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Delaleu J, Bouaziz JD. Overview of Neutrophilic Biology, Pathophysiology, and Classification of Neutrophilic Dermatoses. Dermatol Clin 2024; 42:147-156. [PMID: 38423677 DOI: 10.1016/j.det.2023.08.002] [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
Neutrophilic dermatoses are a group of inflammatory skin conditions characterized by a neutrophilic infiltrate on histopathology with no evidence of infection. These conditions present with a wide range of clinical manifestations, including pustules, bullae, abscesses, papules, nodules, plaques, and ulcers. The classification of neutrophilic dermatoses is based on the localization of neutrophils in the skin. The pathogenic mechanisms of neutrophilic dermatoses involve autoinflammation, neutrophilic dysfunction, clonal somatic mutation and differentiation of the myeloid precursors as encountered in myeloid neoplasm.
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Affiliation(s)
- Jérémie Delaleu
- Dermatology Department, Saint Louis Hospital, APHP Nord Université Paris Cité and INSERM u976 "Human Immunology, Pathophysiology and Immunotherapy", Paris, France
| | - Jean-David Bouaziz
- Dermatology Department, Saint Louis Hospital, APHP Nord Université Paris Cité and INSERM u976 "Human Immunology, Pathophysiology and Immunotherapy", Paris, France.
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2
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Kipers T, Tolkachjov SN. Postoperative and Peristomal Pyoderma Gangrenosum: Subtypes of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:171-181. [PMID: 38423679 DOI: 10.1016/j.det.2023.12.001] [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
Postoperative pyoderma gangrenosum and peristomal pyoderma gangrenosum are 2 subtypes of pyoderma gangrenosum. The diagnosis is made as a clinicopathologic correlation when assessing a rapidly progressing ulcer with irregular and undermined borders following a surgical procedure, trauma, or the creation of a stoma. Familiarity with the associated risk factors and distinguishing features of these disorders can facilitate prompt recognition, proper diagnosis, and the initiation of treatment. Management usually involves the use of corticosteroids and steroid-sparing agents as immunomodulators to shift the inflammatory neutrophilic dermatoses to chronic noninflammatory wounds and eventual healing.
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Affiliation(s)
- Théodora Kipers
- School of Medicine, Texas A&M University School of Medicine, 5536 Tremont Street, Dallas, TX 75214, USA
| | - 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, TX 75056, USA.
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3
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Wei H, Wang K, Huang W, Liu Y. Postoperative Pyoderma Gangrenosum in a Patient Presenting with Acute Peripheral Artery Disease Secondary to Antiphospholipid Syndrome: A Case Report. Clin Cosmet Investig Dermatol 2024; 17:451-455. [PMID: 38404477 PMCID: PMC10887867 DOI: 10.2147/ccid.s451771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/06/2024] [Indexed: 02/27/2024]
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic dermatosis clinically characterized by painful nodules, red papules or plaques that rapidly erode into ulcers. We report a 53-year-old febrile male patient with acute peripheral arterial disease who underwent transtibial amputation after failed thrombolysis. Five days after amputation, an ulcer developed around the cannulation site of the right internal jugular vein that was indicative of pathergy. The patient's fever did not improve after surgery, and purpuric discoloration and punctate ulcers of the skin near the amputation site became apparent, leading to re-debridement. Finally, consultation with a dermatologist raised the possibility of postoperative PG, and additional laboratory tests revealed positive anticardiolipin autoantibodies consistent with antiphospholipid syndrome. The patient was treated with intravenous glucocorticosteroids and antibiotics, and the amputation wound and cannulation site ulcer were found to have healed at the 2-month follow-up. The current report raises the need for vascular surgeons to be aware of this uncommon etiology of arterial thrombosis, and the postoperative appearance of dermatosis and pathergy should alert for PG.
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Affiliation(s)
- Haijun Wei
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People’s Republic of China
| | - Ke Wang
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People’s Republic of China
| | - Wei Huang
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People’s Republic of China
| | - Yang Liu
- Department of Vascular Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, People’s Republic of China
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4
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Taheri A, Mansoori P, Sharif M. Wound Debridement in Pyoderma Gangrenosum. Adv Skin Wound Care 2024; 37:107-111. [PMID: 38241454 DOI: 10.1097/asw.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
BACKGROUND Wound debridement improves healing in a variety of acute and chronic ulcers. However, there is concern that debridement may trigger pathergy and worsen pyoderma gangrenosum (PG). OBJECTIVE To determine whether published evidence supports conservative wound debridement for PG. DATA SOURCES The authors reviewed the literature published in MEDLINE through January 2023 using the search germs "pyoderma gangrenosum" and "debridement." STUDY SELECTION Articles reporting sharp surgical debridement or maggot debridement for PG were included in the review. The authors also searched the reference sections of the reviewed articles for additional reports on debridement for PG. DATA EXTRACTION Clinical data regarding patient status, procedures performed, and patient outcomes were extracted from the selected articles. DATA SYNTHESIS There are multiple reports of uncontrolled, active-phase PG wounds worsening after aggressive excisional debridement of viable inflamed tissues. In contrast, there is no evidence indicating that conservative debridement of nonviable necrotic tissue worsens PG wounds, regardless of the disease activity. There are multiple reports of successful debridement and surgical grafting for PG in remission. CONCLUSIONS There is no evidence in favor of or against using conservative debridement of nonviable necrotic tissue for a PG wound. Therefore, it should not be considered contraindicated, even in the active phase of the disease.
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Affiliation(s)
- Arash Taheri
- Arash Taheri, MD, is Internal Medicine Physician, JenCare Senior Medical Center, Atlanta, Georgia, United States. Parisa Mansoori, MD, is Dermatopathologist, Atlanta Dermatopathology, Atlanta, Georgia. Mohammad Sharif, DPM, is Podiatrist, Village Podiatry Centers, Atlanta, Georgia
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5
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Edek YC, Temirkaynak MK, Temel B, Urgancı M, Öğüt B, Adışen E. Postoperative Pyoderma Gangrenosum Following Carpal Tunnel Surgery: A Case Report and Review of the Literature. Cureus 2024; 16:e54590. [PMID: 38523971 PMCID: PMC10959458 DOI: 10.7759/cureus.54590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by painful ulcerated lesions. Postoperative PG, which typically begins with erythema and severe pain within two weeks after surgery, progresses into ulcerated lesions. It is often misdiagnosed as it resembles necrotizing skin infections, resulting in delayed treatment. Cases of postoperative PG located in the upper extremity are uncommon. In this case report, we discuss a male patient who developed postoperative PG after carpal tunnel surgery.
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Affiliation(s)
| | | | - Berkay Temel
- Dermatology, Ankara Training and Research Hospital, Ministry of Health, Ankara, TUR
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6
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Obinwanne V, Hoffmann Guarda N, Araoye E, James AJ. Extensive Pyoderma gangrenosum following breast reduction and abdominoplasty: a challenging case. Case Reports Plast Surg Hand Surg 2024; 11:2302124. [PMID: 38274559 PMCID: PMC10810620 DOI: 10.1080/23320885.2024.2302124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024]
Abstract
Post-surgical pyoderma gangrenosum (P SP G) is a subtype of pyoderma gangrenosum in which non-infectious, painful, inflammatory ulcerative nodules develop in incision sites. Delayed diagnosis and surgical interventions of P SP G often contribute to worsened morbidity. We present a case of a 55-year-old female diagnosed with severe P SP G after breast augmentation and abdominoplasty.
