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Tan MG, Tolkachjov SN. Treatment of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:183-192. [PMID: 38423680 DOI: 10.1016/j.det.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that results in painful cutaneous ulcers and is frequently associated with underlying hematologic disorders, inflammatory bowel disease, or other autoimmune disorders. Pathogenesis involves an imbalance between proinflammatory and anti-inflammatory mediators, leading to tissue damage from neutrophils. First-line treatment options with the greatest evidence include systemic corticosteroids, cyclosporine, and tumor necrosis factor alpha inhibitors. Other steroid-sparing therapies such as dapsone, mycophenolate mofetil, intravenous immunoglobulin, and targeted biologic or small molecule inhibitors also have evidence supporting their use. Wound care and management of underlying associated disorders are critical parts of the treatment regimen.
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Affiliation(s)
- Marcus G Tan
- Division of Dermatology, University of Ottawa, 737 Parkdale Avenue, 4th Floor Dermatology, Ottawa, ON K1Y1J8, Canada.
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology, Department of Dermatology, Baylor University Medical Center, University of Texas at Southwestern, Texas A&M University School of Medicine, 1640 FM 544, Suite 100, Lewisville, TX 75056, USA
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2
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Was der Rheumatologe vom Dermatologen lernen kann – oder: Gute Freunde kann niemand trennen. Z Rheumatol 2018; 77:484-492. [DOI: 10.1007/s00393-018-0499-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Toh JWT, Young CJ, Rickard MJFX, Keshava A, Stewart P, Whiteley I. Peristomal pyoderma gangrenosum: 12-year experience in a single tertiary referral centre. ANZ J Surg 2018; 88:E693-E697. [DOI: 10.1111/ans.14707] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/17/2018] [Indexed: 11/26/2022]
Affiliation(s)
- James W. T. Toh
- Division of Colorectal Surgery, Department of Surgery; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
- Division of Colorectal Surgery, Department of Surgery; Westmead Hospital, Westmead Clinical School, The University of Sydney; Sydney New South Wales Australia
| | - Christopher J. Young
- Division of Colorectal Surgery, Department of Surgery; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
- Division of Colorectal Surgery, Department of Surgery; Royal Prince Alfred Hospital, RPAH Clinical School, The University of Sydney; Sydney New South Wales Australia
| | - Matthew J. F. X. Rickard
- Division of Colorectal Surgery, Department of Surgery; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
| | - Anil Keshava
- Division of Colorectal Surgery, Department of Surgery; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
| | - Peter Stewart
- Division of Colorectal Surgery, Department of Surgery; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
| | - Ian Whiteley
- Division of Colorectal Surgery, Department of Surgery; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
- Division of Colorectal Surgery, Department of Surgery; Royal Prince Alfred Hospital, RPAH Clinical School, The University of Sydney; Sydney New South Wales Australia
- Stoma Therapy; Concord Hospital, Concord Clinical School, The University of Sydney; Sydney New South Wales Australia
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Afifi L, Sanchez IM, Wallace MM, Braswell SF, Ortega-Loayza AG, Shinkai K. Diagnosis and management of peristomal pyoderma gangrenosum: A systematic review. J Am Acad Dermatol 2018; 78:1195-1204.e1. [DOI: 10.1016/j.jaad.2017.12.049] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/14/2017] [Accepted: 12/17/2017] [Indexed: 01/31/2023]
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Tolkachjov SN, Fahy AS, Cerci FB, Wetter DA, Cha SS, Camilleri MJ. Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases. Mayo Clin Proc 2016; 91:1267-79. [PMID: 27489052 DOI: 10.1016/j.mayocp.2016.05.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/26/2016] [Accepted: 05/02/2016] [Indexed: 12/12/2022]
Abstract
Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.
