Sexually transmitted infections in Turkey.

Turkey is a Moslem country where lay knowledge regarding sexually transmitted infections (STIs) is poor. Surveillance arrangements are limited, and frequently ignored, with the result that the true incidence of STIs is unknown. The prevalence of syphilis is definitely increasing, and probably that of the other infections is too. Modern diagnostic techniques are not widely deployed and there is little standardization of medical arrangements. However, there has been a high level of governmental involvement in HIV prevention in recent years and it is now believed that most HIV transmission in Turkey is by the heterosexual route.

Drug related clinical pattern in fixed drug eruption.

Fixed drug eruption (FDE) represents a frequent type of drug eruption in Turkey. The aim of this open study is to analyze the clinical features with special emphasize on drug related pattern in our case series. Sixty-four cases with established FDE by oral provocation were clinically evaluated. Cotrimoxazole, a combination of sulfamethoxazole and trimethoprim, was the most common offender for FDE (75%), followed by naproxen sodium (12.5%), dipyrone (9.5%), dimenhydrinate (1.5%) and paracetamol (1.5%). Sensitivity to more than one drug was not observed. Cotrimoxazole-induced FDE was mainly located on male genitalia. Naproxen predominantly affected lips and face whereas dipyrone mainly caused FDE on trunk and extremities. Statistical analysis revealed a significant difference only for dipyrone versus cotrimoxazole over trunk and extremities (p = 0.03). Familial occurrence, symmetrical and asymmetrical nonpigmenting FDE, linear FDE, solitary plaque on the cheek, and "wandering" FDE were unusual findings of cotrimoxazole-induced FDE. Cotrimoxazole was the leading etiological agent in our series. Cotrimoxazole-induced FDE had some rarely or previously unreported features, but a significant relation between drugs and involved areas or clinical pattern could not be established.

Reticulate acropigmentation of Kitamura: a case report.

A Turkish female patient from Eastern Anatolia is described with the clinical and histopathological features of reticulate acropigmentation of Kitamura (RAK). The brother of the patient, who has similar clinical features, refuses to give a biopsy specimen. No similar lesions are noted on the other members of the patient's family. We have found the case worthwhile to report, since case reports on RAK from ethnic groups other than Japanese are still rare at present.

Efficacy and safety of oral fluconazole in the treatment of patients with tinea corporis, cruris or pedis or cutaneous candidosis : a multicentre, open, noncomparative study.

The efficacy, safety, required duration of treatment, and patient preference for oral fluconazole 150 mg/week in the treatment of 521 patients with cutaneous candidosis, tinea corporis, tinea cruris or tinea pedis were assessed in an open, multicentre, noncomparative trial. Patients received weekly doses of fluconazole 150mg for an average of 4.65 weeks. Cultures were examined microscopically at baseline, at 2-week intervals, at study end, and at long term follow-up (4 to 6 weeks after the last dose). All adverse events were recorded and rated; patients with laboratory findings outside normal values were monitored. Forms regarding patient preference for oral or topical medication type were assessed from 19 centres at study end. Clinical evaluation demonstrated an overall success rate (cure plus improvement) of 96% at the end of therapy, and 92% overall success rate at long term follow-up. Eradication of pathogens based on culture was equally high, with 92% eradicated at the end of therapy and 89% eradicated at long term follow-up. Patient tolerability was good; only 7 patients (1.3%) discontinued therapy because of adverse events, in 2 cases because of laboratory abnormalities. These findings suggest that oral fluconazole therapy is safe. This study demonstrated that weekly oral doses of fluconazole 150mg were effective in the treatment of tinea corporis, tinea cruris, tinea pedis and cutaneous candidosis. Furthermore, there was a high patient preference for oral fluconazole over previous topical therapy.

[Oral DMSO therapy in 3 patients with lipoidproteinosis. Results of long-term therapy]. / Orale DMSO-Therapie bei 3 Patienten mit Lipoidproteinose. Ergebnisse einer Langzeittherapie.

Lipoid proteinosis is a rare autosomal recessive disorder with a chronic, benign course. There is no generally accepted systemic therapy apart from the experimental oral use of dimethyl sulphoxide (DMSO) and etretinate in two single cases. We treated two sisters and an unrelated man with lipoid proteinosis with longterm oral DMSO (60 mg/kg/d). At the end of an average treatment time of 3 years, DMSO was withdrawn because it produced no beneficial effects with regard to their skin, mucosal lesions or hoarseness. Additionally, one patient showed progression of her disease with worsening hoarseness and onset of dyspnea, requiring surgical removal of vocal cord infiltrates. Three patients with lipoid proteinosis failed to show any beneficial response to long term treatment with DMSO.

HLA in alopecia areata.

