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5/7*83’7’4 5)’83>=3 5"’803>=>7> 5’-13>=>7> 51*’3>=>7> 58783>=>7> 5/<14*83>=>4 5’3>=4 5)’83>=4 5)=’73>=4 5 ’=3>=4 5*13>=4 5"8’33>=4’7 ’5’7= -/3 ’5’7*4" ’5-’="’7’8 ’5D4=’"7/<8 ’5D4=’18 ’5’=’’7@*8 ’5’= 7*8/<=1 ’5’778 >=>8& ’571 3’ /">@ ’5-’?=D4"?8/<=1 ’5)/8"-’4 ’58’-78-7" ’57@@’ ’7 ’588’7 ’5= 817/ )D4 ’5’’17-18 ’5@ 8-= ’58’783>=>7> 0(3@8 171=1@ 1$5-’&’ 1$51*77’?7=> >8=0’7 -’=&3>7=> /<14’8)4 3= 71=1 7* & 17/=> ; 5"5-<=> 8=><> !"#$!#% & !"#$% ’ #( #!" # ’& #! " #$% ’ #$% )* #+ ’* #!, #! & #!" # * + * ! & ! # !!###!# !!!!" ’ " &- ,! +! * !"## &- * & ##### ! & +!" -* !,!"### & !"### & ! * #!" ** !#,! - # ! ) ",! # * , & ,!!## ! & $!#% & (". !" &- ,!"# & ,# ’ ,! ! ,!!"## ’ (!" ,! &* (" ( - ( -& ( " - ( & (" &- !" &- ! * !!" )* !#,!#$!#% !#,!#$% ! $ !#% & #,!# &- " -* !#!$% & ) " & " & " & !!!" ’ !+,"$% ) ! !!!"### )& !! , ** ##" !#, && !!" # !"### ’ !!" ( & !,!#,!"## ’ !!!" * !! ’ !!!!" ’* !"### ’ ,# -- "!! - !$!#% -* !/+ !# - !+!"### )& !!,# & -) ," - ( & !"!!"### )- !!,!!"## )* # & " &- !" * !! * ’ !!,! * !!"!" * !!,+ !#!$% - !!"### ’ !!" -* # ##!# ##!"## ###"# -) & !##!#,!# #!+" -* & (!"### ’ "!!!" 1 AKNE VULGARYS 2003 AKNE VULGARYS (beyaz nokta). ? Akne rozasea ? ? Perioral dermatit ? Follikülit ? Ykinci dönem sifiliz püstülleri Akne vulgaris, psikososyal sorunlara yol açmasy ve skar byrakabilmesi nedeniyle A. Lokal tedavi 1. Ylaçsyz tedavi BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I Akne vulgaris, kyl kökü ve ya? bezinin enflamatuvar bir hastaly?ydyr, 12-15 ya? arasynda %85 syklyktadyr. 25 ya? dolayynda kendili?inden sonlanmakla birlikte, özellikle kadynlarda 40 ya?a kadar süren ?iddetli bir seyir gösterebilir. Genetik yatkynlyk, stres, ya?ly kozmetik uygulamalar ve hiperandrojenizm ba?lyca risk faktörleridir. Tany Birincil yerle?im yeri yüzdür, syrt ve gö?üste de görülebilir. Enflamatuvar olan ve olmayan lezyonlardan olu?ur. Enflamatuvar olmayan lezyonlar, açyk komedon (siyah nokta) ve kapaly komedondur Enflamatuvar lezyonlar papül, püstül, kist ve nodüldür. En çok komedon, papül ve püstüllerle seyreder. Kistik ve nodüler lezyonlar skar byrakarak geriler. (Sayfa : 302) Tany öykü ve klinik bulgularla konur. Ayyrycy Tany Ylaç akneleri (kortikosteroidler, halojenler, antitüberküloz ilaçlar, lityum) Tedavi mutlaka tedavi edilmelidir. Hastaya, tedavinin uzun süreli olaca?y ve beklenen etkinin en erken 1-2 aydan sonra ba?layaca?y açyklanmalydyr. Tedavi seçiminde lezyonlaryn ?iddeti, yaygynly?y, hastanyn ya?y önemlidir. Tedavide ilk basamaktyr, hafif ve orta dereceli aknede uygulanyr. Hafif (yalnyzca komedon bulunan) aknede tek olarak yeterlidir. TANI VE TEDAVY REHBERY BYRYNCY BASAMA?A YÖNELYK ? ? ? 2. Ylaçly tedavi ? %2?lik salisilik asit krem, jel (0,25-1 mg/gün), morötesi y?yn duyarly?y nedeniyle yalnyzca ak?amlary, adapalen ? Antibakteriyel ilaçlar Enflamatuvar aknede; - Klindamisin - Eritromisin (%3) ve benzoil peroksit - Eritromisin ? Komedolitik ve antibakteriyeller - Benzoil peroksit (%2,5-10): (%20 krem): tetrasiklin , ikinci seçenek 2 2003 Komedonlu aknede ilk seçenek Temizleyiciler, sabunlar, tercihen antibakteriyel ve pH'sy ayarly olanlar, günde 2-3 kez kullanylmalydyr. Kozmetik uygulamalardan kaçynylmalydyr. Lezyonlar sykylmamaly ve koparylmamalydyr. Orta dereceli aknede, ilaçsyz tedaviye ek olarak keratolitikler ve antibakteriyel ilaçlar uygulanyr. Komedolitikler, Keratolitikler Tretinoin jel (%1) günde iki kez kullanylyr. Topikal preparatlaryn mukoza ve bütünlü?ü bozulmu? deriyle temasy ve kyvrym yerlerinde birikiminden kaçynylmalydyr. (%1) losyon günde iki kez kullanylyr. (%2-4) jel günde iki kez kullanylyr. Günde bir kez, tercihen ak?am uygulanyr. Tedaviye dü?ük konsantrasyonlu preparatla ba?lanyr. Yki ay içinde yanyt alynamazsa, topikal antibiyotik kullanymy uygundur. En önemli yan etki olan lokal deri irritasyonu doz azaltymyyla hafifletilir. - Azelaik asit Özellikle postenflamatuvar hiperpigmentasyon geli?enlerde seçilir. Günde iki kez kullanylyr. Gebelik ve emzirme döneminde dikkatli kullanym gerekir. Gözle temas ettirilmemelidir. En önemli yan etki olan lokal irritasyon, uygulama sykly?y azaltylarak veya tedaviye ara verilerek önlenebilir. Seyrek olarak y?y?a duyarlylyk gözlenir. B. Sistemik Tedavi ?iddetli enflamatuvar aknede öncelikle antibiyotik kullanymy gerekir. Ylk seçenek - Tetrasiklin: Günde iki kez 500 mg kullanylyr. 4-6 hafta sonra doz a?amaly olarak azaltylyr ve tedavi günlük 250 mg dozla 8-12 ay sürdürülür. Ylk 3 ayda düzelme olmazsa antibiyotik de?i?tirilir. ve emziren kadynlar, böbrek ve karaci?er hastalary ve y?yk duyarly?y olanlarda kullanylmamalydyr. Süt, antiasit, kalsiyum, demir, magnezyum tuzlary emilimi azaltyr. T .C. SA?LIK BAKANLI?I tretinoin , ikinci seçenek adapalen dir. Bu ilaçlar (jel, losyon) ile kombine edilebilir. (%5) birlikte günde iki kez kullanylyr. doksisiklin dir. Tetrasiklin ve türevleri 8 ya?yn altyndaki çocuklar, gebeler AKNE VULGARYS ___________________________________ lokal irritasyon, gastrointestinal yakynma, ilaç reaksiyonlary geli?ti?inde hekime Akne fulminans (ate?, artralji, genel durum bozuklu?u gibi sistemik bulgularla 3 2003 Günde 2 kez 100 mg 4-6 hafta, sonra günde 100 mg 8-12 ay süreyle kullanylyr. Ylk üç ay ayda 1, sonra üç aylyk aralarla en az bir yyl izlem gerekir. Tedavi syrasynda Odom RB, James WD, Berger TG. Acne. Disases of the Skin. Philadelphia: Saunders. 