Reconstructive microsurgical approach for the treatment of pyoderma gangrenosum

The role of split-thickness skin grafting in the treatment of vasculitic and pyoderma gangrenosum ulcers in a multidisciplinary wound centre

Vasculitic and pyoderma gangrenosum ulcers are traditionally treated with immunosuppressants, and the role of surgery in the treatment of these atypical ulcers remains unclear. This study aimed to investigate the need for surgical intervention as well as the outcome and safety of skin grafting in the treatment of 46 patients with vasculitic ulcers and 34 with pyoderma gangrenosum ulcers using data recorded in the validated Wound Registry. Of the 80 patients with atypical ulcers, 14% (n = 11) were treated surgically; these patients were older (p = 0.039), had lower mobility status (p = 0.002), and more often pulmonary diseases, rheumatoid arthritis, and previous arterial procedures (p = 0.007; p = 0.031; p = 0.031, respectively) than those treated conservatively. Of 181 ulcers, 15% (n = 27) were surgically treated, 78% once and 22% multiple times. During follow-up, 92.3% of both surgically and conservatively treated ulcers with available data healed. Of the surgically treated ulcers, median healing time after first surgical procedure was 96 days, and post-surgical complications were considered mild or unrelated to surgery. Our results suggest that if surgery is indicated, skin grafting is a safe and efficient treatment method provided that multidisciplinary approach is applied.

Pyoderma gangrenosum following reduction mammoplasty: Systematic review of the literature and case report

BACKGROUND

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that can develop at a surgical site. Diagnosis can be challenging at its presentation causing delays in appropriate treatment. The aim of this study is to review the current literature as well as to describe the clinical presentation, diagnostic pathway, and treatment of PG after reduction mammaplasty in order to define a standardized multidisciplinary diagnostic and therapeutic approach. In the future, this may ease early identification and prompt treatment, and eventually minimize severe morbidity and long-term sequelae.

METHODS

The entire PubMed/Medline database was screened following the PRISMA guidelines to identify studies describing PG that have occurred after reduction mammoplasty.

RESULTS

Twenty-eight articles including 31 patients reported a PG after breast reduction surgery between January 1988 and March 2022. Twenty-one (68%) patients presented with skin ulcerations, 14 (45%) with erythema, and 5 (16%) with vesicles. Out of the 30 cases that underwent bilateral surgery, 18 (60%) developed PG bilaterally. In 12 out of 31 patients, nipple-areolar complex (NAC) involvement was evaluated, though in 10 patients (83%) the NAC was spared. Of the 20 patients (65%) who underwent skin biopsies for histopathological examination, 18 (90%) showed neutrophilic infiltration of the dermal layers. All 31 patients (100%) showed rapid clinical improvement after the introduction of immunosuppressive therapy.

CONCLUSIONS

PG can result in devastating skin alterations also after reduction mammoplasty, if misdiagnosed. However, it presents with constant yet unspecific local and general signs and symptoms that can be recognized to early initiate an appropriate pharmacological treatment.

The Subcalcaneal Fat Pad: An Innovative Space for Passage of the Pedicle in Free Flap Reconstruction of Lateral Heel Defects

Soft-tissue defects of the lateral heel remain a challenge for reconstructive surgeons. Although a reliable vascular supply for free flap anastomosis is available anteriorly from the anterior tibial vessels and medially from the posterior tibial vessels, the vascular anatomy of the lateral side lacks suitable donor vessels for free flap anastomoses. Although the pedicle can be passed either ventrally beneath the skin or dorsally between the Achilles tendon and calcaneus, these passages are hardly applicable for lateral heel defects. We identified the space between the plantar surface of the calcaneus and the plantar aponeurosis as an innovative approach for reconstruction. Therefore, we propose the subcalcaneal fat pad as an alternative and reliable route for the passage of the flap pedicle to the posterior tibial vessels in free flap reconstruction of soft-tissue defects in the lateral calcaneal region. Consequently, the vascular pedicle can be safely anastomosed to the posterior tibial vessels. This approach provides a new option for recipient vessels in free flap reconstruction.

Practical aspects of the diagnosis and management of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.