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Affiliation(s)
| | | | - Felipe B Cerci
- Department of Dermatology, Hospital Santa Casa de Curitiba, Curitiba, Brazil
| | | | - Stephen S Cha
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Koo K, Brem H, Lebwohl M. Pyoderma Gangrenosum versus Chronic Venous Ulceration: Comparison of Diagnostic Features. J Cutan Med Surg 2016; 10:26-30. [PMID: 17241569 DOI: 10.1007/7140.2006.00011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: Diagnosis of pyoderma gangrenosum can be difficult, leading to overdiagnosis or underdiagnosis. Objective: To identify clinical features helpful in establishing a diagnosis of pyoderma gangrenosum and to compare the characteristics of patients with pyoderma gangrenosum with those of patients with chronic venous ulcers. Method: A retrospective chart review was performed in 28 patients with typical pyoderma gangrenosum and compared with the clinical features in 28 patients with chronic venous ulcers. Results: (1) Even when other body sites are affected, pyoderma gangrenosum usually affects the upper and lower legs and feet or peristomal sites compared with chronic venous ulcers that are limited to the lower legs and feet. (2) Pyoderma gangrenosum can be associated with systemic diseases, especially inflammatory bowel disease. (3) Pustules and purulent discharge are features of pyoderma gangrenosum but not of chronic venous ulcers. (4) Crater-like holes or cribriform scarring is commonly seen in pyoderma gangrenosum but not in chronic venous ulcers. (5) Pathergy is a specific but not sensitive finding of pyoderma gangrenosum. It does not occur in patients with chronic venous ulcers. Conclusions: Diagnosis of pyoderma gangrenosum should be considered in patients with purulent ulcers affecting the legs or peristomal sites. To confirm the diagnosis, specific features should be sought, including pathergy, crater-like holes or cribriform scarring, and association with inflammatory bowel disease. Other causes of ulceration should be excluded.
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Affiliation(s)
- Kathie Koo
- Department of Dermatology, Mount Sinai School of Medicine of New York University, New York, USA
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Rahvar M, Kerstetter J. Cutaneous manifestation of gastrointestinal disease. J Gastrointest Oncol 2016; 7:S44-54. [PMID: 27034812 PMCID: PMC4783618 DOI: 10.3978/j.issn.2078-6891.2015.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/10/2015] [Indexed: 12/29/2022] Open
Abstract
The gastrointestinal (GI) and cutaneous systems are closely linked in origin. Skin manifestations are frequently seen as a part of different GI syndromes. Gastroenterologists play an important role in recognizing the symptoms, patient workup and arriving at appropriate diagnoses, often in consultation with dermatologists. This review discusses the diseases with both cutaneous and intestinal involvement. Hereditary polyposis GI cancers, hereditary nonpolyposis colorectal cancers (CRCs), hamartomatous disorders, and inflammatory bowel disease (IBD) are reviewed with emphasis on the genetic basis, diagnostic, histologic findings, screening modalities, and therapeutic options.
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Affiliation(s)
- Maral Rahvar
- Department of Pathology and Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Justin Kerstetter
- Department of Pathology and Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, CA, USA
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Rodenbeck DL, Kennon AW, Davis LS. Peristomal pyoderma gangrenosum (PG): A simple hydrocolloid dressing technique to promote wound healing. J Am Acad Dermatol 2015; 73:e107-8. [DOI: 10.1016/j.jaad.2015.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/04/2015] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
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Cutaneous manifestations of gastrointestinal disease: part II. J Am Acad Dermatol 2013; 68:211.e1-33; quiz 244-6. [PMID: 23317981 DOI: 10.1016/j.jaad.2012.10.036] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 10/02/2012] [Accepted: 10/03/2012] [Indexed: 02/07/2023]
Abstract
The gastrointestinal (GI) and cutaneous organ systems are closely linked. In part I of this continuing medical education article, the intricacies of this relationship were explored as they pertained to hereditary polyposis disorders, hamartomatous disorders, and paraneoplastic disease. Part II focuses on the cutaneous system's links to inflammatory bowel disease and vascular disorders. An in-depth analysis of inflammatory bowel disease skin findings is provided to aid dermatologists in recognizing and facilitating early consultation and intervention by gastroenterologists. Cutaneous signs of inflammatory bowel disease include fissures and fistulae, erythema nodosum, pyoderma gangrenosum, pyostomatitis vegetans, oral aphthous ulcers, cutaneous polyarteritis nodosa, necrotizing vasculitis, and epidermolysis bullosa acquisita. Additional immune-mediated conditions, such as diverticulitis, bowel-associated dermatosis-arthritis syndrome, Henoch-Schönlein purpura, dermatitis herpetiformis, and Degos disease, in which the skin and GI system are mutually involved, will also be discussed. Genodermatoses common to both the GI tract and the skin include Hermansky-Pudlak syndrome, pseudoxanthoma elasticum, Ehlers-Danlos syndrome, hereditary hemorrhagic telangiectasia, and blue rubber bleb nevus syndrome. Kaposi sarcoma is a neoplastic disease with lesions involving both the skin and the gastrointestinal tract. Acrodermatitis enteropathica, a condition of zinc deficiency, likewise affects both the GI and dermatologic systems. These conditions are reviewed with updates on the genetic basis, diagnostic and screening modalities, and therapeutic options. Finally, GI complications associated with vascular disorders will also be discussed.
