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Geniþ vücut yüzeylerini tutan pek çok hastalýðýn tedavisi sýrasýnda yoðun bakým takibi gerektiren önemli komplikasyonlar oluþabilmektedir. Toksik epidermal nekroliz, stafilokokal haþlanmýþ deri sendromu, büllöz hastalýklar, deri nekrozu, nekrotizan selülit ve eksfoliyatif dermatit dermatolojik yoðun bakým hastalarýnýn önemli bir bölümünü oluþturur. Derinin bariyer, immunolojik ve termoregulatuar foksiyonlarýnýn bozulmasý ile sývý, elektrolit, protein, ýsý, enerji kaybý; beslenme bozukluklarý; ciddi enfeksiyonlar gibi sorunlar yaþayan bu hastalar eðitimli personel tarafýndan uygun ekipmanla donatýlmýþ ünitelerde yoðun bakým disiplini ile monitorize ve tedavi edilmelidir. Bu derlemede hastalarýn yaþam sürelerini etkileyebilen komplikasyonlar ve tedavi prensipleri üzerinde durulmaktadýr.

Important complications requiring intensive care may occur in dermatologic diseases which affect large body surface areas. Toxic epidermal necrolysis, staphylococcal scalded skin syndrome, bullous diseases, skin necrosis, gangrenous cellulitis and exfoliative dermatitis constitute the great portion of dermatologic intensive care patients. Because of the disturbances in barrier, immunologic and thermoregulatory functions of the skin, these patients lose fluid, electrolytes, protein and energy; have nutritional problems and/or severe infections. Considering these problems, such
patients should be monitorized and treated in an intensive care discipline. Here in some complications affecting survival of these patients are reviewed.

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Çivi belirtisi, kaldýrýlan bir kurutun altýnda boynuzumsu çýkýntýlarýn gözlenmesidir. Diskoid lupus eritematozusun iyi bilinen bir özelliði olmakla beraber diðer bazý skuamlý veya kurutlu lezyonlarda özellikle kutanöz leishmaniasis lezyonlarýnda da görülebilir. Bu çalýþma, çivi belirtisinin kutanöz leishmaniasisin klinik tanýsýndaki deðerini ortaya koyabilmek amacýyla planlandý. Bu amaca yönelik olarak çivi belirtisinin görüldüðü bilinen hastalýk gruplarýndan 472 olgu çalýþma kapsamýna alýndý. Söz konusu olgularda kurutlar dikkatlice kaldýrýlarak çivi belirtisi arandý ve pozitif olgularýn özellikleri kayýt edildi. Çivi belirtisi olgularýn %10'unda pozitif saptandý. Bunlarýn %75'den fazlasýný kutanöz leishmaniasisin geç ülser evresindeki olgular oluþturmaktaydý. Çivi belirtisinin kutanöz leishmaniasis tanýsýndaki sensitivite ve negatif prediktif deðerleri düþük ama spesifite ve pozitif prediktif deðerleri yüksek bulundu. Çivi belirtisinin, nonspesifik bir bulgu olmasýna karþýn, endemik bölgelerde büyük bir olasýlýkla kutanöz leishmaniasisi iþaret eden önemli bir klinik bulgu olduðu sonucuna varýlmýþtýr.

Background: The 'tin-tack' sign (TTS) is the appearance of horny processes that project from the under-surface of a crust. Although it is a well-known feature of discoid lupus erythematosus it may be also seen in other crusted lesions particularly in cutaneous leishmaniasis (CL). Objective: The purpose of this study was to determine the value of TTS in the clinical diagnosis of CL. Materials and Methods: We studied 472 patients with diseases known to have the potential of producing 'tin-tack' crusts or scales. After detection of the crusted lesions, the presence of TTS was investigated in these lesions. Results: TTS was positive in approximately 10% of the study group. The positive TTS
was a frequent finding (over 75%) in the late ulcer stage of CL. The positive TTS was found to have a poor sensitivity and negative predictive value but a high specificity and positive predictive value in diagnosis of the patients with CL. Conclusion: Although it is not disease-specific, a positive TTS may be an indicative sign of CL with a high probability in the regions where CL is endemic.