BACKGROUND: The aim of this study was to investigate the human leukocyte antigen (HLA) characteristics of Turkish alopecia areata patients, and the correlation of the HLA profile with age of onset, severity and duration of the disease, presence of ophiasis, and family history. METHODS: A total of 88 patients with alopecia areata, alopecia totalis, or alopecia universalis were compared with 100 healthy controls. HLA typing was performed by the Terasaki microlymphocytotoxicity method. RESULTS: The frequency of HLA-A1, HLA-B62(15), HLA-DQ1, and HLA-DQ3 was significantly higher in patients than in controls. HLA-DR16 was significantly less common in patients than in the control group, and we concluded that this allele might have a protective role for alopecia areata. Juvenile onset and severe involvement were related with HLA-Cw7 and HLA-DR1, respectively. The HLA profile was independent of the existence of long-standing disease, presence of ophiasis, and a positive family history. CONCLUSIONS: In HLA-alopecia areata association, ethnic differences may play a role.

Topical provocation in 27 cases of cotrimoxazole-induced fixed drug eruption.

The purpose of this study was to investigate the usefulness of topical provocation in the diagnosis of cotrimoxazole-induced fixed-drug eruption (FDE). 27 patients with established cotrimoxazole-induced FDE by oral provocation and 20 healthy controls were tested with drugs at increasing concentrations in white petrolatum and dimethyl sulfoxide (DMSO) both on previously involved and uninvolved skin sites. Tape-stripping occlusive patch testing in petrolatum remained negative in 19 tested patients. Open testing with drug preparations in DMSO revealed positive results in 25 of 27 tested patients. 1 patient showed an additional positive reaction on previously uninvolved skin. Lesions on male genitalia and on face reacted to testing once with 10% or 20% of the suspected drug, whereas repeated testing with concentrations up to 50% was necessary in lesions on trunk & extremities. Open testing with drug preparations in DMSO at concentrations of 10%, 20% and 50% and pure DMSO remained negative in 20 healthy controls. The present study shows that repeated open testing with graded concentrations of the drugs up to 50% in DMSO is a reliable test method in sulfamethoxazole/trimethoprim-induced FDE. Patients and physicians should be aware of the transient irritant reaction to DMSO that is not infrequent, so as to avoid false-positive interpretations.

Intermittent use of topical dimethyl sulfoxide in macular and papular amyloidosis.

BACKGROUND: Severe and therapy-resistant pruritus is the most prominent feature of macular (MA) and lichen (LA) amyloidosis that leads to further amyloid deposition by recurrent frictional trauma to the epidermis. Of the various therapeutic modalities with variable success, the most encouraging and beneficial effect has been observed with topical dimethyl sulfoxide (DMSO) therapy. In a previous study, we achieved marked clinical improvement in nine of 10 patients in a daily treatment regimen over 6-20 weeks, but relapses occurred in the post-treatment follow-up period. The aims of this study are to investigate whether the patients would benefit from intermittent therapy and to determine the optimal application interval of DMSO to maintain the relief of symptoms. METHODS: Thirteen patients with histopathologically verified cutaneous amyloidosis (five MA, two LA and six biphasic) were enrolled in the study. They were treated once daily with a 50 or 100% DMSO solution until pruritus disappeared. Then, DMSO was applied at increasing intervals until the widest effective application interval for maintenance of relief was reached. Patients were regularly followed-up by a scoring system for pruritus, papules, and pigmentation, control biopsies, photographs, blood biochemistry, and side-effects. RESULTS: The mean time required for the disappearance of pruritus was 4.1 weeks. Remarkable flattening of the papules was achieved after an average therapy period of 9 weeks. After a total therapy period of 6.5 months, a nearly 50% remission in pigmentation and >70% flattening of papules were achieved. The widest effective DMSO application interval was 8.6 days. The side-effects of therapy were contact urticaria, desquamation, burning sensation, and garlic-like breath odor, which were more prominent with the higher concentration of DMSO. In interval therapy, side-effects were tolerated more easily than in daily therapy. No reduction of amyloid deposits was revealed in control biopsies. CONCLUSIONS: Locally applied DMSO can break the vicious "pruritus-amyloid deposition-pruritus" cycle in patients with MA and LA. In addition to its daily use, interval therapy seems to maintain this effect and enables patients to tolerate side-effects more easily.

[Behçet disease in Turkey]. / Morbus Behçet in der Türkei.

In the last 12 years, we treated 427 Turkish patients suffering from Behçet's disease. We report on the frequency of symptoms as well as the modes of therapy in Turkey.

A new kind of skin lesion in Behçet's disease: extragenital ulcerations.

A new skin lesion was encountered in 29 of 970 Behçet's patients. The lesions resembled oral aphthae clinically, were recurrent and left a scar tissue like genital ulcers but were located extragenitally. Skin biopsies could be done in only 4 cases and they all showed vasculitis.

Re-evaluation of the pathergy test in Behçet's disease.