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Konopka CL, Padulla GA, Ortiz MP, Beck AK, Bitencourt MR, Dalcin DC. Pioderma Gangrenoso: um Artigo de Revisão. J Vasc Bras 2013. [DOI: 10.1590/s1677-54492013000100006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O pioderma gangrenoso (PG) é uma dermatose crônica com características peculiares e de etiologia desconhecida, muitas vezes de difícil diagnóstico. Manifesta-se através de lesões cutâneas ulceradas e dolorosas com evolução rápida e progressiva, mais comumente em membros inferiores. As ulcerações podem surgir espontaneamente ou depois de variados tipos de trauma. O período entre o início das lesões e o diagnóstico correto costuma ser prolongado. Não existe nenhum tratamento padronizado ou algoritmo simples para a escolha da terapia. Neste artigo, os autores fazem uma ampla revisão da literatura atual acerca da fisiopatologia, do diagnóstico e do tratamento desta patologia através de análise sistemática das referências bibliográficas atuais nas bases de dados PubMed, Scielo, Medline e Lilacs.
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Bonamigo RR, Razera F, Olm GS. Dermatoses neutrofílicas: parte I. An Bras Dermatol 2011; 86:11-25; quiz 26-7. [DOI: 10.1590/s0365-05962011000100002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Indexed: 12/16/2022] Open
Abstract
Os autores apresentam uma revisão das dermatoses neutrofílicas que possuem grande repercussão à saúde dos pacientes: síndrome de Sweet, pioderma gangrenoso, doença de Behçet e urticária neutrofílica. São discutidos, baseados nos resultados e conclusões de estudos relevantes publicados recentemente e na experiência dos autores, os principais aspectos clínicos, as importantes alterações histopatológicas e as opções para o manejo.
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Kaplan R, Baitoo H, Kuchera E. Peristomal pyoderma gangrenosum. J DERMATOL TREAT 2009. [DOI: 10.3109/09546639309084520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Alkhouri N, Hupertz V, Mahajan L. Adalimumab treatment for peristomal pyoderma gangrenosum associated with Crohn's disease. Inflamm Bowel Dis 2009; 15:803-6. [PMID: 18942748 DOI: 10.1002/ibd.20748] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Zabalza M, Feu F, Panés J. Electronic clinical challenges and images in GI. Image 2: Peristomal ulcer after colectomy. Gastroenterology 2008; 135:e3-4. [PMID: 18848936 DOI: 10.1053/j.gastro.2008.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Michel Zabalza
- Gastroenterology Unit, Hospital Clínic, Barcelona, Spain
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Abstract
Pyoderma gangrenosum (PG) is a rare, inflammatory, noninfective, nonneoplastic skin disorder, which is often associated with systemic diseases. These include inflammatory bowel disease, rheumatoid arthritis, paraproteinaemia, or hematologic malignancy, which can be found in up to 50% of patients with some variants of PG. Brunsting et al (Arch Dermatol 1930;22:655-80) first described PG as a disease entity in 5 patients who had painful, enlarging necrotic ulcers with bluish undermined borders surrounded by advancing zones of erythema. Four of these patients had chronic ulcerative colitis. They felt that the condition might be associated with bacterial infection (pyoderma) and considered it as linked to the underlying bowel disease. Although the cause of PG remains obscure, bacterial infection seems to be unrelated to its causation, rendering the term pyoderma redundant. In addition, the number of conditions reported in association with PG has markedly expanded in recent years, showing clearly that this is not solely a cutaneous manifestation of inflammatory bowel disease. The clinical concept of PG has also been broadened, and certain clinical variants of PG have been linked with different types of associated disease seen in these patients.