2000: 284-306. Braun -Falco O, Plewig G, Wolff HH. Diseases of the Sebaceous Glands. Dermatology. Heidelberg: Strauss JS, Thiboutot DM. Diseases of the Sebaceous Glands. Freedberg IM, Eisen AZ, Wolff K, ed. Cunliffe WJ, Simpson NB. Disorders of the Sebaceous Glands. Champion RH, Burton JI, Burns DA, T ANI VE TEDA VY REHBERY T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK - Doksisiklin: Tedavi syrasynda y?y?a duyarlyk gözlenebilir. Yzlem ba?vurulmasy önerilmelidir. Sevk ? ?iddetli nodülokistik akne ? seyreden, syklykla genç erkeklerde görülen a?yr akne) ? Tedaviye yanytsyzlyk * ? Yleri ya?a kadar süren akne * ? Yirmi be? ya?yn üstünde (geç) ba?layan akne * ? Hir?utizmin e?lik etti?i akne * durumlarynda hasta sevk edilmelidir. * Hiperandrojenizm olasyly?y söz konusudur. Kaynaklar 1. 2. Springer. 2000: 1051-82. 3. Dermatology in General Medicine. New York: McGraw-Hill. 1999: 769-84. 4. ed. Textbook of Dermatology. London: Blackwell Science. 1998: 1927 - 84. AKNE VULGARYS 4 2003 T.C. SA?LIK BAKANLI?I Risk Faktörleri ? Sycak ve nemli ortam ? Hamam, sauna, plaj ve havuz gibi ortak kullanym alanlary ? ve i?çilerde) ? Sentetik çama?yr kullanymy ? Ymmün sistemi baskylayycy durumlar Klinik görünüm ve kepeklerden alynan kazynty ve bir pens ile çekilen kyl örne?ine Nativ preparat , alynan örne?e %10-20?lik KOH damlatylarak Favus, seboreik dermatit, sifiliz 2. dönem lezyonlary, alopesi areata, psöriyazis, trikotillomani. 5 2003 Mantar enfeksiyonlary önemli bir toplumsal sa?lyk sorunudur; dermatoloji birimlerine ba?vurularyn %10?unu olu?turur. Yüzeyel mantar enfeksiyonlary deri, mukoza, kyl ve tyrnakta görülür. Yüzeyel mantar enfeksiyonlary syklyk syrasyna göre, dermatofit enfeksiyonlary (dermotofitozlar), pitriyazis versikolor ve kandidiyazdyr. Kapaly ve havalanmasy iyi olmayan ayakkaby kullanymy (örne?in; asker, mahkum DERMATOFYT ENFEKSYYONLARI TYNEA KAPYTYS (SAÇKIRAN) Saçly derinin mantar enfeksiyonudur, genellikle 3-5 ya? grubu çocuklarda görülür. Pubertede spontan iyile?ir. Kyryk ve cansyz kyllar, ince kepeklenme, lokal alopesi temel bulgularydyr. Bu bulgulara iltihabi de?i?iklikler eklenirse tümör benzeri püstüler, nodüler lezyonlar (kerion celsi) ortaya çykar ve kalycy alopesi ile sonuçlanyr. (Sayfa 304-305) Tany nativ preparat yapylyr. yapylan mikroskobik incelemedir. Tany, nativ preparatta hif ve sporlaryn görülmesiyle konur. Ayyrycy tany Tedavi Sistemik antifungal ilaçlar 4-6 hafta süreyle kullanylyr. DERYNYN YÜZEYEL MANTAR ENFEKSYYONLARI BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I DERYNYN YÜZEYEL MANTAR ENFEKSYYONLARI Ketokonazol Lokal antifungal ilaçlar: prednizolon yan taraflarynda yerle?im gösteren vezikülobülloz, sulantyly, masere, skuamly de?i?ken Klinik belirtiler bazen ellerde de görülebilir (tinea manum). Psöriyazis, kontakt dermatit, hiperhidrozis, sifiliz 2. dönem lezyonlary. 6 2003 Griseofulvin Itrakonazol Ketokonazol 3-5 T .C. SA?LIK BAKANLI?I Terbinafin ilk 2 ya?taki çocuklarda sistemik olarak kullanylmamalydyr. ciddi hepatotoksik etkileri nedeniyle synyrly ve zorunlu durumlarda kullanylmalydyr. Karaci?er fonksiyon testleri ayda 1 kez kontrol edilmelidir. Günde 2 kez 4-6 hafta kullanylyr. Kerion celsi olu?mu?sa ek olarak kysa süreli (7-10 gün) 1 mg/kg/gün verilebilir ve lezyon üstündeki kyllaryn cymbyzla temizlenmesi önerilir FAVUS Saçly derinin mantar enfeksiyonudur. Daha çok çocuklarda görülür. Tedavi edilmezse ya?am boyu sürer. Temel bulgular; çanak biçimi sary-ye?il krut (skutula, godet) atrofik skatris, cylyz gri-beyaz normal uzunlukta saçlar ve kötü kokudur. Tany, ayyrycy tany ve tedavi Tinea kapitis ile aynydyr. (Sayfa : 305/1) TYNEA PEDYS En syk yüzeyel mantar enfeksiyonu olup ayaklarda görülür. Erkeklerde daha syk, çocuklarda seyrektir. En syk ayak parmaklary arasynda, ayryca ayak tabany, ayak klinik bulgularla görülebilir. Tany Klinik görünüm ve nativ preparatla konur. (Sayfa : 306) Ayyrycy tany Tedavi Bölgenin kuru tutulmasy en önemli faktördür. Lokal antifungal ilaçlar, 4-6 hafta süreyle günde 2 kez kullanylyr. 10-20 mg/kg/gün Terbinafin BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY Çocuklarda Yeti?kinlerde 500 mg/gün ? 250 mg/gün ? 100 mg/gün mg/kg/gün 200 mg/gün DERYNYN YÜZEYEL MANTAR ENFEKSYYONLARI Bifanozol, izokonazol, klotrimazol, ketokonazol, mikonazol, naftifin, oksikonazol, Saçly deri, el-ayak, tyrnak ve kasyk dy?yndaki bölgelerde yerle?en yüzeyel mantar sary?kahverengi renk de?i?ikli?i, subungual hiperkeratoz, tyrnakta kolay kyrylma temel 7 2003 sulkonazol, sikloproksolamin, terbinafin, tiokonazol, tolnaftat, undesenoatlar. Dirençli olgularda lokal antifungallere sistemik tedavi de eklenebilir. hastaly?ydyr. Her ya?ta görülebilir. Çevreye do?ru geni?leyen, ortadan iyile?en, keskin Tyrnakta yerle?en mantar hastaly?ydyr. Sykly?y, kronikle?mesi ve tedavinin zorlu?u Onikomikoz tüm tyrnak hastalyklarynyn %20?sini olu?turur. Genel olarak eri?kinlerde görülür. 40-60 ya? arasynda toplumda sykly?y %15-20?dir. En syk ayak tyrnaklaryndan özellikle birinci tyrnaktan ba?lar. Genellikle tinea pedis ertesinde geli?ir. Tyrnakta Tedaviye en dirençli yüzeyel mantar hastaly?ydyr. Sistemik antifungaller 3?12 ay T ANI VE TEDA VY REHBERY T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK Lokal antifungaller: Sistemik tedavi tinea kapitis tedavisi ile aynydyr. TYNEA KORPORYS synyrly, eritemli-skuamly lezyonlarla karakterizedir. Tany Klinik görünüm ve nativ preparat ile konur. (Sayfa : 303) Ayyrycy tany Ekzema, psöriyazis, pitriyazis rozesea, sifiliz 2. dönem lezyonlary. Tedavi Lokal antifungal ilaçlar 3-4 hafta, günde 2 kez kullanylyr. ONYKOMYKOZ nedeniyle özel bir öneme sahiptir. belirtilerdir. Tyrnak çevresi normaldir. Tany Klinik görünüm ve nativ preparat ile konur. Ayyrycy Tany Psöriyazis, liken planus, egzamalar, kandidiyaz Tedavi kullanylyr. Hastalykly tyrnaklaryn törpülenmesi tedavi etkinli?ini arttyryr. DERYNYN YÜZEYEL MANTAR ENFEKSYYONLARI M. furfur Gövde, boyun, ekstremitelerin üst kysymlarynda sütlü kahverengi, düzensiz ve 2. dönem, vitiligo, tüberküloid lepra. Selenyum sülfit, çinko pirition veya ketokonazol içeren ?ampuanlar bir ay süreyle haftada iki kez en az veya ketokonazol içeren krem veya losyonlar 2 hafta süreyle günde 2 kez, terbinafin %1?lik krem veya solüsyon Kandidiyaz rehberine bakynyz. (Sayfa 15) ? Geni? alan ve kylly bölgelerdeki uygulama için genellikle losyon ya da spreyler ? ? ? 