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Affiliation(s)
- Vera Obinwanne
- Western Michigan Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Nathalia Hoffmann Guarda
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - Erinolaoluwa Araoye
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alaina J. James
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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7
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Varas-Rodríguez E, Cedeño F, Gonzalez-Diaz G, Vivas J, Salgueiro A, Dávila K, Nevarez Pomales O, Duyos O. Postsurgical Pyoderma Gangrenosum After Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00034. [PMID: 38015935 DOI: 10.2106/jbjs.cc.23.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
CASE A 61-year-old woman with lower back and radicular leg pain underwent minimally invasive spinal fusion at L5-S1. By postoperative day 6, she exhibited erythema, wound dehiscence, and necrotic changes. Although a necrotizing infection was initially suspected, multiple debridements and antibiotic therapy failed to improve her condition. The patient was eventually diagnosed with pyoderma gangrenosum (PG) and was managed with immunosuppressants and extended wound care. CONCLUSION PG is a rare dermatosis that is often misdiagnosed, leading to inappropriate treatment, debridements, and additional complications. Prompt identification and multidisciplinary collaboration are key to preventing unnecessary interventions and achieving the best outcomes.
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Affiliation(s)
| | - Francis Cedeño
- School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Joshua Vivas
- School of Medicine, Ponce Health Sciences University, Ponce, Puerto Rico
| | - Ariana Salgueiro
- Department of Environmental Sciences, Loyola University, New Orleans, Louisiana
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8
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Wang J, Jiang S, Shi X, Li W, Yu Q, Pan T, Mu Y, Chen L. A Case of Pyoderma Gangrenosum after Partial Small Bowel Resection. Adv Skin Wound Care 2023; 36:1-3. [PMID: 37729170 DOI: 10.1097/asw.0000000000000045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
ABSTRACT Pyoderma gangrenosum (PG) is a rare, noninfectious inflammatory disease of unknown etiology that affects the skin and mucous membranes. The development of PG after partial small bowel resection is very rare and can initially resemble an infectious complication, although it is an inflammatory disease.This report presents the case of a 55-year-old man who underwent partial small bowel resection for incomplete intestinal obstruction and developed postoperative infection-like manifestations, including redness and swelling of the incision, severe pain, and yellow-green turbid fluid from the drainage tube. After completing a skin biopsy that suggested massive neutrophil infiltration, multiple secretion cultures for Pseudomonas aeruginosa (+), and systemic screening without other comorbidities, a diagnosis of postoperative PG and P aeruginosa infection was determined.Early detection of this complication is essential for patient recovery because primary surgical treatment, which is contraindicated in such cases, can worsen PG. Therefore, PG should be treated conservatively with corticosteroids.
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Affiliation(s)
- Jianing Wang
- In the Department of Dermatology, the Second Affiliated Hospital of Soochow University, Suzhou, China, Jianing Wang, MD, and Shiyao Jiang, MD, are Residents; Xin Shi, BS, is Chief Physician; and Wenlin Li, MD, and Qianchun Yu, MD are also Residents. In the Department of Dermatology, Suzhou Municipal Hospital, Ting Pan, MD, and Yuzhu Mu, MD, are Residents; and Lingling Chen, MD, is Chief Physician
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9
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Ragsdale LB, Sarhaddi D, Nathan C. Novel Use of Wound Matrix in Mastopexy Complicated by Pyoderma Gangrenosum. Aesthet Surg J Open Forum 2023; 5:ojad085. [PMID: 37899911 PMCID: PMC10603583 DOI: 10.1093/asjof/ojad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a relatively uncommon inflammatory skin disorder that is characterized by rapid onset, ulcerative lesions, and often triggered by trauma or surgery. Although rare, PG of the breast has been well described in the plastic surgery literature, most often reported following breast reductions and reconstructions. The authors present a case of PG that developed in a 56-year-old patient, with a history of essential thrombocytosis, following mastopexy. Her significant full-thickness skin loss was successfully treated with steroids and then reconstructed via serial applications of porcine placental extracellular matrix grafts. Her wounds were completely healed in 3.5 months for the left, and 5 months for the right breast. To the best of the author's knowledge, this is the first published case in which placental grafts have been successfully used to reconstruct pyoderma wounds of the breast. Given their advantageous scarring and lack of donor-site morbidity, placental grafts should be considered for all breast surgery patients afflicted by PG. Level of Evidence 5
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Affiliation(s)
| | | | - Charles Nathan
- Corresponding Author: Dr Charles Nathan, 17300 N. Outer 40 Rd., Chesterfield, MO 63005, USA. E-mail:
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10
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Yamamoto T, Yamasaki K, Yamanaka K, Komine M, Kawakami T, Yamamoto O, Kanekura T, Higuchi T, Takahashi T, Matsushima Y, Kikuchi N. Clinical guidance of pyoderma gangrenosum 2022. J Dermatol 2023; 50:e253-e275. [PMID: 37311717 DOI: 10.1111/1346-8138.16845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.
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11
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Shono Y, Sekioka A, Ota S, Ito T, Adachi Y. A Rare Case of Severe Post-operative Pyoderma Gangrenosum After Surgery for Perforated Diverticulitis at the Sigmoid Colon. Cureus 2023; 15:e35807. [PMID: 37025752 PMCID: PMC10074223 DOI: 10.7759/cureus.35807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a nonbacterial ulcerating skin condition. It is typically associated with other systemic disorders. However, approximately 20%-30% of cases are idiopathic. Post-operative PG (PPG) is a rare type of PG with a rapidly expanding cutaneous ulcer at a surgical site and is often misdiagnosed as a wound infection. The difficulty in diagnosis can lead to unnecessary surgical interventions and delay in the treatment of PG. Herein, we present the case of a 68-year-old patient with severe PPG with no underlying diseases. He underwent an emergency laparotomy (Hartmann's procedure) for perforated diverticulitis. After the operation, systemic inflammatory response syndrome (SIRS) developed and the skin around the incisional wound, stoma, injection venous lines, and electrocardiogram monitoring pads gradually became erythematous. Skin biopsy and the absence of a source of infection confirmed the diagnosis of PG. Drug therapy for PG with steroids, and tumor necrosis factor-α inhibitors improved SIRS and the patient recovered.