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Affiliation(s)
- Sharareh Ahmadi
- Regional Dermatology Centre, Mater Misericordiae Hospital, Dublin, Ireland
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Kiran RP, O'Brien-Ermlich B, Achkar JP, Fazio VW, Delaney CP. Management of peristomal pyoderma gangrenosum. Dis Colon Rectum 2005; 48:1397-403. [PMID: 15868233 DOI: 10.1007/s10350-004-0944-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to evaluate the presentation, management, and outcome of peristomal pyoderma gangrenosum at a specialist colorectal unit and develop a strategy for therapy. METHODS Patients with peristomal pyoderma gangrenosum were identified from a prospectively accrued Institutional Review Board-approved stoma database. Data were collected regarding demographics, disease status, history of illness, time to healing, and treatments used from the database and by chart review. RESULTS Sixteen patients presented between 1997 and 2002 with peristomal ulceration consistent with a diagnosis of peristomal pyoderma gangrenosum. Diagnosis was predominantly clinically based on a classic presentation of painful, undermined peristomal ulceration. The underlying diagnosis was Crohn's disease in 11 patients, ulcerative colitis in 3, indeterminate colitis in 1, and posterior urethral valves in 1. At the time of development of peristomal pyoderma gangrenosum, the underlying disease was active in 69 percent of patients. Stoma care, ulcer debridement with unroofing of undermined edges, and intralesional corticosteroid injection was associated with a 40 percent complete response rate and further 40 percent partial response rate. Of five patients who received infliximab, four (80 percent) responded to therapy. Complete response after all forms of therapy, including stoma relocation in seven patients, was 87 percent. CONCLUSIONS Local wound management and enterostomal therapy are extremely important for patients with peristomal pyoderma gangrenosum. Infliximab may provide a useful option for those failing other forms of medical therapy. Relocation of the stoma is reserved for persistent ulceration failing other therapies, because peristomal pyoderma gangrenosum may recur at the new stoma site.
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Affiliation(s)
- R P Kiran
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
Pyoderma gangrenosum (PG) is a non-infectious reactive neutrophilic dermatosis which typically starts with pustules which rapidly evolve to painful ulcers of variable size and depth with undermined violaceous borders. Since its first description in 1930, the pathogenesis of PG has remained elusive even as an ever-widening range of systemic diseases has been described in association with it. The diagnosis of PG is based on clinical and pathologic features and requires exclusion of other conditions that produce ulcerations, since misdiagnosis exposes patients to risks associated with treatment. Critical to proper management are correct diagnosis, identification and treatment of any underlying disorder, and the appropriate choice of topical and systemic therapy. PG has four distinctive clinical and histologic variants, and the specific clinical features of the lesion may provide a clue to the associated disease. The most common associated diseases are inflammatory bowel disease, rheumatological or hematological disease or malignancy. Although there is no single successful treatment for PG, certain type of PG lesions are recognized to respond more readily to accepted therapies than others. Local treatment may be sufficient for mild disease, while systemic immunosuppressive therapy is necessary for severe cases. The treatments with the best clinical evidence are oral or pulse intravenous corticosteroids, and cyclosporine. Surgical therapy is useful in selected cases in conjunction with immunosuppression. Wound stabilization is obtained only through control of the systemic and local inflammatory process. Emerging therapies include use of platelet-derived growth factor and cell culture grafts when re-epithelialization is slow, and the TNF-alpha blocking agent infliximab for refractory disease. Despite advances in therapy, the long-term outcome for patients with PG remains unpredictable, because relapses are common.
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Affiliation(s)
- Curdin Conrad
- Department of Dermatology, University Hospital of Zurich
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Gray M, Catanzaro J. What Interventions Are Effective for Managing Peristomal Pyoderma Gangrenosum? J Wound Ostomy Continence Nurs 2004; 31:249-55. [PMID: 15867722 DOI: 10.1097/00152192-200409000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mikel Gray
- WOCN Center for Clinical Investigation, and Department of Urology and School of Nursing, University of Virginia, Charlottesville, VA 22908, USA.
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Kugathasan S, Miranda A, Nocton J, Drolet BA, Raasch C, Binion DG. Dermatologic manifestations of Crohn disease in children: response to infliximab. J Pediatr Gastroenterol Nutr 2003; 37:150-4. [PMID: 12883301 DOI: 10.1097/00005176-200308000-00013] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Dermatologic extraintestinal manifestations of Crohn disease may be refractory to treatment with corticosteroids and immunomodulators. The authors describe four children with Crohn disease with dermatologic manifestations: pyoderma gangrenosum, orofacial involvement, erythema nodosum, and idiopathic lymphedema. These dermatologic conditions were unresponsive to conventional therapy but had rapid and sustained response to the anti-TNF-alpha antibody infliximab. No adverse reactions occurred. Infliximab should be considered for treating the extraintestinal dermatologic manifestations of Crohn disease in children.