8 2003 250 mg/gün Ytrakonazol 2x200 mg/gün Ylk 7 gün / ay Flukonazol 150 mg/hafta T .C. SA?LIK BAKANLI?I PYTRYYAZYS VERSYKOLOR ?un neden oldu?u, syk görülen yüzeyel bir mantar hastaly?ydyr. Çocuklukta seyrektir. Nemli ve sycak iklimlerde görülme sykly?y %40?a çykabilir. keskin synyrly, üzeri ince skuamly maküller ?eklindedir. Güne?le kar?yla?ma sonucu lezyonlar hipopigmente de görülebilir. Tany Klinik görünüm ve nativ preparat ile konur. Ayyrycy tany Tinea korporis, seboreik dermatit, psöriyazis, pitriyazis rozasea, hipopigmente formda sifiliz Tedavi güna?yry lezyonlu vücut bölgesine uygulanyp 5 dakika bekletilerek yykanyr. Ertesinde üç ay süreyle kullanylyr. Topikal imidazol günde iki kez 7 gün süreyle kullanylyr. KANDYDYYAZ Mantar Hastalyklarynda Tedavi Ylkeleri seçilir. Merhemler, örtücü özelliklerinden dolayy nemli yüzeylerde kullanylmamalydyr. Tyrnak cilalary formundaki antimikotik preparatlar, tyrnaklarda mantara ba?ly erken distrofide etkili olabilir ve en çok iki tyrnak birden etkilendi?inde kullanylmalydyr. Mantar enfeksiyonlarynyn tedavisinde, tuvalet ve kozmetik amaçlar dy?ynda pudralaryn yeri ve tedavi edici etkisi yoktur ve deride irritasyona neden olabilir. Terbinafin BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY el tyrna?ynda 6 hafta ayak tyrna?ynda 12 hafta el tyrna?ynda 2 ay ayak tyrna?ynda 3 ay el tyrna?ynda 9 ay ayak tyrna?ynda 12 ay DERYNYN YÜZEYEL MANTAR ENFEKSYYONLARI Havlu, ?apka, tarak, fyrça, ayakkaby, terlik, çorap, giysi gibi ki?isel e?yalaryn ortak Karaci?er bozuklu?u, böbrek bozuklu?u, gebelik, emzirme dönemi ve diabetes GS. Superficial Fungal Diseases with Cutaneous Involvement. Freedberg Im, 9 2003 kullanymyndan kaçynma önemlidir. Mantar enfeksiyonu olu?um ve bula?masyny kolayla?tyrycy mellitus varly?ynda sistemik tedavinin uzman denetiminde yapylmasy önerilir. Tedaviye dirençli onikomikozda ve cerrahi tedavi gerektiren durumlarda hasta sevk edilmelidir. Odom RB, James W.D. Berger TG. Diseases Resulting from Fungi and Yeast. Diseases of The Skin. Braun-Falco O, Plewig G, Wolff HH. Fungal Disease. In: Dermatalogy. Heidelberg: Springer: Martin AG, Kobayashi Eisen AZ, Wolff K, ed. Dermatology in General Medicine. New York: McGraw-Hill. p. 2337-88, 1999. Hay RJ, Moore M. Mycology. Champion RH, Burton JI, Burns DA, ed. Textbook of Dermatology. T ANI VE TEDA VY REHBERY T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK Korunma nedenler hastaya anlatylmalydyr. Sevk Kaynaklar 1. Philadelphia: Saunders; 2000: 358-416, 2. 2000: 313-81, 3. 4. London: Blackwell Science: 1998: 1277-1376, DERYNYN YÜZEYEL MANTAR ENFEKSYYONLARI 10 2003 T.C. SA?LIK BAKANLI?I En syk görülen iki tipi vardyr: ? Atopik dermatit ? Kontakt dermatit Nedenleri ? ? ? Mikrobiyal etkenler (bakteri ve virüsler) ? Erken ba?lama ya?y ? Ailesel atopi öyküsü ? Ka?ynty, yaygyn deri kurulu?u ? Lezyonlaryn tipik da?ylymy - Bebeklerde yüz, ekstremitelerin dy? kysymlary ve boyun - Çocuk ve eri?kinlerde kyvrym bölgeleri, özellikle antekübital ve popliteal bölgeler ? Kronik olarak tekrarlayan dermatit tablosu ? Seboreik dermatit ? Kontakt dermatit ? Psöriyazis 11 2003 Egzema/dermatit, bedensel veya dy? nedenlerle deride ortaya çykan enflamatuvar bir yanyttyr. Akut tipinde deride ka?yntyly, eritemli, veziküllü, sulantyly lezyonlarla karakterizedir. Kronikle?ti?inde ka?ynty, kuruluk, hiperkeratoz ve fissürler görülür. Bu lezyonlaryn bir kysmy veya hepsi bir arada olabilir. ATOP?K DERMATYT Aile öyküsünde deri ve/veya solunum yolu alerjisi bulunabilen egzema türüdür. Besinler* (yumurta, süt, çerezler, soya, balyk ve bu?day) Ynhalanlar (akarlar, polenler, küf ve mantar sporlary) * Etiyolojideki rolü kanytlanmadykça besinler yasaklanmamalydyr. Tany Öykü ve klinik bulgularla konur. Ayyrycy tany EGZEMA / DERMATYT BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I EGZEMA / DERMATYT ? Çocuklarda bazy immün yetmezlik hastalyklary ? Yüzeyel mantar enfeksiyonlary Ylaçsyz tedavi ? Ylaçly tedavi ? - Bebeklerde az güçlü (hidrokortizon %0,5) pomad veya kremler Günde 1-2 kez, ince bir tabaka halinde, lezyonlar geçene kadar veya en %0,05, hidrokortizon butirat Yüz, kyvrym bölgeleri ve çocuklarda altbezi alanynda az güçlü topikal ? Oral antihistaminik Hidroksizin: Çocukta ? mupirosin veya sodyum fusidat 12 2003 Güç Az %1?lik hidrokortizon Orta %0,05?lik klobetazon butirat Güçlü %0,1?lik betametazon ve hidrokortizon butirat Çok güçlü %0,05?lik klobetazol propiyonat - - T .C. SA?LIK BAKANLI?I Tedavi Temel amaç ka?ynty ve ka?yntyyy tetikleyen ya da neden olabilen faktörlerin azaltylmasydyr. Bu nedenle, öncelikle bazy genel önlemler alynmalydyr. Ya?anan ortam kuru olmamaly ve ysysy sabit tutulmalydyr. Banyo suyu ylyk olmalydyr. Giysiler pamuklu, tyrnaklar kysa olmalydyr. Akut ataklarda çocukluk ça?y a?ylary uygulanmamalydyr. Nemlendiriciler: Syvy vazelin veya uygun nemlendiriciler banyodan sonra ilk 3 dakika içinde uygulanmaly ve gün içinde deri kurudukça tekrarlanmalydyr. Topikal kortikosteroid Topikal kortikosteroidler güçlerine göre tercih edilebilir. kullanylyr. çok 2 hafta kullanylyr. Daha uzun süre kullanmak gerekiyorsa, en az 1 hafta ara verilir ve bu dönemde nemlendiricilerle tedavi sürdürülür. Daha büyük çocuklar ve eri?kinlerde orta güçlü topikal kortikosteroid tercih edilir. Yanyt alynamazsa veya kalyn plakly lezyonlaryn oldu?u durumlarda çok güçlü veya güçlü %0,01) topikal kortikosteroidler gerekebilir. kortikosteroidler seçilmelidir. Bakteri veya mantar enfeksiyonlarynyn varly?ynda topikal kortikosteroid kullanylmamalydyr. Yeti?kinde : Oral antihistaminik kullanymyna ka?ynty kontrol altyna alynana dek devam edilir. Topikal antibiyotik Akut sulantyly lezyonlar üzerinde sary, bal rengi kurutlar görüldü?