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12
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Delaleu J, Lepelletier C, Calugareanu A, De Masson A, Charvet E, Petit A, Giurgea I, Amselem S, Karabina S, Jachiet M, Mahevas T, Ram-Wolff C, Vignon-Pennamen MD, Bagot M, Battistella M, Bouaziz JD. Neutrophilic dermatoses. Rev Med Interne 2022; 43:727-738. [PMID: 35870984 DOI: 10.1016/j.revmed.2022.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 04/27/2022] [Accepted: 06/12/2022] [Indexed: 10/17/2022]
Abstract
Neutrophilic dermatoses (ND) are a group of inflammatory skin conditions characterized by a neutrophilic infiltrate on histopathology with no evidence of infection. ND are classified based upon the localization of neutrophils within the skin and clinical features. Recent findings suggest that ND are due to two main mechanisms: i) a polyclonal hereditary activation of the innate immune system (polygenic or monogenic); or ii) a clonal somatic activation of myeloid cells such as encountered in myelodysplastic syndrome or VEXAS syndrome. ND belong to internal medicine as a great number of patients with ND suffer from an underlying condition (such as hematological malignancy, inflammatory bowel disease, auto-immune and auto-inflammatory diseases). ND are diagnoses of exclusion and physicians should always consider differential diagnoses, particularly skin infections. Here, we review the pathophysiology and classification of the main ND (i.e., subcorneal pustular dermatosis (Sneddon-Wilkinson Disease) and Intercellular IgA dermatoses, aseptic pustulosis of the folds, Sweet syndrome, neutrophilic eccrine hidradenitis, pyoderma gangrenosum, erythema elevatum diutinum, neutrophilic urticarial dermatosis and neutrophilic panniculitis), their clinical and histopathological features, and we highlight the investigations that are useful to identify ND-associated diseases and to exclude the differential diagnoses.
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Affiliation(s)
- J Delaleu
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France; Inserm u933, "Childhood genetic disorders", service de génétique, Sorbonne université, hôpital Armand-Trousseau, AP-HP, Paris, France
| | - C Lepelletier
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - A Calugareanu
- Service de dermatologie, Severe Cutaneous Adverse Reaction (SCAR) Regional Center, HCL, CHU de Lyon Centre, Lyon, France
| | - A De Masson
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - E Charvet
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - A Petit
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - I Giurgea
- Inserm u933, "Childhood genetic disorders", service de génétique, Sorbonne université, hôpital Armand-Trousseau, AP-HP, Paris, France
| | - S Amselem
- Inserm u933, "Childhood genetic disorders", service de génétique, Sorbonne université, hôpital Armand-Trousseau, AP-HP, Paris, France
| | - S Karabina
- Inserm u933, "Childhood genetic disorders", service de génétique, Sorbonne université, hôpital Armand-Trousseau, AP-HP, Paris, France
| | - M Jachiet
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - T Mahevas
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - C Ram-Wolff
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - M-D Vignon-Pennamen
- Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France; Service d'anatomie pathologique, hôpital Saint-Louis, AP-HP, Paris, France
| | - M Bagot
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France
| | - M Battistella
- Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France; Service d'anatomie pathologique, hôpital Saint-Louis, AP-HP, Paris, France
| | - J-D Bouaziz
- Service de dermatologie, hôpital Saint-Louis, AP-HP, Paris, France; Inserm u976 "Human Immunology, Pathophysiology and Immunotherapy", université Paris Cité, Paris, France.
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13
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Coste V, Klopfenstein T, Andreoletti JB, Clerc J, Noel AC, Gendrin V, Ducournau A, Zayet S. Pyoderma Gangrenosum as Differential Diagnosis to Post-Operative Infection after Breast Plastic Surgery. Surg Infect (Larchmt) 2022; 23:604-606. [PMID: 35649209 DOI: 10.1089/sur.2021.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Pyoderma gangrenosum is a scarce ulcerating inflammatory skin disease, which requires excluding other causes of ulceration such as infections, malignancies or connective tissue diseases. Case Report: We report the case of a 38-year-old woman who developed a progressive bilateral breast skin ulcer after breast plastic surgery, suspected initially with an early postoperative infection. The lack of improvement despite adequate antimicrobial drugs conducted to perform a skin biopsy, concluding to an ulcerated neutrophil dermatosis which led to the diagnosis of postoperative pyoderma gangrenosum. The clinical course was favorable with a systemic treatment based on steroids. Conclusions: In order to prevent debridement and extension of local complications, this case report illustrates the importance to suspect pyoderma gangrenosum as differential diagnosis of infection after surgery.
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Affiliation(s)
- Victor Coste
- Infectious Disease Department, Nord Franche-Comté Hospital, Trevenans, France
| | | | | | - Johanna Clerc
- Pathology Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Albin Chevet Noel
- Plastic Surgery Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Vincent Gendrin
- Infectious Disease Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Anne Ducournau
- Dermatology Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Souheil Zayet
- Infectious Disease Department, Nord Franche-Comté Hospital, Trevenans, France
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14
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Michel D, Dege T, Kneitz H, Stumpf M, Goebeler M, Schmieder A. Pyoderma gangraenosum als diagnostische und therapeutische
interdisziplinäre Herausforderung. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1798-5164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDas Pyoderma gangraenosum (PG) ist eine neutrophile Dermatose unklarer Genese,
die sowohl in Assoziation zu hämatologischen und neoplastischen
Systemerkrankungen, chronisch-entzündlichen Darmerkrankungen und
autoinflammatorischen Syndromen als auch idiopathisch auftreten kann. Sowohl die
Diagnosestellung wie auch die Therapie des PG stellen aufgrund seiner
Seltenheit, des Fehlens großer randomisierter kontrollierter Studien und
der unzureichend verstandenen Pathogenese eine Herausforderung in der klinischen
Praxis dar. Diese Übersichtsarbeit beschreibt und diskutiert aktuelle
Erkenntnisse, die das PG als autoinflammatorische Erkrankung beschreiben. Durch
eine Dysregulation von T-Lymphozyten und myeloiden Zellen wie den neutrophilen
Granulozyten kommt es zur Entstehung von Pusteln und
großflächigen Ulzera. Klassische Therapieansätze
umfassen eine anti-inflammatorische topische Therapie, eine Analgesie sowie die
systemische Gabe von Immunmodulantien oder -suppressiva. Neuere, bisher nicht
zugelassene Therapieoptionen sind der Einsatz von Biologika und
JAK-Inhibitoren.
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Affiliation(s)
- Daniel Michel
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Tassilo Dege
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Hermann Kneitz
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Marco Stumpf
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Matthias Goebeler
- Dermatologie, Universitätsklinikum Würzburg Klinik und
Poliklinik für Dermatologie Venerologie und Allergologie,
Würzburg, Germany
| | - Astrid Schmieder
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
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15
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Rasul TF, Mathew M, Anderson JD, Bergholz DR, Henderson A. Resource-Limited Management of Presumptive Pyoderma Gangrenosum in an Unsheltered Patient. Cureus 2022; 14:e21629. [PMID: 35228976 PMCID: PMC8877731 DOI: 10.7759/cureus.21629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/05/2022] Open
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16
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Dermatologic Complications Following Cosmetic and Reconstructive Plastic Surgery: A Systematic Review of the Literature. Aesthetic Plast Surg 2021; 45:3005-3018. [PMID: 34231016 DOI: 10.1007/s00266-021-02362-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Plastic surgery procedures, including minimally invasive cosmetic procedures, continue to grow in popularity. Although dermatologic complications following plastic surgery procedures are rare, the authors have encountered several of these complications in their practice, including herpes simplex virus (HSV-1) and varicella zoster virus (VZV) infections, pyoderma gangrenosum (PG), contact dermatitis, and suture hypersensitivity. These cases prompted a systematic literature review of dermatologic complications following plastic surgery procedures. METHODS The authors conducted a systematic review of PubMed, MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Library to identify relevant articles published from 1975 to 2021. Articles were independently reviewed by the authors to determine whether studies met inclusion criteria. RESULTS The majority of articles that met inclusion criteria represented level V evidence. The most robust evidence in the literature was for PG, for which there were 63 total studies. Pyoderma gangrenosum was most frequently reported following breast surgery (85.1%), while HSV-1 infections were frequently seen following minimally invasive procedures (84.6%). VZV reactivation was reported after a range of interventions, including pedicled flap surgeries and laser treatments. Other complications, such as suture hypersensitivity, were less frequently reported in the literature, usually as isolated case reports. CONCLUSIONS Dermatologic complications represent a rare but serious concern following plastic surgery procedures. While most dermatologic complications resolve with appropriate treatment, sequelae of these conditions can be devastating to the patient's overall outcome. Plastic surgeons performing procedures at a high risk of these complications should recognize the diagnostic criteria to facilitate appropriate treatment. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Bellamy JT, Ananthakrishnan D. Postoperative Pyoderma Gangrenosum After Thoracolumbar Spinal Fusion with Instrumentation: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00051. [PMID: 34762609 DOI: 10.2106/jbjs.cc.21.00461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 65-year-old man with scoliosis underwent posterior spinal fusion with instrumentation from T4 to pelvis and subsequently developed wound complications eventually diagnosed to be secondary to postoperative pyoderma gangrenosum (PPG). Once immunosuppressant medications were initiated, the wound gradually improved and went on to heal after a prolonged period of wound care. CONCLUSION Postoperative PG is a challenging problem for the orthopaedic surgeon; a multidisciplinary approach is beneficial. Early recognition of the diagnosis is imperative to limit morbidity because debridements for a presumed infectious etiology are likely to exacerbate the disease through a process called pathergy.