Successful Management of a Young Patient Suffering From Pyoderma Gangrenosum Following Gastric Bypass Surgery: A Case Report

Pyoderma gangrenosum (PG) is a pathogenetically ill-defined neutrophilic dermatosis frequently characterized by severely painful ulcerations with no identifiable infective pathogens. There are no diagnostic criteria for PG, nor specific gold standard management, which may complicate the process of dealing with patients suffering from this disease. Here, we report a case of a 27-year-old male patient, with a history of gastric bypass surgery three years ago, who presented with a left leg non-healing ulcer diagnosed as a PG by the clinical presentation and biopsy of the ulcer. He was managed by the administration of systemic immunomodulators, a surgical debridement procedure, and the application of a vacuum. The patient was discharged with vitamin B complex and vitamin D supplements as well as zinc sulfate and folic acid. Also, multiple doses of Infliximab intravenously and vitamin B 12 intramuscularly result in a satisfactory healing process of the ulcer. Since PG is a diagnosis of exclusion, clinicians must be aware of the need for highly specific history-taking, previous surgical history, laboratory investigations, and histopathological workup in order to reach the diagnosis.

[Pyoderma gangrenosum of the breast – Case report]

Pyoderma gangrenosum (PG) of the breast is a rare, ulcerative disease of rapid onset normally associated with systemic disorders and triggered by surgery or trauma. Early diagnosis and appropriate treatment of this disease pose a real challenge. We present a case of a PG of the breast in a patient with associated diabetes mellitus, with minor triggering injury. Our patient's condition was diagnosed and treated as an infected breast ulcer; after getting the correct diagnosis we treated her with systemic steroids and finally (at the patient's request) with breast ablation.

The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis

INTRODUCTION

 Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades.

METHODS

 PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test.

RESULTS

 The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p < 0.001). Functional outcomes were more commonly reported between 1990 and 2012 (78.0 vs. 47.5%, p = 0.003); similarly, ambulatory status was reported more often in the previous review (70.0 vs. 40.0%, p = 0.004). This study solely examined the rate at which PCO were reported in the literature; the individual importance and effect on medical outcomes of each PCO was not evaluated.

CONCLUSION

 Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.

The surgical approach to Pyoderma gangrenosum: A retrospective monocenter study

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: A systematic review and personal experience

Pyoderma gangrenosum (PG) is a rare painful ulcerative neutrophilic inflammatory skin disease, necessitating a high level of diagnostic suspicion associated with appropriate treatment to avoid progression. Negative pressure wound therapy (NPWT) has been efficiently used in the treatment of different types of wounds. However, the role of NPWT in the management of PG is still controversial, due to the risk of the pathergy phenomenon. In this article, we conducted a systematic review (according to the PRISMA guidelines) on the use of NPWT in the treatment of PG, and we report our personal experience with two patients treated with this device. The result of the review showed that articles on the topic are, in their entirety, of low levels of evidence, such as case series, case reports, and reviews. Improvement in wound healing with the use of NPWT was observed in 85.1% of the patients studied. Besides, a significant association between improvement in wound healing with NPWT and immunosuppressive therapy was observed. Regarding the cases reported here, both showed good outcomes with the use of NPWT and skin graft during the treatment of PG injuries. Due to the rarity of PG, there is a scarcity of studies with robust evidence for standardization and comparison between treatments, which consequently makes it difficult to select therapeutic options. However, based on this systematic review and reported cases, we consider NPWT a safe option for adjuvant treatment of wounds caused by PG if combined with systemic immunosuppression, which plays a key role in greater chances of successful treatment. This approach should be recommended, whenever possible, associated with skin grafting to accelerate wound closure. The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: a systematic review and personal experience.

[Targeted therapies in Pyoderma gangrenosum: deciphering pathophysiology and improving disease management]

The immune response is a central process during wound healing. Malfunctions often lead to chronic inflammation, barrier disorders, and ulcerations of the skin. The underlying pathomechanisms are complex and the subject of current dermatological research. The care of wound healing disorders is still inadequate and urgently needs improved therapy concepts. For several years now, the development of modern immunomodulators has enabled the targeted regulation of specific signaling cascades, and their effectiveness in the treatment of wound healing disorders has been proven in numerous case studies. Thus, their use not only leads to more efficient therapeutic approaches, but also provides deeper insight into the pathomechanistic importance of specific signaling pathways in inflammatory and degenerative diseases of the skin, which are poorly understood so far. Pyoderma gangrenosum, an autoinflammatory disease, provides a good example to illustrate the progress in therapy and pathomechanistic understanding through the use of new immunomodulators and is explained in more detail in the following article.