ünde içeren pomadlar 7-10 gün süre ile günde iki kez uygulanyr. BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY Örnek (klobetazon butirat %0,05) (klobetazol propiyonat 25 mg/doz 3-4 kez tekrarlanabilir. : 2 mg/kg/gün 3-4 dozda (en çok 120 mg/gün) EGZEMA / DERMATYT Akut sulantyly lezyonlarda güçlü kortikosteridli (klobetazol propiyonat) kremler 13 2003 Atopik dermatit kronik ve tekrarlayan ataklarla süren bir hastalyktyr. Ataklar Tedaviye dirençli kronik atopik dermatitli hastalar sevk edilmelidir. Deriye temas eden maddelerle olu?an egzema türüdür. Etkenler çevre ko?ullary, meslek ve ki?isel faktörlere göre farklylyk gösterir. Syklykla sabun, deterjan ve çe?itli kimyasal maddeler (metaller, boyalar, bitkiler, topikal ilaçlar) neden olur. Genellikle irritan ve alerjik olmak üzere iki farkly mekanizma ile olu?ur. Etkenin deriye temas etti?i bölgelerde ?iddetli ka?ynty, eritem, vezikül, sulanty Kronik olgularda deri sert, fissürlü, ka?yntyly ve kurutlu bir görünüm alyr. Temel amaç alerjenle temasy önlemektir. Bu da, alerjenden uzakla?mak veya koruyucu malzeme (eldiven, koruyucu giysi gibi) kullanmak ile mümkündür. tercih edilmeli ve semptomlar düzelene kadar ya da en çok 2 hafta devam edilmelidir. Sulu lezyonlarda ilacyn krem formu, kuru lezyonlarda pomad formu kullanylmalydyr. Tedaviye dirençli yaygyn lezyonlary olan hastalar nedene yönelik ara?tyrma için T ANI VE TEDA VY REHBERY T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK Yzlem syrasynda uygun tedavi önerileri ile izlenmelidir. Sevk ? Önerilen tedavilerle kontrol altyna alynamayan ? Yaygyn egzematöz bulgulary olan ? KONTAKT DERMATYT Tany ? ve kurutlu lezyonlar. ? Öykü ve klinik bulgularla konur. Ayyrycy tany ? Atopik dermatit ? Seboreik dermatit ? Psöriyazis ? Herpes simpleks enfeksiyonu ? Yüzeyel mantar enfeksiyonlary Tedavi Topikal kortikosteroidler: Sevk sevk edilmelidir. EGZEMA / DERMATYT Kaynaklar 2. 3. 457-64. 4. 5. Saunders. 2000; 95-123. 6. Saunders. 2000; 69-76. 7. 2001;44:13-6. 14 2003 T .C. SA?LIK BAKANLI?I 1. Belsito DV. Allergic Contact Dermatitis. Freedberg IM, Eisen AZ, Wo Medicine. New York: McGraw Hill. 1999;1447-61. Kayaalp S O, ed, BNF/TYK Türkiye Ylaç Kylavuzu, Ystanbul: Turgut Yayyncylyk, 2001 Braun FO, Plewig G, Burgdorf WHC. ed. Dermatology. Berlin: Springer-Verlog. 2nd ed. 2000; Leung DYM, Tharp M, Boguniewicz M. Atopic Dermatitis: Freedberg IM, Eisen AZ, Woff K, ed. Dermatology in General Medicine. New York: McGraw Hill. 1999;1464-80. Odom RB, James WD, Berger TG. Contact Dermatitis: Disease of The Skin. 9th ed. Philadelphia: Odom RB, James WD, Berger TG. Atopic Dermatitis: Disease of The Skin. 9th ed. Philadelphia: Tofte SJ, Hanifin JM. Current Management and Therapy of Atopic Dermatitis. J Am Acad Dermatol BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY ff K, ed. Dermatology in General EGZEMA / DERMATYT Mukokutanöz kandidiyaz, patojen kandidalaryn, en syk olarak Candida albicans ?yn antibiyotik ve immün baskylayycy ilaç kullanymy, diabetes mellitus, a?yry su ve sabun Deri ve tyrnak kandidiyazy ? Erezyo interdigitalis blastomiçetika: ? Yntertrigo: ? Tyrnak kandidiyazy: Paroni?i Oni?i ? Perianal kandidiyaz: Mukoza kandidiyazy ? Perle?: Dudak kö?elerinde, mukoza ile deri birle?im yerlerinde a?ry ve yanma ile birlikte ? Pamukçuk: ? Kronik glossit: ? 15 deri ve mukozalarda olu?turdu?u enfeksiyondur. Kötü hijyen ko?ullary, uzun süreli temasy risk faktörleridir. Syk görülür. El ve ayak parmaklary arasynda kyzaryk plaklar ?eklinde beliren bir enfeksiyondur. Plaklaryn üzerinde beyaz kabuklar olu?ur, deri sulantylydyr. Koltuk alty, meme alty, göbek ve kasyklarda keskin synyrly, eritemli, skuamly eksüdatif lezyonlarla karakterizedir. tyrnak çevresinin a?ryly, kyzartyly ?i?li?i ile karakterizedir. Cerahatsizdir. de tyrnak sertle?ir, kalynla?yr, rengi de?i?ir, esmerle?ir. Psödomonas eklenirse tyrnakta ye?il renk olu?ur. Anüs çevresinde beyaz, masere ve ka?yntyly lezyonlarla karakterizedir. sulantyly, eritemli lezyonlardyr. En syk kar?yla?ylan kandidiyaz tipidir. Genellikle zayyf, hastalykly, bakymsyz süt çocuklarynda görülür. A?yz içinde, dil üstünde beyaz ve gri küçük plaklar olu?ur. Ya?lylar ve sindirim sistemi bozuk ki?ilerde geli?ir. Dil papillalary atrofiye olur ve dilde derin çatlaklar olu?ur. Dilde a?ry ve yanma vardyr. Dil üzerinde gri renkte zarymsy plaklar bulunabilir. Vajinal kandidiyaz: Gebeler ve diyabetlilerde syk görülür. Vajen mukozasynda kyzaryklyk, ?i?lik ve yer yer yapy?yk beyaz plaklar vardyr. Hastada "süt kesi?i" tarzynda vajinal akynty, a?ry ve ka?ynty olur. (Tedavi için sayfa 187) KANDYDYYAZ BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY MAYIS 2003 T.C. SA?LIK BAKANLI?I KANDYDYYAZ ? Kyvrym bölgesi lezyonlarynda; psöriyazis, seboreik dermatit, kontakt dermatit, atopik dermatit. ? Tyrnak tutulumunda; psöriyazis, liken planus, onikomikoz, travma. ? Perianal ve vajinal mukoza tutulumunda; kontakt dermatit, liken skleroatrofikus ? Oral mukoza lezyonlarynda; liken planus, sifiliz 2. dönem mukoza lezyonlary, aft, Oral enfeksiyonlar: Sodyum bikarbonat solüsyonu lavajlary ve/veya viole de gentione %1?lik çözeltisi ile atu?manlar yapylyr veya Nistatin süspansiyon (1 ml = 20 damla = 100.000 ünite) toplam 400.000-600.000 Tyrnak tutulumu nda (9-12 ay) ve 16 2003 Flukonazol : Itrakonazol : Ketokonazol* : *Ketakonazol Korunma Havlu, ?apka, tarak, fyrça, ayakkaby, terlik, çorap, giysi gibi ki?isel e?yalaryn ortak Sevk Karaci?er bozuklu?u, böbrek bozuklu?u, gebelik ve laktasyonda, diabetes mellitusta ve immün baskylanmy? hastalarda sistemik tedavinin uzman kontrolünde yapylmasy T .C. SA?LIK BAKANLI?I Tany Klinik görünüm ve nativ preparatla konur. KOH damlatylarak yapylan mikroskobik incelemedir. Blastospor ve yalancy hif yapan maya hücreleri görülür. Ayyrycy Tany Behçet Hastaly?y, herpes simpleks, enfeksiyonu dü?