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Kronik ürtikerin etyolojisi ve yapýlacak araþtýrmalar halen çok önemli bir problemdir. Büyük grubu oluþturan fizik ürtikerlerin ayýrt edilmesine yönelik uygun "challenge" testler ve fonksiyonel otoantikorlarýn tespitine dayalý otolog serum testi etyolojiyi aydýnlatabilecek yöntemlerdir. Buradan yola çýkarak kronik ürtiker tanýsý alan 88 olguya belli bir algoritmik yaklaþým dahilinde kan, idrar, gayta incelemeleri ve sýk görülen fizik ürtikerler için uygun "challenge" testler uygulandý. Olgularýn 73'ünde (%83,3) fizik ürtiker saptandý. En sýk kolinerjik ürtiker (29 olgu, %39,72) görüldü. Fizik ürtikerli olgularýn 27'sinde (%36,98) birden fazla fizik ürtiker mevcuttu. Tüm olgularýn 38'ine otolog serum testi uygulandý. Yirmidördünde (%63,15) test pozitif idi. Bu sonuçlar fizik uyaranlar ile otoimmun mekanizmanýn kronik ürtiker etyolojisindeki önemini ortaya koyarak, pahalý ve ayrýntýlý araþtýrmalarýn gereksizliðini gösterdi.

Background and Design: Chronic urticaria remains a major problem in terms of etiology and investigation. Physical stimuli and functional autoantibodies are main causes of chronic urticaria. Appropriate challenge tests to identify patient whom physical urticaria and autologous serum skin test to identify patients who have functional autoantibodies are most important tests to show the etiology of chronic urticaria. Materials and Methods: Basic blood, urine and stool examinations and appropriate challenge tests to determine physical urticaria had been performed in 88 patients with
chronic urticaria. The patients associated with angioedema were investigated for the level of C4. The patients who had cholinergic urticaria were examined for atopic dermatitis, allergic asthma, allergic rhinitis and investigated for the level of total IgE /specific IgE. The patients with cold urticaria evaluated for cryoglobulin, cold agglutinin and cryofibrinogen. Autolog serum skin test was performed in 35 patients with chronic urticaria. Results and Conclusion: Challenge tests to determine physical urticaria were positive in 73 (%83,3) of the 88 patients. Cholinergic urticaria was present in 29 (%39,72) of the 73 patients and was the most common of all the physical urticaria. Twenty- seven patients (%36,98) had physical urticaria types concurrently. Autologous serum skin test was positive in 24 (%63,15) of 35 patients with chronic urticaria. We suggest that
physical stimuli and autoimmune antibodies play the most important role in the etiopathogenesis of chronic urticaria.

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Kronik ürtikerin büyük çoðunluðunda altta yatan bir neden bulunamamaktadýr. Etyolojide %20-30 oranda fiziksel ürtikerlerin olduðu bilinirken; son zamanlarda yapýlan çalýþmalar bu oranýn %71-80'e kadar çýktýðýný göstermektedir. Kronik ürtikerin nedenini araþtýrmak hem çok zaman alýp, hem de maddi yük getirdiðinden, bu çalýþmada kolay uygulanabilen testlerle fiziksel ürtikerin ne oranda saptanabileceði araþtýrýldý. Çalýþmaya en az son dört hafta boyunca, her gün ürtiker lezyonlarý meydana gelen 53 hasta alýndý. Hastalara sýrasýyla dermografizm, basýnç ürtikeri, soðuk ürtikeri, sýcak ürtikeri, akuajenik ürtiker ve kolinerjik ürtiker için gerekli standartize testler uygulandý. 53 hastanýn 37'sinde(%69.8) en az bir fiziksel ürtiker bulundu, 28 hastada(%52.8) yalnýzca dermografizm, üç hastada(%5.7) basýnç ürtikeri, iki hastada(%3.8) kolinerjik ürtiker, iki hastada(%3.8) kolinerjik ürtiker ve dermografizm, bir hastada(%1.9) basýnç ürtikeri ve dermografizm,bir hastada(%1.9) ise kolinerjik ürtiker, sýcak ürtikeri, soðuk ürtikeri ve dermografizm birarada bulunmakta idi. Hiçbir hastamýzda akuajenik ürtiker saptanmadý Oldukça yüksek bir oranda (%70'e yakýn) saptadýðýmýz fiziksel ürtikerler, bizce kronik ürtiker etyolojisini araþtýrmada ilk basamak olmalýdýr.

