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DERLEME Pruritus Skroti

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DERLEME Pruritus Skroti http://www.dermatoz.org.tr/2019/2/dermatoz19102d1.pdf doi: 10.15624.dermatoz19102d1 DERLEME Pruritus Skroti Dr. Muazzez Çiğdem Oba*1, Prof. Dr.Yalçın Tüzün1 *İstanbul Üniversitesi-Cerrahpaşa, Cerrahpaşa Tıp Fakültesi, Deri ve Zührevi Hastalıklar Anabilim Dalı, İstanbul Yazışma Adresi: Dr. Muazzez Çiğdem Oba, İstanbul Üniversitesi-Cerrahpaşa, Cerrahpaşa Tıp Fakültesi, Deri ve Zührevi Hastalıklar Anabilim Dalı E-posta: [email protected] Özet Abstract Pruritus Skroti Pruritus Scroti Pruritus skroti skrotuma sınırlı kaşıntıları tanımlamaktadır. İdi- Pruritus scroti is defined as itching localized to scrotum. In id- yopatik olgularda altta yatan bir sebep bulunmaz iken sekonder iopathic pruritus scroti there is no underlying cause whereas sec- pruritus skrotide başta infeksiyonlar, infestasyonlar ve inflama- ondary pruritus scroti develops due to various inflammatory tuvar hastalıklar olmak üzere birçok organik sebep tespit edile- disorders, infections, infestations etc. Management of pruritus bilir. Hastalığın tedavisinde terleme, sıcaklık, okluzyon ve irritasyon gibi tetikleyicilerden kaçınmak için genel önlemler ile scroti involves general measures to reduce triggering factors such birlikte topikal kortikosteroidler ve topikal kalsinörin inhibitörleri as sweating, heat, occlusion and irritation along with medical başta olmak üzere medikal tedaviler uygulanmalıdır. Bu derle- treatment. Mainstay of medical treatment is topical corticos- mede pruritus skrotinin etyopatogenez ve tedavisi tartışılmıştır. teroids and calcineurin inhibitors. Anahtar Kelimeler: Genital, pruritus, skrotum Keywords: Genital, pruritus, scrotum Tüzün Y, Oba MÇ. Pruritus skroti Dermatoz 2019; 10 (2): dermatoz19102d1 Giriş tışı tetiklemektedir. Bu durum kaşıma-ka şıntı-ka- şıma kısır döngüsü olarak adlandırılır (2). Pruritus skroti skrotuma sınırlı kaşıntıları tanımla- mak için kullanılan bir terimdir. Kadınlarda pruritus Cohen ve ark. idyopatik skrotal pruritus ile spinal vulva, pruritus skrotinin analoğudur. Skrotumda ka- sinirlere veya sinir köklerine olan bası arasında bir şıntı-kaşınma-kaşıntı kısır döngüsü çok inatçıdır. ilişki olabileceğini öne sürmüşlerdir. Bu çalışmada Skrotal pruritus hastalar için belirgin derecede ra- anogenital prurituslu 20 hastanın 16’sında lumbo- hatsız edici olabilir. Duygudurum ve uykuda anlamlı sakral radikülopati tespit edilmiştir. Bu hastalara tri- derecede bozulmaya yol açabilir (1). amsinolon asetonid ve lidokain ile paravertebral blok uygulandığında skrotal kaşıntıda olumlu sonuç- Etyopatogenez lar elde edilmiştir.(3) Kaşıntı duyusu dermoepidermal bileşkede bulunan Skrotal pruritus etyolojik açıdan primer ve sekonder serbest sinir uçları tarafından alınır. Miyelinsiz C lif- olarak sınıflandırılabilir. Primer veya idyopatik skro- leri tarafından taşınarak omurilik arka kordonuna tal pruritusta etyolojik ajan bulunmaz iken sekonder gelir. Uyarı burada sekonder nöronlarla karşı spino- skrotal pruritusta altta yatan organik bir sebep bu- talamik yola aktarılır ve talamusa ulaşır. Tersiyer nö- lunur (4). ronlar aracılığıyla da uyarı talamustan serebral