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Affiliation(s)
- Subra Kugathasan
- Division of Pediatric Gastroenterology and Nutrition, Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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Mancini GJ, Floyd L, Solla JA. Parasternal Pyoderma Gangrenosum: A Case Report and Literature Review. Am Surg 2002. [DOI: 10.1177/000313480206800919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Parasternal pyoderma gangrenosum (PPG) is an exceedingly rare disease process most often observed in inflammatory bowel disease patients with an ileostomy. Fewer than 50 cases have been reported in the medical literature. The incidence is 0.6 per cent of patients with ileostomy and inflammatory bowel disease. The rarity of the disease leads to misdiagnosis and mistreatment of the lesion. The intense pain and disruption of ostomy function greatly impair affected individuals beyond the limit of their underlying disease. Current best care practices observed in small study series indicate long-term intensive medical therapy aimed at systemic disease suppression to optimize PPG wound healing. Our patient had no signs of active Crohn disease at the time of PPG presentation. She was initially treated with minimal wound debridement and intralesional triamcinolone. Finally under the care of an enterostomal/wound care therapist the patient achieved excellent PPG resolution in 6 months.
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Affiliation(s)
- Gregory J. Mancini
- From the Graduate School of Medicine, Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Lennis Floyd
- From the Graduate School of Medicine, Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Julio A. Solla
- From the Graduate School of Medicine, Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
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Batres LA, Mamula P, Baldassano RN. Resolution of severe peristomal pyoderma gangrenosum with infliximab in a child with Crohn disease. J Pediatr Gastroenterol Nutr 2002; 34:558-60. [PMID: 12050585 DOI: 10.1097/00005176-200205000-00016] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- L Arturo Batres
- Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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24
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Abstract
The management of pyoderma gangrenosum (PG) requires a structured approach to establishing diagnosis of the disease and assessment of the patient. Clinical management of active PG lesions should be carried out in coordination with other specialists (such as nurses and pain managers) and often necessitates a flexible, innovate attitude to therapy, because the needs of individual patients may vary widely. Although there is no single successful treatment for this disease, certain types of PG lesions are recognized to respond more readily to accepted therapies than others. We outline guidelines to the management of the patient with PG and discuss alternative therapies.
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Affiliation(s)
- Frank C Powell
- Regional Centre of Dermatology, Mater Hospital, Eccles Street, Dublin 7, Ireland.
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25
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Abstract
The management of the patient with inflammatory bowel disease (IBD) is challenging for both the physician and the patient. IBD imposes both a physical and emotional burden on patients' lives. Palliative care is important for IBD patients because it focuses on improving quality of life. While palliative care does not change the natural history of the disease, it provides relief from pain and other distressing symptoms. This article focuses on various aspects of care for IBD patients including pain control, management of oral and skin ulcerations, stomal problems in IBD patients, control of nausea and vomiting, management of chronic diarrhea and pruritus ani, evaluation of anemia, treatment of steroid-related bone disease, and treatment of psychological problems associated with IBD. Each of these areas is reviewed using an evidence-based approach. Evidence in category A refers to evidence from clinical trials that are randomized and well controlled. Category B Evidence refers to evidence from cohort or case-controlled studies. Category C is evidence from case reports or flawed clinical trials. Evidence from category D is limited to the clinical experience of the authors. Evidence labelled as category E refers to situations where there is insufficient evidence available to form an opinion. Algorithms for management of pain and nausea in IBD patients are presented.
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Affiliation(s)
- L B Gerson
- VA Palo Alto Health Care System, California 94304, USA.