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Affiliation(s)
- J Taylor Bellamy
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Thornburg DA, Aime V, James S, Gupta N, Bernard R, Johnson ML. Pyoderma Gangrenosum: A Rare Disease With Dire Consequences in Facial Aesthetic Surgery Patients. Aesthet Surg J 2021; 41:NP709-NP716. [PMID: 33471065 DOI: 10.1093/asj/sjab026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, inflammatory dermatologic condition characterized by painful cutaneous ulcerations. Herein, we describe the third documented case of PG arising in an elective plastic surgery patient who had undergone an otherwise uncomplicated facelift. We describe the course of her diagnosis and management of PG, which involved her face and neck and then progressed to her lower extremities. Although the etiology remains unknown, PG often arises in a host with another autoimmune disease. In the case described, the patient was diagnosed with an immunoglobulin A gammopathy shortly after she developed PG. Following the case report, the pathogenesis, diagnosis, and treatment strategy of PG is briefly reviewed. Level of Evidence: 5.
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Affiliation(s)
- Danielle A Thornburg
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
| | - Victoria Aime
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
| | | | - Nikita Gupta
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Robert Bernard
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
| | - Martin L Johnson
- Mayo Clinic Arizona, Division of Plastic and Reconstructive Surgery, Phoenix, AZ, USA
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Postsurgical pyoderma gangrenosum: A diagnosis we cannot miss. Med Clin (Barc) 2021; 157:597. [PMID: 34045074 DOI: 10.1016/j.medcli.2021.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 11/20/2022]
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21
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Milam EC, Rangel LK, Pomeranz MK. Dermatologic sequelae of breast cancer: From disease, surgery, and radiation. Int J Dermatol 2020; 60:394-406. [PMID: 33226140 DOI: 10.1111/ijd.15303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 01/24/2023]
Abstract
The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.
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Affiliation(s)
- Emily C Milam
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Lauren K Rangel
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Miriam K Pomeranz
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
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Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that presents with rapidly developing, painful skin ulcers hallmarked by undermined borders and peripheral erythema. Epidemiological studies indicate that the average age of PG onset is in the mid-40s, with an incidence of a few cases per million person-years. PG is often associated with a variety of other immune-mediated diseases, most commonly inflammatory bowel disease and rheumatoid arthritis. The cause of PG is not well understood, but PG is generally considered an autoinflammatory disorder. Studies have focused on the role of T cells, especially at the wound margin; these cells may support the destructive autoinflammatory response by the innate immune system. PG is difficult to diagnose as several differential diagnoses are possible; in addition to clinical examination, laboratory tests of biopsied wound tissue are required for an accurate diagnosis, and new validated diagnostic criteria will facilitate the process. Treatment of PG typically starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) to reduce inflammation followed by the addition of more slowly acting immunosuppressive drugs with superior adverse event profiles, including biologics (in particular, anti-tumour necrosis factor (TNF) agents). Appropriate wound care is also essential. Future research should focus on PG-specific outcome measures and PG quality-of-life studies.
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Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines. Ann Plast Surg 2020; 83:63-68. [PMID: 31095530 DOI: 10.1097/sap.0000000000001782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery. METHODS This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included. RESULTS Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days. CONCLUSIONS Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.
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Alonso-León T, Hernández-Ramírez HH, Fonte-Avalos V, Toussaint-Caire S, E Vega-Memije M, Lozano-Platonoff A. The great imitator with no diagnostic test: pyoderma gangrenosum. Int Wound J 2020; 17:1774-1782. [PMID: 32779354 DOI: 10.1111/iwj.13466] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022] Open
Abstract
Pyoderma gangrenosum is a rare, neutrophil-mediated, auto-inflammatory dermatosis that wound care specialists must be prepared to recognise. This condition has clinical features analogous to infectious processes. There is no specific diagnostic test and the diagnosis is usually obtained from exclusion. Its early recognition and proper management with prompt initiation of immunosuppressive therapy are essential to improve the quality of life and the prognosis of patients.
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Affiliation(s)
- Teresa Alonso-León
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | | | - Veronica Fonte-Avalos
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Sonia Toussaint-Caire
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - María E Vega-Memije
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
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Cabañas Weisz LM, Vicario Elorduy E, García Gutiérrez JJ. "Pyoderma gangrenosum of the breast: A challenging diagnosis". Breast J 2020; 26:2188-2193. [PMID: 32713082 DOI: 10.1111/tbj.13984] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022]
Abstract
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.
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Hoelscher S, Hunter A, Barcak E, Wheeler M, Mapula S. Orthopaedic Trauma-Induced Pyoderma Gangrenosum: A Case Report. JBJS Case Connect 2020; 10:e0562. [PMID: 32649133 DOI: 10.2106/jbjs.cc.19.00562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a case of a 60-year-old polytraumatized man who developed postoperative pyoderma gangrenosum (PG) after his initial stabilization procedures, mimicking a postoperative infection. This caused a delay in diagnosis, leading to progression of his wounds and a delay in initiation of the appropriate treatment. Once his PG was appropriately treated, his clinical status and wounds improved. He underwent successful wound coverage by plastic surgery and has been recovering from his injuries. CONCLUSION Prompt identification and initiation of treatment for postoperative PG is critical to avoid exacerbation of wounds and subsequent morbidity to the patient.