kortekse iletilerek kaşıntı duyusu algılanır (1). Çeşitli İdiyopatik skrotal pruritusta kötü hijyen, psikojenik nedenlerle (çevresel, anatomik vb.) skrotum deri- faktörler ve diyet ilişkili nedenler tetikleyici olabilir. sinde başlayan inflamatuvar süreç sırasında salınan Demir, çinko veya riboflavin gibi vitamin ve mineral inflamatuvar medyatörler ve proteolitik ajanlar ka- eksiklikleri skrotal irritasyon, ekzematöz lezyonlar şıntıya neden olmakta, kaşıntı ise inflamasyonda ar- ve pruritusa neden olabilir (2). Sayfa 1/4 http://www.dermatoz.org.tr/2019/2/dermatoz19102d1.pdf Oba MÇ. ve ark. Pruritus skroti Kaşıntı başta psoriasis ve atopik dermatit gibi infla- 50-80 yaş erkeklerde skrotumda yavaş seyirli, bazen matuvar deri hastalıkları olmak üzere çok çeşitli has- ülserasyon ve ekzematizasyonun eşlik edebildiği, ka- talıkların bir bulgusu olabildiğinden sekonder şıntılı eritemli plaklar varlığında ekstramammaryen pruritus skrotide ayırıcı tanı listesi uzundur (Tablo Paget hastalığı akla gelmelidir. Apokrin bezlerden 1). Akut skrotal pruritusta infeksiyonlar ve allerjik zengin bölgeleri tutan bir intraepitelyal neoplazidir. ve iritan kontakt dermatitler ön sırada yer alan ne- Hastalara çoğunlukla yanlış olarak ekzema tanısı denlerdir. Kronik pruritus skrotide psoriasis ve liken konur. Bu nedenle topikal steroidlere yanıt verme- planus gibi papuloskuamöz hastalıklar, atopik der- yen plaklardan mutlaka biyopsi alınmalıdır (10). matit gibi inflamatuvar hastalıklar, maligniteler, me- kanik sebepler, psikojenik faktörler ve idyopatik İdiyopatik skrotal kalsinozis skrotum derisinde kal- pruritus akla gelmelidir (5,6). siyum fosfat tuzlarının birikimine bağlı gelişen, ka- şıntıya sebep olabilen, nodüler lezyonlardır. Dermatofitik infeksiyonlarda büyük çoğunlukla Etyolojisi tam olarak bilinmese de travma suçlan- skrotum korunmuştur. Buna karşın, kandidal infek- maktadır. Kaşıntının yanında kozmetik soruna da siyonlar sıklıkla skrotal deride tutulum yapar. Uyuz yol açan bu selim tablonun tedavisinde eksizyon uy- tipik olarak generalize kaşıntı ile seyretse de erkek- gulanmaktadır (11). lerde skrotal tutulum yaptığında akut pruritus skroti Klinik sebeplerinden biridir (5). Semptomatik dermografizm merdiven çıkma, bisik- Pruritus skrotide genellikle akşam başlayan veya lete binme, koşma vb egzersizler veya cinsel temas alevlenme gösteren veya gün boyu süren kaşıntı ya- sonrası gelişen eritem, ödem ve kaşıntı ile karakte- kınması bulunur. Sürtünme, terleme, irritasyon ve rizedir. Dermatolojik muayenede skrotal deri doğal- okluzyon kaşıntıyı arttıran faktörlerdir. Dermatolo- dır. Künt bir cisim ile skrotal deriye travma jik muayenede skrotal deri tamamen normal görü- uygulandığında kızarıklık ve kabarıklık gelişimi göz- nümde olabileceği gibi değişen şiddetlerde eritem, lenir (7). ödem, skuam, eksoryasyonlar ve likenifikasyon da mevcut olabilir. Likenifikasyon hem epidermis Genital allerjik kontakt dermatit akut olgularda eri- (akantoz) hem de stratum korneumun (hiperkera- tem, ödem, erozyon; kronik olgularda likenifikas- toz) kalınlaşması sonucu oluşur. Kronik kaşıma ve yonla seyreder. Tanısında yama testi yardımcıdır. En sürtünme travmalarına koruyucu bir yanıt olarak ge- sık genital allerjenler topikal ilaçlardan lokal