Background and Design: The cause of chronic urticaria can not be determined in most cases. Though it is known that physical stimuli are mentioned etiologically in 20- 30 % of all urticarias, the recent studies have shown that this rate can increase up to 71-80 %. Since the studies to determine the cause of chronic urticaria requires too much time and costs a lot of money which may be exhausting. In this study, the rate of physical urticarias has been searched by easily applicable tests. Materials and Methods: 53 patients, who had urticaria lesions everyday in their bodies for at least last four weeks have been included to this study. The standardized tests for dermographism, pressure urticaria, cold urticaria, heat urticaria, cholinergic urticaria and aquagenic urticaria were applied to patients respectively. Results: At least one physical urticaria was found in 37 patients (69.8 %), dermographism in 28 patients (52.8 %), pressure urticaria in three patients (5.7 %),
cholinergic urticaria in two patients (3.8 %), cholinergic urticaria and dermographism in two patients (3.8 %), pressure urticaria and dermographism in one patient (1.9 %), cholinergic urticaria, heat urticaria, cold urticaria and dermographism in one patient (1.9 %) out of 53 patients with chronic urticaria were found. Aquagenic urticaria was determined in none of the patients. Conclusion: Physical urticarias, which are determined at a very high rate (70 % approximately) should be the first step of investigating the etiology of chronic urticaria according to us.

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Kronik idiyopatik ürtiker (KÝU) sýk rastlanan ve tedaviye dirençli patogenezi henüz tam anlaþýlamamýþ bir hastalýktýr. Son yýllarda konu ile ilgili yapýlan çalýþmalarda KÝU olgularýnýn üçte birinde patogenezde otoimmunitenin rol oynadýðý gösterilmiþtir. Bu çalýþmada KÝU patogenezinde HLA Sýnýf I ve Sýnýf II antijenleri ile iliþkisinin gösterilmesi amaçlandý. Çalýþmada KÝU tanýsý konulan 55 hastada HLA Sýnýf I (ABC) ve HLA Sýnýf II (DQ,DR) antijenleri, iki adýmlý mikrolenfositotoksisite testi ile araþtýrýldý. Saðlýklý ve akrabalýk iliþkisi olmayan 71 kiþi kontrol grubu olarak deðerlendirildi. HLA Sýnýf I antijenlerinin tamamýnda ve HLA Sýnýf II antijen grubunda DQ lokusunda iki grup arasýnda istatistiksel olarak anlamlý farklýlýk yokken, HLA-DR13 antijen sýklýðýnda hasta grubunda artýþ saptandý( p=0.03). HLA-DR13 antijen varlýðýnýn kronik idiyopatik ürtiker riskini arttýrabileceði ve patogenezde rol oynayabileceði düþünüldü.