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Affiliation(s)
- Skyler Hoelscher
- 1Department of Orthopaedic Surgery, JPS Health Network, Fort Worth, Texas
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Pyoderma Gangrenosum Masquerading as Necrotizing Infection after Autologous Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2596. [PMID: 32440390 PMCID: PMC7209838 DOI: 10.1097/gox.0000000000002596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022]
Abstract
Pyoderma gangrenosum (PG) is a diagnostic dilemma when it presents with a superimposed infection and previous surgery without subsequent inflammatory infection. In this setting, PG is not at the forefront of the surgeon’s mind. Furthermore, the treatment for PG, systemic steroids, may cause serious morbidity if the necrotizing infection is the actual culprit. We present an autologous breast reconstruction patient with previous uncomplicated surgery and no personal history of inflammatory disease. Important clinic clues to aid the surgeon in diagnosis include irregular violaceous undermined border, purulence limited to the skin, bilateral involvement, the involvement of the abdominal wound, sparing of the mastectomy site, and relative sparing of the nipples and umbilicus.
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Rare Presentation of Postsurgical Pyoderma Gangrenosum Presenting as Necrotizing Soft Tissue Infection. Adv Skin Wound Care 2020; 32:507-511. [PMID: 31498172 PMCID: PMC7328872 DOI: 10.1097/01.asw.0000579692.74662.bb] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis believed to be mediated by an autoimmune reaction. Typical treatment includes autolytic debridement, management of exudate, protection from trauma, and steroid therapy. A diagnosis of exclusion, PG is frequently mistaken for a wound infection, but antibiotics do not alleviate the condition. Incision and debridement has been observed to cause further spread of the lesions because of pathergy resulting from the additional trauma. This case report describes a patient who was misdiagnosed with necrotic soft tissue infection that was actually postsurgical PG.
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Snyder MH, Ampie L, Forrester VJ, Wilson JC, Nguyen JH, Shaffrey CI, Buchholz AL. Postoperative pyoderma gangrenosum after spinal fusion with instrumentation: case report. J Neurosurg Spine 2020; 32:285-291. [DOI: 10.3171/2019.7.spine19708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/31/2019] [Indexed: 11/06/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory dermatosis that is most often associated with inflammatory bowel disease, but which can occur as a pathergic reaction around surgical incisions. The authors report the case of a patient who developed postoperative PG over the course of several months after undergoing extensive spinal instrumentation between the T4 and iliac levels. This is only the second such case occurring after spine surgery to be reported. The authors additionally review the literature to characterize treatment approaches and outcomes for this condition. The case highlights a potentially severe adverse effect of surgery that can be difficult to recognize and causes delays in effective treatment. It also demonstrates the importance of multidisciplinary collaboration in the effective care of patients.
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Affiliation(s)
| | | | - Vernon J. Forrester
- 2Dermatology, University of Virginia Health System, Charlottesville, Virginia; and
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Diez S, Syed J, Müller H, Besendoerfer M, Schellerer V. Pediatric Cullen gangrene: Case report of postoperative pyoderma gangrenosum in a preterm infant with a complex gastrointestinal malformation. Int J Surg Case Rep 2020; 66:381-384. [PMID: 31954341 PMCID: PMC6962632 DOI: 10.1016/j.ijscr.2019.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 11/26/2022] Open
Abstract
Postoperative pyoderma gangrenosum is a rare condition in children. Diagnosis is based on exclusion of other diseases. An intraabdominal infection or other diseases can occur simultaneously. Early diagnosis and treatment are evident to optimal patient’s care.
Introduction Pyoderma gangrenosum (PG) is a rare condition in infants, children and adolescents. The postoperative variant of this rapidly progressive ulceration is known as Cullen gangrene. Only a few case reports of pediatric Cullen gangrene have been published. Presentation of case We present a male infant (gestational age 31 + 6 weeks) with gastroschisis and intrauterine volvulus. After multiple operations due to his complex gastrointestinal malformation, the patient showed classical symptoms of postoperative PG (PPG) 4 weeks after birth. Diagnosis could be made early in an interdisciplinary approach, differentiating intraabdominal infection (vancomycin resistant enterococcus (VRE), candida albicans) from epifascial occurrence. Treatment with high-dose steroids and immunoglobulins was initiated immediately and led to rapid recovery. Discussion The unusual combination of a complex gastrointestinal malformation and an intraabdominal infection with VRE and candida albicans made the diagnosis difficult. However, early diagnosis is crucial in the treatment of Cullen gangrene. Conclusion This is the first case report of Cullen gangrene presenting in an infant (at 4 weeks of age).
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Pyoderma Gangrenosum following Pacemaker Implantation: A Case Report and Review of Literature. Case Rep Cardiol 2019; 2019:8010895. [PMID: 31827938 PMCID: PMC6886312 DOI: 10.1155/2019/8010895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 11/11/2019] [Indexed: 11/18/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by noninfectious, inflammatory, ulcerating lesions. Pathergy can be seen in these patients, whereby minor trauma or surgery can result in the development of PG ulcerations. Here, we present a case of PG following pacemaker implantation. A 76-year-old male with a history of rheumatoid arthritis presented to the cardiology team with symptomatic bradycardia. Indications for implantation were met, and the procedure was performed in a routine fashion. The patient returned to clinic for follow-up four days later, complaining of pain at the incision site, coupled with erythema and purulent drainage. Consultations with an infectious disease specialist and a dermatologist were requested, and the diagnosis of pyoderma gangrenosum was considered. The patient underwent device removal and received systemic corticosteroids at a dose of 1 mg/kg prednisone with complete lesion healing in 3 weeks. While being maintained on steroids, the patient underwent reimplantation of a new pacemaker on the contralateral side without complication and had a normal postoperative course. We present this case report, along with the review of literature, in order to highlight the multidisciplinary approach to management, which requires dermatologic treatment in order to achieve pacemaker success.
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Abstract
Pyoderma Gangrenosum (PG) is a rare neutrophilic dermatosis with multiple different clinical presentations and associated comorbidities. PG has historically been a challenging disorder to diagnose, leading to the development of new diagnostic criteria rather than the traditional approach of a diagnosis of exclusion. The pathophysiology is thought to involve both innate and adaptive immune system dysregulation, neutrophilic abnormalities, environmental, and genetic factors. As of today, no gold standard therapy exists for the treatment of PG, and the literature is restricted to mainly case reports, case series, and 2 small randomized clinical trials. Topical, systemic, and biologic therapy, as well as adequate analgesia and proper wound care all play a role in the management of PG. Recent studies have identified additional cytokines and signalling cascades thought to be involved in the pathogenesis of PG, ultimately leading to the development of new targeted therapies. This review will focus on recent advances in the pathophysiology, clinical presentation and associated comorbidities, diagnosis, and management of PG.
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Affiliation(s)
- Josh Fletcher
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| | - Raed Alhusayen
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, M4N 3M5, Canada
| | - Afsaneh Alavi
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Dermatology, Department of Medicine, Women's College Hospital, Toronto, Ontario, M5S 1B2, Canada
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Montagnon CM, Fracica EA, Patel AA, Camilleri MJ, Murad MH, Dingli D, Wetter DA, Tolkachjov SN. Pyoderma gangrenosum in hematologic malignancies: A systematic review. J Am Acad Dermatol 2019; 82:1346-1359. [PMID: 31560977 DOI: 10.1016/j.jaad.2019.09.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/15/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a devastating neutrophilic dermatosis that may be associated with trauma or systemic diseases. The associations, characteristics, and temporal relationship of PG with hematologic malignancies are not well understood. OBJECTIVE We performed a systematic review of PG associated with hematologic malignancies using data from case reports, case series, and retrospective studies. METHODS We searched MEDLINE, EMBASE, Scopus, and Web of Science from each database's inception to December 12, 2018. Two reviewers independently selected studies and extracted data. RESULTS Two hundred seventy-nine publications met the inclusion criteria (340 cases). Myelodysplastic syndrome (MDS) was the most commonly reported hematologic malignancy associated with PG, followed by monoclonal gammopathy of undetermined significance and acute myeloid leukemia. The mean age of patients was 56.5 years, with males being more common. There was a predominance of the ulcerative PG subtype and multifocal distributions across all hematologic malignancies. The majority of MDS cases preceded PG, which was reversed for MGUS. LIMITATIONS The data were limited by reporting bias because PG subtypes rely on the rendered diagnosis reported. In addition, the classification for hematologic malignancies has evolved since 1978. CONCLUSION Patients with PG should be evaluated for hematologic malignancies, with MDS being the most common.