ünülmelidir. Tedavi ünite/gün, günde 4 kez 2 hafta uygulanyr. tedavi uygulanyr. ciddi hepototoksik etkilerinden dolayy synyrly ve zorunlu durumlarda kullanylmalydyr. Karaci?er fonksiyon testleri ayda 1 kez kontrol edilmelidir. kullanymyndan kaçynma önemlidir. Mantar enfeksiyonu olu?um ve bula?ymyny kolayla?tyrycy nedenler hastaya anlatylmalydyr. önerilir. BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY Nativ preparat, alynan örne?e %10-20?lik deri lezyonlary nda (2-3 hafta) topikal ve sistemik Yeti?kinlerde Çocuklarda 150 mg/hafta ? veya 50 mg/gün 1-2 mg/kg/gün 100-200 mg/gün ? 200 mg/gün 3-5 mg/kg/gün KANDYDYYAZ 17 2003 T ANI VE TEDA VY REHBERY Odom RB, James WD, Berger TG. Diseases Resulting from Fungi and Yeast.: Diseases of The Skin. HH. Fungal Disease.: Dermatology. Heidelberg: Springer. p. 2000:313- Martin AG. Kobayashi GS. Superficial Fungal Diseases with Cutaneous Involvement.: Freedberg IM, Eisen AZ , Wolff K, ed. Dermatology in General Medicine. New York: McGraw-Hill. 1999:2337-88, Hay RJ. Moore M , Mycology.: Champion RH. Burton JI. Burns DA, eds. Textbook of Dermatology. Kayaalp S O, ed, BNF/TYK, Türkiye Ylaç Kylavuzu, Ystanbul: Turgut Yayyncylyk 2001. s.356. T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK Kaynaklar 1. Philadelphia:Saunders. 2000:358-416. 2. Braun-Falco O, Plewig G, Wolff 80. 3. 4. London: Blackwell Science. 1998:1277-376 5. KANDYDYYAZ 18 2003 T.C. SA?LIK BAKANLI?I Larinks ödeminin e?lik etti?i akut ürtiker ve anjiyoödem ya?amy tehdit edebilen Ürtiker nedenleri: ? türevleri, radyokontrast maddeler ve ba?ka ilaçlar) ? Besinler (çikolata, süt, yer fysty?y, çilek, domates, yiyecek katky maddeleri, deniz ürünleri) ? Enfeksiyonlar (bakteriyel, viral), parazitik enfestasyonlar ? Fiziksel uyaranlar (sycak, so?uk, egzersiz, basynç, su, dermografizm) ? Emosyonel stres ? ? ? ? ? ? ? ? 19 2003 Ürtiker; ani ba?layan, derinin ka?yntyly, eritemli, ödemli, de?i?ik biçim ve büyüklüklerde papül ve plaklarla özelliklenen, yüzeyel, geçici damarsal bir reaksiyonudur. Deri alty doku ve mukozalary tutan ?ekline anjiyoödem ady verilir. durumlardyr. Lezyonlar 6 haftadan kysa sürerse akut, uzun sürerse kronik ürtiker söz konusudur. Ylaçlar (aspirin, steroid olmayan anti-enflamatuvar ilaçlar, kodein, penisilin ve Tany Öykü ve klinik özelliklere dayanyr. Lezyonlar vücudun herhangi bir yerinde veya yaygyn olabilir. Lezyonlar ka?yntyly, yer de?i?tiren, basmakla solan, eritemli, ödemli plaklardyr. Bir lezyon ayny yerde 2-24 saat kalyr. Anjiyoödem tanysy yüz, göz çevresi, dudaklar ve dilde ?i?lik varly?y ile konur. Bazen larinks ödemi ve solunum sykyntysy e?lik edebilir. (Sayfa : 307) Ayyrycy Tany Böcek sokmasy reaksiyonu: Lezyon ortasynda nokta ?eklinde ysyryk yeri bulunur. Viral döküntü: E?lik eden ba?ka bulgular vardyr. Eritema multiforme minör: Tipik hedef lezyonlar bulunur. Ürtikeryal vaskülit: Lezyonlar basmakla solmaz ve 24 saatten uzun sürer. ÜRTYKER BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I ÜRTYKER Genel önlemler ? kesilmesi veya de?i?tirilmesi ? Sycak, stres, alkol ve ilaç gibi artyrycy nedenlerden sakynylmasy 20 Lezyonlar çok yaygyn de?ilse veya anjiyoödem yoksa Ylk seçilecek ilaç oral antihistaminikler ? Difenhidramin hidroklorür: Çocuk: 5 mg/kg/gün, 3-4 dozda (en çok 300 mg/gün) ? Hidroksizin: Çocuk: 2-4 mg/kg/gün, 3-4 dozda ? Klemastin: Çocuk: 1-3 ya?; 250-500 µg x 2/gün 3-6 ya?: 500 µg x 2/gün 6-12 ya?: 0,5-1 mg/gün ? Setirizin: 2-6 ya?: 5 mg/gün tek doz. 6 ya? üstü ve eri?kin: 10 mg/gün, tek doz ? Loratadin: 2-6 ya?: 5 mg/gün tek doz. 6 ya? üstü ve eri?kin: 10 mg/gün, tek doz Lezyonlar çok yaygynsa veya anjiyoödem belirginse Parenteral antihistaminikler kullanylyr . ? Klorfenoksamin hidroklorür: Eri?kin: 10 mg x 2-3 kez/gün 2-5 ya? çocukta eri?kin dozun 1/3?ü 10 ya? üstü çocukta eri?kin dozu 2003 Tedavi Nedenin (enfeksiyon, besin, emosyonel stres, ilaç) ortadan kaldyrylmasy; neden ilaçsa SOLUNUM SIKINTISI OLMAYAN AKUT ÜRTYKER VE ANJYYOÖDEM TEDAVYSY dir. Yeti?kin: 25-50 mg/gün (en çok 400 mg/gün) Yeti?kin: 25 mg x 3-4/gün Yeti?kin: 1-2 mg/gün Lezyonlar ve ka?ynty tamamen düzelene kadar veya en çok 3 hafta devam edilir. Birinci ku?ak antihistaminiklerin sedatif ve antikolinerjik etkilerinin istenmedi?i durumlarda ikinci ku?ak antihistaminikler tercih edilebilir. Tercihen kas içine veya damar yoluyla, 5 dakika içinde yava? pu?e ?eklinde, uygulanyr 6 saat arayla tekrarlanabilir. 6-10 ya? çocukta eri?kin dozun 1/2?si Hastalyk kontrol altyna alyndyktan sonra tedavi oral antihistaminikler ile 20 gün sürdürülür. T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY ÜRTYKER 21 2003 Antihistaminik kullanylyrken sedasyon, a?yz kurulu?u (antikolinerjik etki), sindirim Anjiyoödemde semptomlar 24 saat içinde gerilemedi?inde veya solunum sykyntysy 1. Adym: Adrenalin ) 0,3 - 0,5 mg, 1:1000?lik adrenalin deri alty veya kas içine solunum sykyntysy gerileyinceye kadar Çocuk dozu: 0,01 mg/kg damar yoluyla 2. Adym: Solunum yolunun açyk tutulmasy, nazal O 2 uygulanmasy 3. Adym: Antihistaminik; Klorfenoksamin hidroklorür Eri?kinde 10 mgx 2-3 kez/gün 2-5 ya? çocukta eri?kin dozun 1/3?