Background and Design: Chronic idiopathic urticaria (CIU) is a common disease of which pathogenesis is unclear and resistant to therapy. Recent investigations have indicated that autoimmunity plays role in nearly one third of CIU patients. The present study aimed to investigate the relationship between HLA Class I and Class II antigens and immune pathogenesis of CIU.
Materials and Methods: HLA Class I and Class II antigens were investigated in 55 patients diagnosed as CIU, utilizing two stage microlymphocytotoxicity test. Seventy one healty and genetically unrelated individuals were evaluated as control group. Results: While significant differences were not found between patient and contro groups in all HLA Class I antigens and DQ locuses of Class II HLA antigens, HLA DR13 antigens were statistically high in patient group( p=0.03). Conclusion: We assume that the presence of antigens HLA DR13 could increase the incidence of CIU and play a role in its pathogenesis.

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Kronik idiyopatik ürtiker (KÝÜ), nedeni bilinemeyen, genç eriþkinlerde ve kadýnlarda daha sýk görülen, altý haftadan daha uzun süren ürtiker ataklarýyla karakterize bir hastalýktýr. KÝÜ tedavisi genellikle ortama salýnan histaminin etkilerinin blokajý temeline dayanýr ve bu nedenle tedavide ilk seçenek olarak birinci kuþak H1-antihistaminikler tercih edilir. Bu antihistaminiklerin etkisini deðerlendirmede sýklýkla epikutan histamin testi kullanýlmaktadýr. Çalýþmamýzda Uludað Üniversitesi Týp Fakültesi Dermatoloji polikliniðine 1999-2000 yýllarý arasýnda baþvurup KÝÜ tanýsý almýþ 15-74 yaþlarý arasýnda 44 kadýn, 16 erkek toplam 60 hastada günlük tek doz feksofenadin 180 mg. üç ay süreyle uygulandý. Tedavi öncesi ve sonrasý hastalarýn klinik belirtileri ve prick test sonuçlarý deðerlendirildi. Tedavi sonrasý yapýlan deðerlendirmelerde hem prick test sonuçlarý hem de klinik semptomlar yönünden anlamlý gerileme saptandý. Sonuç olarak; KÝÜ'de üç ay gibi uzun süreli antihistaminik tedavisi ile semptomlarda gerileme saðlanabileceði fakat bu uzun süreli antihistaminik kullanýmýnda ortaya çýkan histamin yanýtýndaki baskýlanmadan dolayý, epikutan histamin testi uygulanmasý gereken durumlarda en az 10 gün öncesinde ilaçlarýn kesilmesi gerektiði kanaatindeyiz.

Background and Design: Chronic idiopathic urticaria (CIU) is characterized by
urticaria attacks of longer than 6 weeks' duration with unknown etiology and is more
frequent in women and young adolescents. Since the basis of its' therapy depends
on the blockage of the effects of histamine sequestered, first generation H1 histamine
antagonists are preferred as the first option. Epicutaneous histamine test is often
used to evaluate the effects of these drugs.
Materials and Methods: In our study, a total of 60 patient (44 women, 16 men)
applied to Uluda University Medical Faculty, Dermatology Clinic between 1999-2000
years and diagnosed as CIU, aged between 15-74 years were given 180 mg/day
fexofenadine p.o. for three months. The clinical symptoms and prick test results were
evaluated before and after therapy.
Results: Significant regression in both clinical symptoms and prick test results were
detected after therapy.
Conclusion: We believe that long-term use of antihistamines as three months can
provide suppression in the symptoms and because of the suppression of histamine
response in this duration, it is necessary to stop these drugs at least 10 days before
the epicutaneous histamin test applications.

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Pemfigoid gestasyones (PG) büllöz pemfigoidin klinik ve histopatolojik özelliklerini gösteren bir gebelik dermatozudur. Eritemli-ürtikeryal zeminde grup oluþturmaya eðilimli, anüler ve sirsine dizilim gösteren vezikülobüllöz ve target benzeri lezyonlar ile karakterizedir. Tedavisinde prednizolon 40-60 mg/gün genellikle yeterli olduðu halde þiddetli olgularda immünosüpresifler, dapson ve plazmaferez de kullanýlabilmektedir. Bu raporda þiddetli klinik seyir gösteren ve sistemik kortikosteroide yanýt vermeyen, postpartum geliþmiþ þiddetli bir PG olgusunda plazmaferezin etkinliði deðerlendirilmiþ, bu yöntemin güvenilir ve etkili bir seçenek olabileceði vurgulanmýþtýr.