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Affiliation(s)
| | | | - Archna A Patel
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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Xu A, Balgobind A, Strunk A, Garg A, Alloo A. Prevalence estimates for pyoderma gangrenosum in the United States: An age- and sex-adjusted population analysis. J Am Acad Dermatol 2019; 83:425-429. [PMID: 31400451 DOI: 10.1016/j.jaad.2019.08.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/24/2019] [Accepted: 08/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The disease burden of pyoderma gangrenosum (PG) is poorly understood. OBJECTIVE To determine standardized overall and age-, sex-, and race-specific prevalence estimates for PG among adults in the United States. METHODS Cross-sectional analysis of 1971 patients with PG identified using electronic health records data from a diverse population-based sample of more than 58 million patients. RESULTS The age- and sex-standardized prevalence of PG among the study population was 0.0058%, or 5.8 PG cases (95% confidence interval [CI], 5.6-6.1) per 100,000 adults. Adjusted prevalence was nearly twice as high among women (7.1 cases [95% CI, 6.7-7.5] per 100,000) than men (4.4 cases [95% CI, 4.0-4.7] per 100,000). Patients between the ages of 70 and 79 years had the highest standardized prevalence (9.8 cases [95% CI, 8.8-10.9] per 100,000), with patients aged ≥50 years representing nearly 70% of all PG cases. Standardized prevalence was similar among white and African American patients. The female-to-male ratio of PG was >1.8 across all age groups. LIMITATIONS Analysis of electronic health records data may result in misclassification bias. CONCLUSION PG is a rare disease that most commonly affects women and those aged ≥50 years.
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Affiliation(s)
- Amy Xu
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Amrita Balgobind
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Andrew Strunk
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Amit Garg
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Allireza Alloo
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York.
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Hu YQ, Yao XX, Zhang JZ, Li WH. Penile pyoderma gangrenosum: Successful treatment with thalidomide. Dermatol Ther 2019; 32:e12952. [PMID: 31025475 DOI: 10.1111/dth.12952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/12/2019] [Accepted: 04/10/2019] [Indexed: 11/26/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerating inflammatory neutrophilic dermatosis. Different clinical manifestations have been described, including ulcerative, pustular and bullous, and vegetative variants. Classic PG usually occurs on the lower extremities (~70% of cases) but can also involve the hands, head, neck, and scrotum. Genital involvement of PG has rarely been reported. Treatment of the genital PG is usually difficult and resistance to conventional therapeutic regimens was frequently observed. The present authors reported a 16-year-old male patient who presented with progressive genital ulceration for 3 weeks. He was treated successfully low dose thalidomide (50 mg/d) and minocycline.
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Affiliation(s)
- Yu-Qing Hu
- Department of Dermatology, Peking University People's Hospital, Beijing, China
| | - Xu-Xin Yao
- Department of Dermatology, Peking University People's Hospital, Beijing, China
| | - Jian-Zhong Zhang
- Department of Dermatology, Peking University People's Hospital, Beijing, China
| | - Wen-Hai Li
- Department of Dermatology, Peking University People's Hospital, Beijing, China
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Ben Abdallah H, Fogh K, Bech R. Pyoderma gangrenosum and tumour necrosis factor alpha inhibitors: A semi-systematic review. Int Wound J 2019; 16:511-521. [PMID: 30604927 PMCID: PMC7949186 DOI: 10.1111/iwj.13067] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/12/2018] [Accepted: 12/18/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Hakim Ben Abdallah
- Institute of Clinical Medicine, Aarhus Faculty of Health SciencesAarhus UniversityAarhusDenmark
| | - Karsten Fogh
- Department of DermatologyAarhus University HospitalAarhusDenmark
| | - Rikke Bech
- Department of DermatologyAarhus University HospitalAarhusDenmark
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39
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Plumptre I, Knabel D, Tomecki K. Pyoderma Gangrenosum: A Review for the Gastroenterologist. Inflamm Bowel Dis 2018; 24:2510-2517. [PMID: 29788368 DOI: 10.1093/ibd/izy174] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Indexed: 12/20/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative skin disease of unknown etiology often associated with systemic inflammatory conditions, most commonly inflammatory bowel disease (IBD). The most common presentation of PG is spontaneous rapid formation of an extremely painful ulcer on the extremities, associated with significant morbidity and mortality. Rarely, PG can also occur as a chronic peristomal complication or as an acute postoperative complication of a surgical wound. The clinical course is unpredictable; it may not correlate with IBD activity and may even precede a diagnosis of IBD. Pyoderma gangrenosum is a diagnosis of exclusion. Treatment is challenging, often involving a variety of immunosuppressive therapies. This review aims to provide an update for the gastroenterologist on the pathogenesis, presentation, diagnosis, and management of PG, a rare complication of IBD.
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Affiliation(s)
- Isabella Plumptre
- London North West University Healthcare NHS Trust, London, United Kingdom
| | - Daniel Knabel
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth Tomecki
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
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40
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Giugale JM, Balk ML. Pyoderma Gangrenosum Following Carpal Tunnel Release: A Case Report. JBJS Case Connect 2018; 8:e91. [PMID: 30431480 DOI: 10.2106/jbjs.cc.18.00116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 51-year-old woman with diabetes developed wound complications consistent with presumed infection 5 days after undergoing a carpal tunnel release. Despite multiple debridements, the wounds continued to necrose and deteriorate. A diagnosis of pyoderma gangrenosum eventually was made, and the condition improved with the administration of systemic corticosteroids. CONCLUSION Pyoderma gangrenosum, a form of neutrophilic dermatosis that rarely occurs as a complication of surgery, resembles a postoperative infection. Astute awareness of the condition can prevent a delayed diagnosis and unnecessary surgical procedures.
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Affiliation(s)
- Juan M Giugale
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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41
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Rogers P, Jones C, Dean A. A rare skin condition masquerading as a serious wound infection. J Surg Case Rep 2018; 2018:rjy299. [PMID: 30410719 PMCID: PMC6215978 DOI: 10.1093/jscr/rjy299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/21/2018] [Indexed: 11/14/2022] Open
Abstract
Pyoderma gangrenosum is a rare, serious and commonly missed condition that can effect post-operative surgical patients. The condition is commonly misdiagnosed as a wound infection, with subsequent inappropriate antibiotic therapy and wound debridement. We present the case of a 46-year-old patient who suffered this delayed diagnosis and multiple unnecessary interventions. We present this in an effort to raise awareness of the rare but serious condition, pyoderma gangrenosum.