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Lyon CC, Smith AJ, Beck MH, Wong GA, Griffiths CE. Parastomal pyoderma gangrenosum: Clinical features and management. J Am Acad Dermatol 2000. [DOI: 10.1067/mjd.2000.104515] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Affiliation(s)
- F C Powell
- Regional Centre of Dermatology, Mater Hospital, Dublin, Ireland
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Bennett ML, Jackson JM, Jorizzo JL, Fleischer AB, White WL, Callen JP. Pyoderma gangrenosum. A comparison of typical and atypical forms with an emphasis on time to remission. Case review of 86 patients from 2 institutions. Medicine (Baltimore) 2000; 79:37-46. [PMID: 10670408 DOI: 10.1097/00005792-200001000-00004] [Citation(s) in RCA: 255] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pyoderma gangrenosum (PG) is an idiopathic, inflammatory, ulcerative disease of undetermined cause. The diagnosis is based on clinical and pathologic features and requires exclusion of conditions that produce ulcerations. An atypical bullous variant (atypical pyoderma gangrenosum, APG) exists with clinical features similar to those of Sweet syndrome. Because PG is a rare disease, few large case series have been reported. Pyoderma gangrenosum was first recognized as a unique disease entity in the first half of the 20th century. Cumulative knowledge of PG is based on a handful of case series and multiple individual case reports. To augment that knowledge, we present our experience with a large number of patients over a significant time. We performed a retrospective analysis of the medical records of 86 patients with PG who were evaluated and treated over 12 years at 2 university-based dermatology departments. The mean (+/- standard deviation) age of onset of PG and APG, respectively, was 44.6 +/- 19.7 years and 52.2 +/- 15.3 years. Lower extremity involvement was most common in PG, whereas upper extremity involvement was most common in APG. Associated relevant systemic diseases were seen in 50% of patients. Inflammatory bowel disease was the most common association in patients with PG, whereas hematologic disease or malignancy was most common in those with APG. Although a few patients were managed with local measures or nonimmunosuppressive treatment, the majority required oral corticosteroid therapy, often with systemic immunosuppressive treatment. PG patients required a mean 11.5 +/- 11.1 months of treatment to achieve remission compared with 9.0 +/- 13.7 months for patients with APG. Five patients (5.8%) had disease that was extremely refractory to multiple intensive therapies. The prognosis and disease associations for PG and APG appear to be different. Compared with PG, APG is more often associated with hematologic disease or malignancy, and remits more quickly.
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Affiliation(s)
- M L Bennett
- Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Lenane P, McKenna D, Murphy GM. Pyoderma gangrenosum secondary to allergic contact dermatitis from rubber. Contact Dermatitis 1998; 38:238. [PMID: 9565317 DOI: 10.1111/j.1600-0536.1998.tb05734.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- P Lenane
- Mater Misericordiae Hospital, Dublin, Ireland
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Abstract
Pyoderma gangrenosum has previously been reported in four patients with HIV infection. We describe here the case of a fifth HIV-infected patient with pyoderma gangrenosum and review the characteristics of the four previously reported cases.
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Affiliation(s)
- H H Clark
- Department of Dermatology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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Abstract
PURPOSE Parastomal pyoderma gangrenosum is uncommon and its association with inflammatory bowel disease is unclear. This is a review of five patients with parastomal pyoderma gangrenosum. METHODS A retrospective review of five patients with ulcerative colitis (two patients) or Crohn's disease (three patients) who have been seen in one surgical unit was conducted. RESULTS All patients were females and each presented within nine months of abdominal surgery and stoma construction. All had active proctitis (n = 3) or perianal Crohn's disease (n = 2). Both patients with perianal Crohn's disease had a mild clinical course with healing of parastomal pyoderma gangrenosum when treated with steroids with and without low-dose cyclosporin A. They both had curettage of the perineal wound as well. In the remaining three patients with active proctitis, the parastomal lesions failed to resolve despite high-dose systemic steroids. By contrast, the parastomal pyoderma gangrenosum healed promptly in two of these patients following proctectomy for active proctitis. CONCLUSION The variable clinical outcome of parastomal pyoderma gangrenosum may be related to the activity of the underlying inflammatory bowel disease or possibly to low-grade perineal sepsis.
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Affiliation(s)
- J J Tjandra
- Department of Surgery, University of Wales College of Medicine, Cardiff, United Kingdom
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Martín de Hijas C, del-Río E, Gorospe MA, Vélez A, García del Pozo JA. Large peristomal pyoderma gangrenosum successfully treated with cyclosporine and corticosteroids. J Am Acad Dermatol 1993; 29:1034-5. [PMID: 7902367 DOI: 10.1016/s0190-9622(08)82037-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- C Martín de Hijas
- Department of Dermatology, Hospital Universitario San Carlos, Madrid, Spain
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