ü 10 ya? üstü çocukta eri?kin dozu 4. Adym: Kortikosteroid ; Metilprednisolon Eri?kinde 50 mg metilprednisolon Çocuklarda 0,5-2 mg/kg/gün damar yoluyla T ANI VE TEDA VY REHBERY tedavisi akut ürtikerdeki gibidir. Tedavi süresi daha uzundur, Gebeli?in ilk trimestrinde antihistaminik kullanylmamalydyr. Ykinci ve üçüncü Ürtiker tedavisinde topikal antihistaminik ve topikal kortikosteroidlerin yeri yoktur. Odom RB, James WD, Berger TG. Erythema and Urticaria.: Disease of the Skin. Philadelphia:Saunders. Grattan C, Powell S, Humphreys F. Management and Diagnostic Guidelines for Urticaria and Angiooedema. Soter NA. Urticaria and Angioedema. Freedberg IM, Eisen AZ, Woff K, ed. Dermatology in General Black AK, Champion RC. Urticaria.: Champion RC, Burton JL, Burn DA, Breathnach SM, ed. Textbook Cotterill JA, Warin AP. General Aspects of Treatment.: Champion RC, Burton JL, Burn DA, Breathnach SM, ed. Textbook of Dermatology 6th ed. Oxford: Blackwell Science, 1998: 3289-310. Braun Falco O, Plewig G, Burgdorf WHC, eds. Dermatology, 2nd ed. Berlin: Springer-Verlog, 2000; 431- BELYRGYN SOLUNUM SIKINTISI VARLI?INDA AKUT ÜRTYKER VE ANJYYOÖDEM TEDAVYSY (Ülkemizde 0,25, 0,50 ve 1 mg/ml olarak formlary mevcuttur. 10 - 20 dakikada bir tekrarlanabilir. Tercihen kas içine veya damar yoluyla 5 dakika içinde yava? pu?e ?eklinde 6 saat arayla tekrarlanabilir. 6-10 ya? çocukta eri?kin dozun 1/2?si damar yoluyla, 6 saatte bir, 2-4 kez tekrarlanabilir. Kardiyak yan etkileri olabilece?i için infüzyonla uygulanmalydyr. 2-4 doza bölünerek verilir. T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK Kronik ürtiker semptomlar tolere edilebilir düzeye gelinceye kadar sürer. Uyarylar ? sistemi yakynmalary, tremor gibi yan etkiler ortaya çykabilir. ? trimestirde klasik antihistaminikler verilebilir. ? Sevk ? Tedaviye yanyt alynamady?ynda ? devam etti?inde ? Tekrarlayan anjiyoödem varly?ynda hasta sevk edilmelidir. Kaynaklar 1. 2000;160-74. 2. Br J Dermatol 2001;144:708-14. 3. Medicine. New York: McGraHill. 1999:1409-19. 4. Kayaalp S O, Ed. BNF/TYK Türkiye Ylaç Kylavuzu, Ystanbul:Turgut Yayyncylyk, 2001. 5. of Dermatology, 6th ed. Oxford: Blackwell Science, 1998: 2113-39. 6. 7. 56. ÜRTYKER 22 2003 T.C. SA?LIK BAKANLI?I Öykü 1-5 hafta, ortalama 3 hafta önce geçirilmi? tonsillofarenjit öyküsü Belirti ve bulgular ? Gezici poliartrit (%75): Diz, ayak bile?i, dirsek, el bile?i ? kardiyomegali, kalp yetmezli?i bulgulary ? Eritema marginatum (%10): Özellikle gövde ve kollaryn iç yüzünde ? Deri alty nodülleri (%2-10): Ekstansör yüzlerde, tendon kylyflaryna yapy?yk nodüller ? ? Ate? ? Artralji Laboratuvar bulgulary: ? - Periferik yayma: (özellikle ayyrycy tany için) ? Eritrosit sedimentasyon hyzy (ESH): Genellikle 60 mm/st üzerinde ? ? C- reaktif protein (CRP) pozitifli?i ? EKG: Uzamy? PR araly?y, ta?ikardi ? Bo?az kültürü: Syklykla negatif - Ekokardiyografi 23 2003 - Lökositoz A grubu beta-hemolitik streptokoklara ba?ly tonsillofarenjite ikincil olarak geli?en yaygyn enflamatuvar bir ba? dokusu hastaly?ydyr. Streptokok antijenlerine kar?y geli?en antikorlaryn eklem, kalp, bazal gangliyon gibi dokularda olu?turdu?u hasar sonucu geli?ir. Sosyoekonomik durumu dü?ük toplumlarda daha syk görülür. Syklykla 6-15 ya? grubunda ortaya çykar. Akut tonsillofarenjitin tedavisi akut romatizmal ate? geli?imini engeller. Tany Kardit (%40-50): Ta?ikardi, üfürüm (mitral ve aort yetmezli?i), perikardit, Sydenham koresi (%15): Tonsillofarenjitten 1-6 ay sonra Tam kan sayymy Yüksek antistreptolizyn O (ASO) düzeyi, titresi: Eri?kinlerde 240 Todd ü, çocuklarda 320 Todd ü üzerinde - Telekardiyografi AKUT ROMATYZMAL ATE? BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I AKUT ROMATYZMAL ATE? Geçirilmi? streptokok enfeksiyonu kanyty varly?ynda kore bulunmasy akut romatizmal ? ? Reaktif artrit ? Sistemik lupus eritematosus ? Septik artrit ? Akut lösemi - Benzatin penisilin - Penisilin V (a?yzdan) Penisilin alerjisi varsa - Eritromisin (a?yzdan) 24 2003 Modifiye Jones kriterleri Majör bulgular - Kardit - Poliartrit - Sydenham koresi - Eritema marginatum - Deri alty nodülleri T .C. SA?LIK BAKANLI?I Akut romatizmal ate?e özgül bir testin bulunmamasy nedeniyle, tany, belirti ve bulgularyn modifiye Jones kriterlerine göre de?erlendirilmesiyle konur. Geçirilmi? streptokok enfeksiyonunu gösteren bir kanyt e?li?inde, iki majör bulgu ya da bir majör ve iki minör bulgu tanyyy kuvvetle dü?ündürür. ate?i dü?ündürmelidir. Akut romatizmal ate? tanysy dü?ünüldü?ünde bildirimi yapylyr. Ayyrycy Tany Juvenil romatoid artrit Tedavi 1. Streptokok enfeksiyonunun tedavisi BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY Minör bulgular Grup A Streptokok enfeksiyonu kanyty Klinik: - Ate? - Artralji - Yüksek veya yükselmekte olan streptokok Laboratuvar: antikor titresi - Akut faz reaktanlarynda - Pozitif bo?az kültürü (ESH, CRP) arty? - PR araly?ynda uzama (kas içine, tek doz) Çocukta Eri?kinde Çocukta Eri?kinde <27 kg 600.000 ü >27 kg 1.200.000 ü veya 50.000 ü/kg/gün 2-3 milyon ü/gün 2-3 doza bölünerek, toplam 10 gün 40 mg/kg/gün, 2-4 dozda, 10 gün günde 2-4 kez 500 mg, 10 gün AKUT ROMATYZMAL ATE? 50-75 mg/kg/gün (en çok 4 gr) ky? aylarynda 3 haftada bir yaz aylarynda 4 haftada bir rehberine bakynyz. Sayfa 45) yapylyp benzatin penisilin ve antienflamatuvar tedavi - ESH yüksekse benzatin penisilin uygulanyr ve hasta antienflamatuvar tedavi verilmeden benzatin penisilin 25 2003 4 dozda, 2-3 hafta içinde azaltylarak kesilir. Kalp yetmezli?i varsa, diürez, gerekti?inde dijitalizasyon, (Kalp Yetmezli?i Tany kesinse, ve antienflamatuvar tedavi verilir ve hasta sevk edilir. Ayoub EM. Acute Rheumatic Fever. Allen HD, Gutgesell HP, Clark EB, Driscoll DJ, ed. Heart Disease in Infants, Children, and Adolescents. Philadelphia: Lippincott Williams &Wilkins, 2001:1226-41. El Said GM, El-Refaee MM, Sorour KA, El-Said HG. Rheumatic Fever and Rheumatic Heart Disease. Garson A, Bricker JT, Fisher DJ, Neish SR, ed. The Science and Practice of Pediatric Cardiology. Philadelphia: Lan AJ, Colford JM, Colford JM Jr. The Impact of Dosing Frequency on the Efficacy of 10-day Penicillin or Amoxicillin Therapy for Streptococcal Tonsillopharyngitis: A Meta-analysis. Pediatrics 2000; 105: E19. Braunwald, ed. Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed. Philedelphia: Saunders, T ANI VE TEDA VY REHBERY T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK 2. Antienflamatuvar tedavi - Asetil salisilik asit Profilaksi - Benzatin penisilin (kas içine) - Penisilin V (a?yzdan) günde iki kez 250.000 ü Penisilin alerjisi varsa -Eritromisin günde iki kez 250 mg Profilaksi süresi Yzole artrit : Yirmi ya?a kadar veya ataktan sonra en az 5 yyl Kardit: Ya?am boyu Sevk ? uygulanarak hasta acilen sevk edilir. ? Kore ön tanysyyla de?erlendirilen hastalar sevk edilir. ? Tany kesin de?ilse ve kardiyak bulgu yoksa, sevk edilir. - ESH dü?ükse: benzatin penisilin ve izlem yapylyr. ? Kaynaklar 1. 2. Williams & Wilkins, 1998:1691-724. 3. 4. 2001. AKUT ROMATYZMAL ATE? 26 2003 T.C. SA?LIK BAKANLI?I Anjina, genellikle; ? Efor ve emosyonel stresle ortaya çykyp, dinlenmekle veya nitrogliserin sprey ya da izosorbid dinitrat dil alty tablet ile geçen ? Basky, syky?ma veya yanma tarzynda ? Ço?unlukla prekordiyum ve sternum arkasynda duyulup omuz, kol, boyun ve çeneye yayylym gösterebilen Egzersiz veya stres ile gelen ve istirahat ile azalabilen, 5-15 dakika süren, prekordiyal bölgede ba?layyp, boyuna, sol omuz ve kola yayylabilen a?ry tipiktir Hasta; risk faktörleri ve anemi, hipertiroidi, aritmi, stres, a?yr egzersiz gibi anjina Fizik muayene S 3 , S 4 , mitral 27 2003 (a?a?ydakilerden herhangi birinin varly?y tany için yeterlidir) ? Karakteri ne olursa olsun son iki ay içinde ba?layan veya ? Ystirahat halinde gelen veya ? Genellikle 20 dakikadan uzun süren veya ? Ylerleme gösteren; sykly?y, süresi, ?iddeti artan, NG?ye yanyty azalan veya ? Miyokard enfarktüsü, bypass, kalbe invazif giri?im sonrasy yeni geli?en ? Egzersiz ve stresle ortaya çykan ve ? Ystirahat ve nitrogliserin (NG) ile geçen ve ? Genellikle 5-15 dakikadan kysa süren gö?üs a?rysy veya rahatsyzlyk hissidir. Temel sorun kalp kasynyn oksijen gereksinimi ile kalbe gelen oksijen arasyndaki dengenin bozulmasydyr. Tany Yyi bir anamnez anjina pektoris tanysy için yeterlidir. . Ancak hastalar tipik a?ry tarif etmeden, anjina e?de?eri kabul edilen efor dispnesi, sykynty hissi, fenala?ma gibi subjektif yakynmalarla ba?vurabilir. ataklaryny uyarabilen nedenlerin varly?y açysyndan mutlaka sorgulanmalydyr. Fizik muayene ve laboratuvar bulgulary özgül olmayyp ço?u zaman normaldir. Terleme, dispne ve anksiyete görülebilir. Komplikasyonlara ba?ly olarak yetmezlik üfürümü, ral duyulabilir; ödem, nabyz ve kan basyncy de?i?ikli?i saptanabilir. ANJYNA PEKTORYS BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I ANJYNA PEKTORYS Kararsyz Anjina a?ry ile karakterizedir. Kararly Anjina a?ry ile karakterizedir. - - Laboratuvar EKG de?i?iklikleri 28 2003 A?RI KARAKTERY Basky, syky?tyrma, a?yrlyk, yanma tarzynda; egzersiz, so?uk, stres ile artan, istirahat ve NG ile azalan Ani ba?layan, byçak saplanyr tarzda, sürekli Ani ba?langyçly, byçak saplanyr tarzda, nefes almakla artan Ani ba?langyçly, byçak saplanyr tarzda, oturup öne e?ilmekle azalan Ani ba?langyçly, batycy Batycy, nefes almakla artan yemekten sonra, yatar pozisyonda artan Palpasyon ve hareketle artan A?RI YERY Gö?üs, epigastrium Syrt, gö?üs Gö?üs Gö?üs ve yan a?rysy Substernal De?i?ken A?RI Kol, çene, boyun, syrt Sternum arkasyndan yukary soluk görünüm ?ok bulgulary, sa?-sol kol üfürümü, tamponat seslerinde azalma, nefes darly?y Perikardiyal frotman duyulabilir ta?ikardi, derin ven trombozu arayynyz. Pnömonide ral, plörezide plevral frotman Özgül bulgu yok Özgül bulgu yok Yskemik gö?üs a?rysy * ? Akut miyokard enfarktüsü ? Anjina pektoris Aort diseksiyonu * Pnömotoraks * Perikardit * Pulmoner emboli * Plörezi ve pnömoni Reflü özofajit Kas iskelet sistemi * Hasta mutlaka ileri tetkik ve tedavi amacyyla bir üst basama?a sevk kurallaryna uygun ko?ullarda T .C. SA?LIK BAKANLI?I T ANI VE TEDA VY REHBERY (ST ve T de?i?iklikleri, anormal Q dalgasy, ritim ve iletim bozukluklary) tanyyy destekler, EKG de?i?ikli?i olmamasy olasyly?y ortadan kaldyrmaz. Olanak varsa, hemoglobin, açlyk kan ?ekeri, kan kolesterol ve trigliserid düzeyi, akci?er grafisi de?erlendirilmelidir. Ayyrycy tany ANJYNA PEKTORYS BYRYNCY BASAMA?A YÖNELYK ?iddetli, yyrtylma ve Yanma tarzynda, Tek tarafly Yan a?rysy YAYILIMI Yer de?i?tiren a?ry Kalp apeksine, sol kol ve boyuna FYZYK MUAYENE Normal olabilir. üfürüm akci?erde raller, terleme, kan basyncy farky, nörolojik defisit, yeni aort yetmezli?i Tek tarafly solunum Dispne, hemoptizi, takipne, ÖN TANI sevk edilmelidir. (Sayfa 30) sprey: Kontrendikasyon . Aspirin tablet 100-300 mg/gün tek dozda (kontrendikasyon yoksa) Beta-bloker (kontrendikasyon yoksa, hastanyn tolere edebilece?i en üst doza veya Beta-bloker ile a?ry kontrol altyna alynamazsa, tedaviye uzun etkili nitrat ve tablet 30 mg günde 4 kez (ya?lylarda ba?langyçta 2 kez, SR tablet ise * Kombine tedavi ile hastanyn semptomlary kontrol altyna alynamazsa ve semptomlar hastanyn Kan ?ekerinin düzenlenmesi 29 2003 hasta sevk edilmelidir Hasta beta-blokeri tolere edemezse, ilaç kesilip uzun etkili nitrat ve kalsiyum tablet 40 mg günde 2 kez (long retard kapsül ise 50 mg/gün tablet 80 mg günde 3 kez; 3 x 120 mg?a kadar çykylabilir (ya?lylarda (Diabetes Mellitus rehberine bakynyz. Sayfa: 271) Kan basyncynyn düzenlenmesi (Hipertansiyon rehberine bakynyz. Sayfa: 37) Kan lipidlerinin düzenlenmesi (Hiperlipidemi rehberine bakynyz. Sayfa: 31) T ANI VE TEDA VY REHBERY Kararsyz anjinanyn her an miyokard enfarktüsüne ilerleyebilece?i unutulmamaly T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK Tedavi ve hasta acilen sevk edilmelidir. 