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Affiliation(s)
- Peter Rogers
- General Surgery, St John of God Subiaco Hospital, Subiaco, Western Australia
| | - Corinne Jones
- Breast and Endocrine Surgery, St John of God Subiaco Hospital, Subiaco, Western Australia
| | - Andrew Dean
- Medical Oncology, St John of God Subiaco Hospital, Subiaco, Western Australia
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42
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Ariane M, Bouaziz JD, de Masson A, Jachiet M, Bagot M, Lepelletier C. Efficacy and safety of etanercept for postoperative pyoderma gangrenosum after infliximab serum sickness. Dermatol Ther 2018; 32:e12774. [PMID: 30341800 DOI: 10.1111/dth.12774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/19/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
Non-peristomal postoperative pyoderma gangrenosum (PPG) is a rare subtype of pyoderma gangrenosum that occurs in the early postoperative period at surgical incisions, most commonly after breast surgery. Early diagnosis and treatment is essential to prevent severe scaring. TNF-alpha inhibitor infliximab was reported to be efficient in treatment of PPG refractory to systemic corticosteroids. However infliximab can be not well tolerated. We report the first case of etanercept efficacy in post-plastic breast surgery pyoderma gangrenosum after infliximab serum sickness.
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Affiliation(s)
- Molka Ariane
- Assistance Publique- Hôpitaux de Paris, Département de Dermatologie, Hôpital Saint-Louis, Paris, France
| | - Jean-David Bouaziz
- Assistance Publique- Hôpitaux de Paris, Département de Dermatologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | - Adèle de Masson
- Assistance Publique- Hôpitaux de Paris, Département de Dermatologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | - Marie Jachiet
- Assistance Publique- Hôpitaux de Paris, Département de Dermatologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | - Martine Bagot
- Assistance Publique- Hôpitaux de Paris, Département de Dermatologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | - Clémence Lepelletier
- Assistance Publique- Hôpitaux de Paris, Département de Dermatologie, Hôpital Saint-Louis, Paris, France.,Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
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43
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McKenzie F, Cash D, Gupta A, Cummings LW, Ortega-Loayza AG. Biologic and small-molecule medications in the management of pyoderma gangrenosum. J DERMATOL TREAT 2018; 30:264-276. [PMID: 30051737 DOI: 10.1080/09546634.2018.1506083] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder characterized by neutrophil dysfunction. There are currently no FDA-approved drugs for the treatment of this disease, and treatment has typically relied on traditional immunosuppressive medications such as prednisone or cyclosporine. The efficacy of biologics in the treatment of other pro-inflammatory conditions such as psoriasis, rheumatoid arthritis, and inflammatory bowel disease is well-documented in the literature. Therefore, the use of biologic medications for the treatment of rarer inflammatory skin conditions, such as PG, is a compelling topic for investigation. Biologic and small-molecule therapies allow physicians to target specific pro-inflammatory mediators that underlie PG pathogenesis. This review provides an update on the use of biologic and small-molecule medications for the treatment of PG and summarizes the latest data on the clinical efficacy and pharmacology of these treatments.
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Affiliation(s)
- Fatima McKenzie
- a Department of Dermatology , Oregon Health & Science University , Portland , OR , USA
| | - Devin Cash
- b School of Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Angela Gupta
- b School of Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Laurel W Cummings
- b School of Medicine , Virginia Commonwealth University , Richmond , VA , USA
| | - Alex G Ortega-Loayza
- a Department of Dermatology , Oregon Health & Science University , Portland , OR , USA
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44
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Osaka A, Ide H, Ban S, Takimoto T, Aoki K, Kobori Y, Tokumoto T, Arai G, Soh S, Ueda Y, Okada H. Pyoderma gangrenosum after radical prostatectomy: case report. Int Cancer Conf J 2018; 7:114-116. [PMID: 31149527 PMCID: PMC6498321 DOI: 10.1007/s13691-018-0332-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/31/2018] [Indexed: 12/19/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a skin disease characterized by an unknown neutrophilic infiltration in dermis and a nonbacterial destructive ulcer. Post-operative PG is an extremely rare type that occurs around surgical sites during the immediate post-operative period. It is usually diagnosed as surgical site infection at the time of presentation. The condition rapidly worsens despite antibiotic treatment and debridement. We report on a case of post-operative PG in a 64-year-old man after radical prostatectomy. Following the operation, redness and pus from surgical site rapidly progress although repeated antibiotic therapy and debridement were performed. Although the patient received appropriate debridement and broad-spectrum antibiotic treatment, the ulcerative lesion spread surrounding drain region and the condition of the skin region deteriorated. The diagnosis of PG was made by a skin biopsy that presented only neutrophilic invasion in the dermis without vasculitis, tumor, or malignancy. Finally, the patient died of lesion progression in whole body and multiple organ dysfunction. Considering PG along with ulcers, wounds, and post-operative complications is critical for prompt diagnosis and proper treatment.
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Affiliation(s)
- Akiyoshi Osaka
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Hisamitsu Ide
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Shinichi Ban
- Department of Pathology, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Saitama Japan
| | - Toshiro Takimoto
- Department of Pathology, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Saitama Japan
| | - Keiichiro Aoki
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yoshitomo Kobori
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Tadahiko Tokumoto
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Gaku Arai
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Shigehiro Soh
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
| | - Yoshihiko Ueda
- Department of Pathology, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Saitama Japan
| | - Hiroshi Okada
- Department of Urology, Saitama Medical Center, Dokkyo Medical University, 2-1-50, Minamikoshigaya, Koshigaya, Saitama 343-8555 Japan
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45
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Monari P, Moro R, Motolese A, Misciali C, Baraldi C, Fanti PA, Caccavale S, Puviani M, Olezzi D, Zampieri P, Trevisan G, Nan K, Fiorentini C, Pellacani G, Gualdi G. Epidemiology of pyoderma gangrenosum: Results from an Italian prospective multicentre study. Int Wound J 2018; 15:875-879. [PMID: 29877043 DOI: 10.1111/iwj.12939] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/20/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by painful, necrotic ulcerations. PG is described as a rare disease: the world-wide incidence is estimated to be around 3 to 10 cases per million population per year. These estimations are based mostly on case reports and retrospective case series; there are no prospective, multicentre studies on the matter. The apparent rarity of PG is in contrast with our clinical perception as dermatologists: in our opinion, PG is not so uncommon. Therefore, we decide to investigate the epidemiology of PG in the Italian population and confirm our clinical suspicions that it is not an orphan disease. We enrolled all patients diagnosed with PG in 8 Italian Dermatological Departments from 1st October 2014 to 1st November 2015, and we recorded their features. Our data, collected from 64 patients, are in accordance with those of the published literature regarding the epidemiology and features of PG. In an Italian population of roughly 8 million inhabitants of 7 provinces, we found an incidence of 5.17 new cases per million population per year. Unlike our predictions before the study, we confirmed the world-wide incidence of PG. To our knowledge, this is the first observational, multicentre study on PG. We hope that it provides a stimulus for further researches on PG and for the creation of an Italian register.