Pemphigoid gestationis (PG) is a pregnancy dermatosis which has clinical and histopathological characteristics of bullous pemphigoid. The lesions which occur during PG have a tendency to make annular, vesiculobullous groups on erythematous-urticarial bases. Although 40-60 mg/day prednisolone treatment is mostly enough to supress the new blister formation, in severe cases
immunosupressive drugs, dapsone and plasmapheresis are needed. In this report, the efficiency of plasmapharesis is evaluated in a case with postpartum PG who had severe clinical manifestations and did not respond to high dose systemic corticosteroid treatment. We stressed that plasmapheresis could be a safe and effective method as alternatively in the treatment of severe PG.

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Liken planus (LP) deri ve mukozalarý tutan kaþýntýlý ve inflamatuvar bir deri hastalýðýdýr. Koyu kýrmýzý-mor renkli, üzerleri ince kepekli ve köþeli papüllerle karakterize lezyonlarýn lineer daðýlým göstermesi oldukça nadirdir ve genellikle çocukluk çaðýnda görülür. Verrüköz (hipertrofik) LP ise papüllerin bir araya gelerek verrüköz plaklar oluþturmasýyla karakterize ayrý bir klinik LP tipidir. 48 yaþýnda bir erkek olguda sað alt ekstremitede önce hipertrofik karakterde baþlayan sonra lineer daðýlým gösteren LP'a rastlandý. Hastada ayný taraf lomber ve abdominal bölge derisinde zosteriform daðýlýmda yerleþim gösteren lezyonlar vardý. Olgunun mevcut kliniði ile az görülen morfolojik ve daðýlým tiplerini bir arada taþýdýðý, tedavilere de dirençli olduðu görüldü.

Lichen planus (LP) is an itchy, inflammatory skin disorder that involves skin and mucous membranes. Lesions characterized by reddish-violet color, thin scaly and angled papule are extremely rare in linear distribution and generally exhibit in childhood. Verrucous (hypertrophic) LP is a distinct type of LP characterized by verrucous plaques, which consists of papules. A 48-year-old male patient was diagnosed as lichen planus in his right lower extremity, which started initially in hypertrophic character and then showed linear distribution. He had also zosteriform-distributed lesions on the ipsilateral lumbar and the abdominal skin areas. It has been seen that the case was carrying both rare lesional morphology and distribution altogether and resisted to treatments.

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ýktiyozis linearis sirkumfleksa eritemli, çift-kenarlý skuamlý lezyonlarla karakterize nadir bir iktiyoziform dermatozdur. Netherton sendromu ise; genellikle iktiyozis linearis sirkumfleksa þeklinde kendini gösteren iktiyoziform dermatit, kýl gövdesinde çeþitli bozukluklar ve atopik diyatezden meydana gelen klasik bir triad olarak tanýmlanmýþtýr. Burada Netherton sendromlu bir olgu ve atopik diyatez bulgularýnýn eþlik ettiði iki iktiyozis linearis sirkumfleksa olgusu sunulmaktadýr. ýktiyozis linearis sirkumfleksaya atopi bulgularýnýn eþlik edebileceði ve Netherton sendromlu olgularýn saç bulgularýnda spontan düzelmeler olabileceði için, bu iki dermatozun ayný hastalýk spektrumun iki ucu olarak deðerlendirilebileceðini düþünüyoruz.