1- Anjinanyn akut tedavisi - Aspirin tablet 300 mg çi?netilir ve - Yzosorbid dinitrat dil alty tablet 5 mg veya nitrogliserin yoksa, 5 dk ara ile 3 kez verildikten sonra gö?üs a?rysy geçmezse 2- Anjinanyn uzun süreli ilaç tedavisi - - çykylabilir) metoprolol tablet 100 mg/gün 2 doza bölünerek atenolol tablet 50-100 mg/gün tek dozda 1 haftalyk izlemden sonra; kanal blokeri kombinasyonu ba?lanyr kalsiyum kanal blokeri eklenir. - izosorbid mononitrat tek doz) ve - verapamil 40 mg günde 3 kez) veya - diltiazem 120 mg/gün tek doz) veya - amlodipin tablet 5-10 mg/gün tek dozda aktivitelerini kysytlyyorsa hasta sevk edilmelidir 3- Ylaç dy?y tedavi a. Anemi, hipertiroidi gibi tetikleyici nedenlerin düzeltilmesi b. Risk faktörlerinin azaltylmasy - Ya?am ?eklinin de?i?tirilmesi - Sigaranyn byrakylmasy - Hafif egzersiz (yürüyü?) - Diyet - Hasta obez ise a?yrly?yn ideal vücut a?yrly?yna gelmesi - Alkol tüketiminin kysytlanmasy - - - ANJYNA PEKTORYS Sevk 1. T .C. SA?LIK BAKANLI?I BYRYNCY BASAMA?A YÖNELYK T ANI VE TEDA VY REHBERY 2003 ? Kararsyz anjina dü?ünülen hastalar ? A?rysy 15 dakikadan uzun süren, tedaviye yanyt vermeyen tüm olgular Kararsyz anjina ön tanysy ile sevk ederken: ? Damar yolunu aç ? Vital bulgulary izle ? Oksijen 4 L/dk ? Nitrogliserin sprey veya izosorbid dinitrat 5 mg dil alty tablet ? Morfin 2-4 mg 5-10 dk arayla (en çok 10 mg) ? Aspirin tablet 300 mg çi?netilir Kaynaklar Scottish Intercollagiate Guidelines Network. Management of Stable Angina. A national clinical guideline. SIGN:Edinburg, 2001. 2. Management of Patients with Chronic Stable Angina ACC/AHA/ACP-ASIM Practice Guidelines for J Am Coll Cardiol 1999;33:2092-197). 3. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the Era of Reperfusion: Section 1: Acute Coronary Syndromes The American Heart Association in Collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000;102(8 Suppl). 30 ANJYNA PEKTORYS (TK), dü?ük dansiteli lipoprotein kolesterolü (LDL-K) ve trigliserid (TG) Hiperlipidemiler primer ve sekonder olarak synyflandyrylyr: Primer hiperlipidemilerde hiperlipidemiler ise diyabet, kronik böbrek ve karaci?er hastalyklary, obezite, alkol blokerler (bu ilaçlaryn de?i?tirilmesi/kesilmesi için yarar/zarar Ba?vuru hangi nedenle yapylyrsa yapylsyn, a?a?ydaki risklerin en az birini ta?yyan ani ölüm öyküsü olanlar 31 HYPERLYPYDEMY 2003 HYPERLYPYDEMY Hiperlipidemiler, lipoprotein metabolizma bozuklu?u sonucu serum total kolesterol konsantrasyonlarynda yükseklikle giden bozukluklardyr. Yüksek dansiteli lipoprotein kolesterolü (HDL-K) dü?üklü?ü de duruma e?lik edebilir. Hiperlipidemi ateroskleroz ve buna ba?ly komplikasyonlaryn en önemli nedenidir. Ülkemizde TK düzeyleri, baty toplumlaryna göre genelde dü?ük olmakla birlikte, 30 ya? üstündeki eri?kinlerin %25?inde TK 200 mg/dl?nin ve/veya TG 150 mg/dl?nin üstündedir. HDL-K düzeyleri ise, erkeklerin %70?inde, kadynlaryn %50?sinde 40 mg/dl?nin altyndadyr. TK/HDL-K oranynyn artmasynyn, gelecekteki koroner olaylaryn en iyi öngördürücülerinden biri oldu?u gösterilmi?tir. en önemli faktör kalytym olup çevresel faktörler de katkyda bulunur. Sekonder kullanymy, hipotroidi ve ilaç kullanymy [steroid ve steroid yapyly hormonlar, tiazid grubu diüretikler, retinoidler, de?erlendirmesi yapylmalydyr)] gibi faktörlere ba?ly geli?ir. bireylerde lipid profili (TK, LDL-K, HDL-K, TG) ölçülmeli, lipid düzeylerine bakylamayan ancak a?a?ydaki risk faktörleri olan tüm hastalara ya?am biçimi de?i?iklikleri önerilmelidir: 1. 45 ya? üstündeki sa?lykly eri?kinler 2. Postmenopozal kadynlar (fizyolojik ya da cerrahi) 3. Birinci derece akrabalarynda hiperlipidemi ve erken koroner kalp hastaly?y ve/veya 4. Sigara içenler 5. Obezitesi olanlar (Obezite rehberine bakynyz. Sayfa 277) 6. Aterosklerotik damar hastaly?y (ASDH) öyküsü olanlar 7. Sekonder hiperlipidemi riski ta?yyanlar BYRYNCY BASAMA?A YÖNELYK TANI VE TEDAVY REHBERY T.C. SA?LIK BAKANLI?I Semptom ve bulgular Hiperlipidemiler genellikle semptom veya bulguya yol açmaz. Fizik muayene ? Vücut kitle indeksi (VKY) hesaplanmalydyr: Vücut a?yrly?y/(boy) 2 = kg/m 2 (Obezite rehberine bakynyz. Sayfa 277) ? Deri: Ksantalezma, ksantoma ? ? Lipid düzeylerinin normale dönmesi, koroner arter hastaly?y ve inme riski yany syra 32 2003 HYPERLYPYDEMY Metabolik sendrom tany ölçütleri Abdominal obezite Erkek >102 cm Bel çevresi: Kadyn >88 cm >150 mg/dl HDL-K Erkek <40 mg/dl Kadyn <50 mg/dl Kan basyncy ³130/85 mmHg Açlyk kan ?ekeri Lipid düzeyleri synyflamasy TK (mg/dl) LDL-K (mg/dl) TG (mg/dl) Optimal < 100 Normal <200 100-129 <150 Synyrda yüksek 200-239 130-159 150-199 Yüksek ³240 160-189 200-500 Çok yüksek ³190 >500 8. Metabolik sendromu olanlar; tany ölçütlerinden en az 3 tanesi olmalydyr. Tany Ayryntyly öykü alynmaly, tam fizik muayene yapylmalydyr. Kardiyovasküler: Arter traselerinde üfürüm ve/veya nabyz alynamamasy Serebrovasküler: Karotid oskültasyonunda üfürüm ve benzeri bulgular ara?tyrylmalydyr. Tany kan lipid düzeyleri ölçümü ile konur. TG ölçümü için 12 saatlik açlyk sonrasy kan örne?i alynmalydyr. HDL-K düzeyinin 40 mg/dl?nin altynda olmasy dü?ük kabul edilmektedir. 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