigmentationFollicular papules may arise especially at forearm and elbow

Clinical manifestationThe most common sites of involvement are the scalp, the nape of the neck (especially in women), the ankles, the extensor aspects of the extremities, and the anogenital region.

ABC

Lichen simplex chronis at abdomen regio (a); lichenfication area because of scracthing at upper thigh regio (b); Lichen simplex chronic at vulva (c).

Lichen simplex chronic at scalp (a), medial part of ankle joint (b). folikular papule at elbow (c).ABCHistopatologyHiperplasia epidermal, hiperkeratosis with para- and ortokeratosis, akantosis ,dan hipergranulosis with elongation regular rete ridges. Dermis papiler show thickening colagen with rough colagen shaft and vertikal line. There is perivaskular infiltration of lymphocytes and sometimes macrofag

(A)- Histopatology of Lichen skelrosus. (B)-Histopatology of lichen simplex chronic. Differential DiagnosisLichen simplex: erythemateous polygonal papules with white lines (Wickham striea) and scales atop it. Locations usually bilaterally and symmetrically over extremities

Lichen simplexNeurodermatitisDifferential DiagnosisPsoriasis: Red, scaly, symmetrically distributed plaques. Usually found at extensor aspects of the extremities, scalp, lower lumbosacral, buttocks, and genital.

NeurodermatitisPsoriasisDifferential DiagnosisMycosis fungoides: Early lesion is erythematous, scaly macules which may develop into plaques. Usually found at the non sun-exposed sites.

NeurodermatitisMycosis fungoidesDifferential DiagnosisAtopic dermatitis: In chronic, it can be lichenified due to scratching. It is usually found at face and extensor aspect (infant), elbow and knee flexures, sides of neck, wrist, ankle (childhood and adult)

NeurodermatitisAtopic dermatitisDifferential DiagnosisDiseasesEfflorecencesLocationItch sensationOther symptomsNeurodermatitisLichenified, scaly plaques. May develop to hyper/hypopigmentationScalp, nape of neck, extensor aspects of extremities, anogenitalSevereLichen planusErythematous papules with Wickham striae and scalesExtremities (flexural areas), thighs, lower back, trunk, and neckNot always, may be not existPsoriasisErythematous plaques with scalingExtremities (extensor areas), scalp, lower lumbosacral, buttocks, and genital.Varies among patients; usually found at erythrodermic form; may reflect emotional stateNail changes, such as nail pitting, and arthritis may be found in 40% patientsDifferential DiagnosisDiseasesEfflorecencesLocationItch sensationOther symptomsNeurodermatitisLichenified, scaly plaques. May develop to hyper/hypopigmentationScalp, nape of neck, extensor aspects of extremities, anogenitalSevereMycosis fungoidesErythematous, scaly macules. Plaques may arise.Non sun-exposed sites.Often intenseFever, chills, weight loss, malaise, insomnia due to pruritusAtopic dermatitisErythematous papules, vesicles. Can develop to lichenification in chronic ADFace and extensor aspect (infant)Elbow and knee flexures, sides of neck, wrist, ankle (childhood and adult)Intense, may get worse in early evening and nightDry skin, allergic rhinitis and asthma may be foundTreatmentTreatment is aimed at interrupting the itchscratch cycle.first-line measures to control itch include potent topical steroids as well as nonsteroidal antipruritic preparations such as menthol, phenol, or pramoxineIntralesional steroid beneficial for thickend plaqueAnti-histamint for abolish nighttime itch and SSRIs for abolish daytime itch in patient OCD

Prognosis The diseases run a chronic course with persistence or recurrence of lesions. Exacerbations occur in response to emotional stress.THANK YOUReferencesBurgin S. Nummular eczema and lichen simplex chronicus/prurigo nodularis. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, eds. Fitspatrickss Dermatology In General Medicine. 8th ed. New York: The McGraw-Hill Companies, Inc.; 2012. p. 184-87.Sularsito SA, Suria D. Dermatitis. Dalam: Djuanda A, Hamzah M, Aisah S, editor. Ilmu Penyakit Kulit dan Kelamin.5th ed. Jakarta: Badan Penerbit Fakultas Kedokteran Universitas Indonesia; 2010. p. 129-53, 190.Cohen AD, Andrews ID, Medvedovsky E, Peleg R and Vardy DA. Similarities between Neuropahtic Pruritus Sites and Neurodermatitis Sites. IMAJ. 2014; 16: 88-90Martin-Brufau R, Corbalan-Berna J, Ramirez Andreo A, Brufau-Redondo C, and Liminana-Gras R. Personality differences between patientswith neurodermatitis and normalpopulation: A study of pruritus. Eur J Dermatol. 2010; 20(3): 359-63Jones JB. Eczema, Lichenification, Prurigo and Erythroderma. In: Burns T, Breathnach S, Cox N, Griffiths C, eds. Rooks Textbook of Dermatology.8th edition. UK: Wiley-Blackwell; 2010. p.23.39-40. Bolognia JL, Jorizzo JL, Rapini RP. Dermatology. 2nd edition. US: Mosby Elsevier; 2008. p.16-7.Lotti T, Prignano F. Prurigo Nodularis dan Lichen Simpleks Kronis. Dermatologic Therapy. 2008; 21: 42-6.

ReferencesHabif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th edition. Philadelphia: Mosby; 2010. p.115-9.Rubakovic, Steffen. Dermatopathology in Historical Perspective: The Montgomery Giant Cell of Lichen Simplex Chronicus. Skin Med. 2010 January; 8(1): 54-5.Gudjonsson JE and Elder JT. Psoriasis. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, eds. Fitspatrickss Dermatology In General Medicine. 8th ed. New York: The McGraw-Hill Companies, Inc.; 2012. p. 208-16.Daoud MS and Pittelkow MR. Lichen Planus.In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, eds. Fitspatrickss Dermatology In General Medicine. 8th ed. New York: The McGraw-Hill Companies, Inc.; 2012. p. 296-312Leung DYM, Eichenfield LF and Boguniewicz. Atopic Dermatitis (Atopic Eczema). In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, eds. Fitspatrickss Dermatology In General Medicine. 8th ed. New York: The McGraw-Hill Companies, Inc.; 2012. p. 165-82Beyer M and Sterry W Cutaneous Lymphoma. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, eds. Fitspatrickss Dermatology In General Medicine. 8th ed. New York: The McGraw-Hill Companies, Inc.; 2012. p. 1748-52Kim, Lockey. Dermatology for the Allergist: Lichen Simplex Chronicus. USA: World Allergy Organization; 2010. p. 212-213.

Emotion related lichen simplex chronicsWhether these emotional factors are secondary to the primary dermatologic disease or whether they are primary and causative, altering perception of itch, is unclear. It has been postulated that neurotransmitters that affect mood, such as dopamine, serotonin, or opioid peptides modulate perception of itch via descending spinal pathways