Ichthyosis linearis circumflexa is a rare ichthyosiform dermatosis characterized by erythmatous, double-edged scaling lesions. Netherton syndrome is defined as a classical triad composed of ichthyosiform dermatosis presenting mostly as ichthyosis linearis circumflexa, various hair shaft defects and atopic manifestations. We report 2 cases of ichthyosis linearis circumflexa associated with some atopic manifestations and 1 case of Netherton syndrome. Since atopic manifestations may be associated with ichthyosis linearis circumflexa and spontaneous remission may be observed in hair abnormalities in Netherton syndrome, we think that these two dermatoses might be regarded as two ends of the same disease spectrum.

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Fox-Fordyce hastalýðý nadir görülen, sporadik, apokrin ter bezi retansiyonu sonucu oluþan, kaþýntýlý, foliküler papüllerle karakterize bir dermatozdur. Patogenezindeki en önemli basamak apokrin ter bezi duktuslarýnýn týkanmasý ve rüptürüdür. Bu makalede, Fox-Fordyce tanýsý alan bir olgu sunulmuþ ve literatür ýþýðýnda klinikopatolojik özellikleri tartýþýlmýþtýr.

Fox-Fordyce disease is a rare and sporadic cutaneous disorder characterized by pruritic follicular papules as a result of apocrine sweat retention. The most important step in the pathogenesis of the disease is the keratinious obstruction and rupture of apocrine ducts. Herein we report a typical case of Fox-Fordyce disease and discuss the clinicopathological features of the disorder in view of the medical literature.

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Karsinoma erizipelatoides (KE), internal neoplazilerin deri metastazý ve metastatik hücrelerinin dermal lenfatikleri týkamasýyla oluþan erizipel benzeri tablodur. En sýk meme kanserine baðlý ortaya çýkmakla beraber gastrik malignite gibi diðer kanserlerle de iliþkili olabilir. Burada, sol pektoral bölgede eritemli, endüre plaklar þeklinde KE ortaya çýkan ve gastrik adenokarsinoma ile iliþkili olan 55 yaþýnda bir erkek olgu sunuyoruz. Hasta Türk Dermatoloji literatüründe bildirilen gastrik adenokarsinomla iliþkili ilk olgudur.

Carcinoma erysipelatoides (CE) is an erysipelas like condition resulting from cutaneous metastases and lymphatic dermal occlusion with metastatic cells of internal malignancies. Although, most commonly it occurs due to breast carcinoma, it may also be associated with other carcinomas such as gastric malignancy. Here, we present a 55-year-old male with CE, who has erythematous indurated plaques in the left pectoral area and associated with a gastric adenocarcinoma. This
is the first case of CE associated with gastric adenocarcinoma in the Turkish dermatological literature.

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Akut renal allogreft rejeksiyonunun önlenmesinde ve tedavisinde etkin bir ilaç olduðu anlaþýldýktan sonra, mikofenolat mofetil, son yýllarda dermatolojide de kullaným alaný bulmuþ güçlü bir immünsupresandýr. Dermatolojide kullanýmý 1975'de psoriasiste mikofenolik asitin etkinliðinin gösterilmesiyle baþlamýþ; daha sonraki yýllarda da büllöz hastalýklarda etkin ve güvenilir bir ilaç olarak tedavi alternatifleri arasýnda yer almaya baþlamýþtýr. Yapýlan çalýþmalar mikofenolat mofetilin diðer otoimmün ve inflamatuar deri hastalýklarýnda da alternatif bir tedavi olabileceðiyle ilgili görüþleri desteklemektedir.

Mycophenolate mofetil is a potent immunosupressor agent, found its place in the dermatological treatment in the recent years, after it was proved to be effective in the prevention and treatment of acute renal allograft rejection. It was first used in 1975 for the treatment of psoriasis, and then considered as an effective and safe treatment modality for autoimmune bullous diseases. Clinical studies support the opinion that mycophenolate mofetil can be an alternative treatment for a spectrum of autoimmune and inflammatory skin diseases.

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