aneste- lişir. Klinik olarak deri çizgilerinde kalınlaşma ve zikler ve topikal steroidlerdir. Bunların yanında par- palpasyonla etkilenen dokuda kalınlaşma mevcuttur fümler, yapıştırıcılar, boyalar ve lastik ürünleri bildi (Resim 1) (4). rilmiştir (8). Tanı için iyi bir anamnez ve ayrıntılı klinik muayene Fiks ilaç erüpsiyonu skrotumda eritem, ödem bazen çok önemlidir. Sistemik sebepleri dışlamak için ge- bül ve erozyon gelişimi ile seyreden ve sorumlu ila- rekli görülen hastalarda tam kan sayımı, tiroid fonk- cın alındıktan sonra yarım saat ila sekiz saat sonra- siyon testleri, kan glukoz düzeyi, üre, kreatitin, sında aynı bölgede tekrar eden lezyonlardır. karaciğer fonksiyon testler, gaita incelemesi, akciğer Antibiyotikler (florokinolonlar, penisillin, tetrasik- grafisi, batın ultrasonografisi ve yaşa uygun kanser linler, sulfonamidler), antifungaller ve nonsteroidal taramaları yapılmalıdır. Tanıdan emin olunamıyorsa analjezikler en sık suçlanan ilaçlardır (9). deri biyopsisi alınmalıdır (1). Tablo 1. Sekonder pruritus skroti Akut Kronik • İnfeksiyöz ajanlar (Candida, molluskum, HPV vb. ) • Psoriasis • Kontakt dermatit • Atopik dermatit • Böcek ısırıkları • Liken sklerozus • İlaç reaksiyonları • Liken planus • Malign ve premalin durumlar Sayfa 2/4 http://www.dermatoz.org.tr/2019/2/dermatoz19102d1.pdf Oba MÇ. ve ark. Pruritus skroti larından kremlere tercih edilir. Erken dönemde su- lantılı ve ekskoriye lezyonlarda topikal ve sistemik antibiyotikler ile ıslak pansumanlar önerilmelidir. Topikal anezteziklerden %2 lidokain ve %1 pra- moksin ile duyarlanma ihtimali düşük olduğundan kaşıntının giderilmesinde destek tedavide bu ajanlar önerilebilir (6). Topikal kalsinörin inhibitörleri olan takrolimus ve pimekrolimus skrotal pruritusta kullanılabilir. Her iki ajanın da perkütan emilimi düşük düzeydedir. Deri atrofisi yapmazlar. Takrolimusun penetrasyonu pimekrolimusa kıyasla 9-10 kat daha fazla olduğun- dan pruritus skroti tedavisinde öncelikli olarak tak- rolimus tercih edilmesi düşünülebilir (5). Kaşıntı giderici etkileri temel olarak inflamatuvar sitokinle- rin baskılanmasına bağlanmaktadır. Ayrıca, miye- linsiz sinir liflerindeki reseptörlere bağlanarak direk olarak sinir liflerinin fonksiyonuna etki ettikleri dü- şünülmektedir (13). Gece verilen sedatif antihistaminikler ile gece ka- şıntısı kontrol altına alınabilir. Birinci kuşak H1 an- tihistaminiklerden difenhidramin ve hidroksizin bu amaçla en sık tercih edilen antihistaminiklerdir. Ye- terli yanıt alınamaz ise trisiklik antidepresanlar kul- Resim 1. Ense ve kollarda sarı-kahverengi papüler lezyonlar lanılabilir. 10-25 mg doksepin gibi sistemik trisiklik antidepresanlar inatçı kaşıntılarda etkili olabilir. Tedavi Doksepin tedavisi tolere edilirse haftalık 25mg’lık Altta yatan muhtemel bir infeksiyon, inflamatuvar doz artışları yapılarak tedavi dozu 75mg’a çıkılabilir. dermatoz veya allerjen teması ve irritasyon dışlan- Amitriptilin bir diğer trisiklik antidepresan ajandır. malıdır. Primer dermatoz varlığında spesifik tedavi Amitriptilin özellikle nöropatik karakterdeki skrotal verilmelidir (1). pruritusta daha etkilidir. Tedaviye 25 mg/gün dozda başlanabilir. Amitriptilin dozu ise her akşam 5 mg
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