"Pyoderma gangrenosum of the breast: A challenging diagnosis"

Pyoderma gangrenosum (PG) of the breast is a rare, ulcerative disease of rapid onset normally associated with systemic disorders and triggered by surgery or trauma. Pyoderma gangrenosum poses a diagnostic challenge. Early diagnosis and appropriate treatment are essential to minimize morbidity and sequelae. We performed a retrospective review of all breast PG cases admitted to Cruces University Hospital over a 5-year (2015-2019) period. Medical history, clinical course, and management strategies were assessed. Three patients were analyzed. None of them had previous surgery. No definitive etiology was identified in one case, and the other two were probably biopsy-driven. Histological findings were reported as nonspecific. Similar skin lesions elsewhere on the body and resistance to wide-spectrum antibiotic therapy were observed. These features raised awareness on the diagnosis of PG. Ulcerations healed completely within 2 months following treatment with Cyclosporine A or corticosteroid therapy. A complicated late-diagnosis case that presented with advanced breast and forearm necrosis was managed with steroids followed by trans-forearm amputation and mastectomy. The breast is an unusual site for PG, but this differential diagnosis should be considered in the presence of breast ulceration. In patients with a strong clinical and histological PG suspicion, we suggest early management with systemic corticosteroids and immunosuppressive therapy prior to any surgical debridement to minimize morbidity and poor esthetic outcomes.

Surgical Treatment of Pyoderma Gangrenosum with Negative Pressure Wound Therapy and Skin Grafting, Including Xenografts: Personal Experience and Comprehensive Review on 161 Cases

Significance: Pyoderma gangrenosum (PG) is a rare debilitating autoinflammatory ulcerative skin disease. No gold standard has been established for the treatment of PG. The role of surgical interventions and negative pressure wound therapy (NPWT) was discussed controversially until recently as these procedures might pose a trigger to further aggravate the condition. Recent Advances: Recent advances confirm the paradigm change that a surgical approach of PG with split thickness skin grafting (STSG) secured by NPWT is a safe and valuable treatment if performed under adequate immunosuppression. We elaborate this on the hand of a broad literature search retrieving 101 relevant articles describing 138 patients complemented with our personal experience on 23 patients, including 2 patients treated with a porcine xenodressing. Critical Issues: A wide range of surgical approaches have been reported, including xenografts. Treatment was finally successful in 86%, including the xenotransplant cases. Ten percent improved and failures were mainly reported without immunosuppression. Despite halting the inflammatory process, NPWT alone, without skin grafting, does not much accelerate healing time. The best surgical approach appears to be STSG fixed with NPWT as this leads to higher skin graft take. There remains the problem of the chronic nature of PG and the recurrence after tapering of immunosuppression or trauma; therefore, a sustained immunosuppressive treatment is suggested. Future Directions: While surgical treatment is supported by the published data, the exact immunosuppression is still evolving. Due to deeper insights into pathogenesis and growing clinical reports, a broader utilization of biologic treatments and a shift from tumor necrosis factor (TNF)-alpha to interleukin (IL)-12/23 or IL-23 antibodies alone are predictable, as IL-12/23 antibodies show good clinical responses with fewer side effects. The positive results with porcine xenodressings might be due to immunological effects of the xenomaterial; they appear promising, but are preliminary and should be confirmed in a larger patient collective.

Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review

Pyoderma gangrenosum (PG) is a rare ulcerative skin disease that presents a therapeutic challenge. Tumour necrosis factor alpha (TNFα) inhibitors have been reported to successfully control PG. Our aim was to systematically evaluate and compare the clinical effectiveness of TNFα inhibitors in adults with PG. A literature search including databases such as PubMed, Embase, Scopus, and Web of Science was conducted, using search terms related to PG and TNFα inhibitors. Studies and case reports were included if patients were diagnosed with PG, over the age of 18 and administered TNFα inhibitor. A total of 3212 unique citations were identified resulting in 222 articles describing 356 patients being included in our study. The study we report found an 87% (95% CI: 83%-90%) response rate and a 67% (95% CI: 62%-72%) complete response rate to TNFα inhibitors. No statistically significant differences in the response rates (P = 0.6159) or complete response rates (P = 0.0773) to infliximab, adalimumab, and etanercept were found. In our study TNFα inhibitors demonstrated significant effectiveness with response and complete response rates supporting the use of TNFα inhibitors to treat PG in adults. Our study suggests that there is no significant difference in effectiveness among infliximab, adalimumab, and etanercept.