A positive pathergy test in patients with Behçet's disease has been accepted as a diagnostic criterion by many authors, but in recent years it has been claimed that the test has a decreased positivity. We have examined the test in 92 proven cases of Behçet's disease, using 20G and 26G disposable needles and evaluated them after 48 h. Maximum positivity was found to be 65% when we used needles of size 0.9 mm (20G), but the reactivity was considerably less when 0.3 mm diameter (26G) needles were used. The disposable needles used nowadays are less traumatic to initiate the reaction than were the non-disposable ones used in the pre-AIDS era.

Refractory ulcerative lupus vulgaris associated with CD4 lymphocytopenia, inversion of chromosome 14, primary amenorrhoea and mental retardation.

A case of ulcerative lupus vulgaris, confirmed by polymerase chain reaction (PCR) is reported. The initial lesion of our case was a papule on the nose, which progressed during antituberculous treatment and caused cartilage destruction and ectropion. Immunological analysis revealed CD4 lymphocytopenia, and the possibility of idiopathic CD4 lymphocyte deficiency was considered. In addition, the patient had primary amenorrhoea, mental retardation and inversion of chromosome 14. CD4 lymphocytopenia and chromosomal abnormality are the possible causes of antituberculous treatment failure.

Screening of sex workers in Turkey for Chlamydia trachomatis.

BACKGROUND: Increasing migration of sex workers across East European borders into Turkey has resulted in increased arrests of unregistered sex workers. There is concern regarding the prevalence of sexually transmitted diseases (STD) such as C. trachomatis in this unregulated group. OBJECTIVE: To measure the prevalence of C. trachomatis infection and selected related demographic and behavioral factors among registered and unregistered sex workers in Istanbul, Turkey. METHODS: In a cross-sectional study, the prevalence of C. trachomatis infection was studied by direct fluorescent antibody testing in 248 sex workers: 158 presented for routine medical screening and 90 who were arrested for lack of registration. All subjects were interviewed regarding demographic factors, sexual activity, and antibiotic and drug use. RESULTS: The overall C. trachomatis prevalence was 12.9% (12.0% registered and 14.4% unregistered). There was a strong association between never using condoms and chlamydia positivity (odds ratio 8.9 [95% confidence interval 3.7 to 21.6]). CONCLUSIONS: The high rate of C. trachomatis among all tested sex workers and the lack of regular condom use, particularly among unregistered sex workers, indicate that there is an urgent need for safe sex education and continued STD screening of unregistered sex workers.

PIP: Accelerating migration of unregistered sex workers from Eastern European countries to Turkey has produced alarm about the potential for increased sexually transmitted disease (STD) transmission. Licensed sex workers are routinely screened for STDs and given medical examinations. However, in Turkey, women with foreign citizenship are ineligible for licensing. This cross-sectional study measured the prevalence of Chlamydia trachomatis in 248 sex workers in Istanbul in 1993. 158 sex workers were enrolled when they presented for routine medical screening, while 90 (from Rumania) were arrested for lack of registration. The overall C. trachomatis prevalence, as detected by direct fluorescent antibody testing, was 12.9% (12.0% among registered and 14.4% among unregistered women); however, the fact that almost half these women reported recent self-prescribed antibiotic use suggests these rates are underestimates. When the analysis was restricted to the 84 women without recent antibiotic use, the C. trachomatis prevalence was 36.9%. There was a significant association between never using condoms and chlamydia infection (odds ratio, 8.9; 95% confidence interval, 3.7-21.6). These findings suggest a need for safe sex education and continued STD screening of sex workers in Turkey. Eligibility for registration, regardless of nationality, should be reconsidered for public health reasons.

Surgical treatment of granuloma inguinale.

Granuloma inguinale is an indolent, progressive, ulcerative and granulomatous skin disease caused by Calymmatobacterium granulomatosis. It is generally treated with antibiotics. However, long-standing and complicated disease requires surgical treatment. Two patients with extensive and multiple perianal fistulas and abscesses unresponsive to medical treatment were managed with radical surgical resection. The first patient healed by primary intention, but a diverting colostomy was made for the second patient and the tissue defect was closed with a rotation flap. Follow-up at 4 years revealed the disappearance of the symptoms and the absence of recurrence in both patients.

The epidemiology of scabies in Turkey.

The epidemiology of scabies for the last twelve years has been studied in Turkey. Information was obtained from three regions (Istanbul, Ankara and Erzurum) having different climates. There has been an increase in scabies in the years following 1969 in Ankara and Erzurum and from 1967 on in Istanbul. It reached its maximum in 1978 in Erzurum, while this peak had been observed in early 1970s in other regions. Scabies incidence has significantly increased and decreased in winters and summers respectively, has been found to affect particularly the age group 15-44, and was observed more frequently in men than in women. Scabies seems to be moving to the eastern parts of Turkey.