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Affiliation(s)
- Paola Monari
- Department of Dermatology, ASST degli Spedali Civili, Spedali Civili di Brescia, Brescia, Italy
| | - Ruggero Moro
- Department of Dermatology, ASST degli Spedali Civili, Spedali Civili di Brescia, Brescia, Italy
| | - Alberico Motolese
- Department of Dermatology, ASST dei Sette Laghi, Ospedale di Circolo e Fondazione Macchi di Varese, Varese, Italy
| | - Cosimo Misciali
- Division of Dermatology, Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Azienda Ospedaliera Sant'Orsola-Malpighi, Bologna, Italy
| | - Carlotta Baraldi
- Division of Dermatology, Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Azienda Ospedaliera Sant'Orsola-Malpighi, Bologna, Italy
| | - Pier Alessandro Fanti
- Division of Dermatology, Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Azienda Ospedaliera Sant'Orsola-Malpighi, Bologna, Italy
| | - Stefano Caccavale
- Department of Dermatology, Second University of Naples, Naples, Italy
| | - Mario Puviani
- Department of Dermatology and Dermatologic Surgery, Ospedale di Sassuolo, Italy
| | - Daniela Olezzi
- Department of Dermatology and Dermatologic Surgery, Ospedale di Sassuolo, Italy
| | - Pierfrancesco Zampieri
- Department of Dermatology, Azienda Sanitaria dell'Alto Adige-Comprensorio Sanitario di Merano, Ospedale "F. Tappeiner", Merano, Italy
| | - Giusto Trevisan
- Department of Dermatology, University of Trieste, Trieste, Italy
| | - Katiuscia Nan
- Department of Dermatology, University of Trieste, Trieste, Italy
| | | | - Giovanni Pellacani
- Department of Dermatology, University of Modena and Reggio-Emilia, Modena, Italy
| | - Giulio Gualdi
- Department of Dermatology, ASST degli Spedali Civili, Spedali Civili di Brescia, Brescia, Italy
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46
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Ashchyan HJ, Nelson CA, Stephen S, James WD, Micheletti RG, Rosenbach M. Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatoses. J Am Acad Dermatol 2018; 79:1009-1022. [PMID: 29653213 DOI: 10.1016/j.jaad.2017.11.063] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/06/2017] [Accepted: 11/08/2017] [Indexed: 01/27/2023]
Abstract
Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The second article in this continuing medical education series reviews the epidemiology, clinical characteristics, histopathologic features, diagnosis, and management of pyoderma gangrenosum as well as bowel-associated dermatosis-arthritis syndrome and the arthritis-associated neutrophilic dermatoses rheumatoid neutrophilic dermatitis and adult Still disease.
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Affiliation(s)
- Hovik J Ashchyan
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caroline A Nelson
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sasha Stephen
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William D James
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert G Micheletti
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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47
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Ehrl DC, Heidekrueger PI, Broer PN. Pyoderma gangrenosum after breast surgery: A systematic review. J Plast Reconstr Aesthet Surg 2018; 71:1023-1032. [PMID: 29748073 DOI: 10.1016/j.bjps.2018.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/16/2018] [Accepted: 03/10/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post-surgical pyoderma gangrenosum (PSPG) is a rare inflammatory skin disorder of unknown aetiology. Given its similar presentation to wound infection and lack of reliable diagnostic tests as well as pathognomonic clinical features, PSPG is difficult to diagnose. The aim of this review was to identify factors contributing to PSPG to aid with timely diagnosis and appropriate therapy. METHODS A systematic literature review was performed by following PRISMA guidelines, focusing on PSPG after reconstructive and aesthetic breast surgery. The online databases PubMed, Medline, EMBASE, Scopus, and Cochrane were used, and additionally, a Google© search was performed. RESULTS A total of 68 articles describing 87 cases of PSPG following aesthetic and reconstructive breast surgery were found. The majority of PSPG (44%) occurred after breast reduction surgery and microsurgical breast reconstruction (16%). The most common associated conditions were malignancies in 37% and autoimmune deficiencies in 17%. Microbiological examinations were found to have a negative result in 90%. The median time from initial presentation with symptoms to correct diagnosis of PG was on average 12.5 days, with unsuccessful first-line therapy on average for 20.0 days. After the diagnosis of PG, medical therapy most commonly involved steroids in 84% and/or Cyclosporine A in 22% of the cases. On average, the duration of this therapy was 4.7 months. CONCLUSION The diagnosis of PSPG remains a challenging issue. However, according to the presented review, several distinct clinical signs in combination with lack of treatment response should prompt further investigation to promote timely diagnosis and correct treatment of this potentially debilitating disease.
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Affiliation(s)
- Denis C Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Marcioninistr. 15, Munich 81377, Germany.
| | - Paul I Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Medical Centre, Franz-Josef-Strauß-Allee, 93053, Regensburg, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Hospital, Engelschalkingerstr. 77, 81925, Munich, Germany
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48
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Freitas VMPD, Pereira SM, Enokihara MMSES, Cestari SDCP. Pyoderma gangrenosum associated with left iliac vein compression syndrome: presentation of difficult diagnosis. An Bras Dermatol 2018; 92:129-131. [PMID: 29267470 PMCID: PMC5726701 DOI: 10.1590/abd1806-4841.20176109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/27/2016] [Indexed: 02/07/2023] Open
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis of unknown etiology, of
which the most frequent clinical manifestations are ulcers. The diagnosis
difficulty is, among other things, to rule out other causes of ulcers, since it
is considered a diagnosis of exclusion. Skin ulcerations may also occur in the
iliac vein compression syndrome, which, like pyoderma gangrenosum, mainly
affects young women. Because they have such similar characteristics, the
presence of vascular disease may hinder the diagnosis of concurrent pyoderma
gangrenosum. Because of the clinical relevance of ulcerated lesions and scars,
the early diagnosis and treatment of this condition is considered extremely
important. We report a case in which the two diseases were associated, hampering
the diagnosis of pyoderma gangrenosum.
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Affiliation(s)
- Verena Mony Paes de Freitas
- Department of Dermatology at Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp) - São Paulo (SP), Brazil
| | - Silvia Marcondes Pereira
- Outpatient Clinic of Geriatric Dermatology of the Department of Dermatology at Escola Paulista de Medicina, Universidade Federal de São Paulo (EPMUnifesp) - São Paulo (SP), Brazil
| | - Mílvia Maria Simões E Silva Enokihara
- Department of Dermatology at Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp) - São Paulo (SP), Brazil.,Department of Pathology at Escola Paulista de Medicinada Universidade Federal de São Paulo (EPM-Unifesp) - São Paulo (SP), Brazil
| | - Silmara da Costa Pereira Cestari
- Department of Dermatology at Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp) - São Paulo (SP), Brazil
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Almukhtar R, Armenta AM, Martin J, Goodwin BP, Vincent B, Lee B, Dacso MM. Delayed diagnosis of post-surgical pyoderma gangrenosum: A multicenter case series and review of literature. Int J Surg Case Rep 2018; 44:152-156. [PMID: 29501933 PMCID: PMC5910501 DOI: 10.1016/j.ijscr.2018.02.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/15/2018] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Pyoderma gangrenosum is a chronic neutrophilic dermatosis which can occur following trauma or surgery and can mimic infection. Surgical intervention can lead to progression of disease. PRESENTATION OF CASES This case series describes 3 cases of post-surgical pyoderma gangrenosum with delayed diagnosis from two large medical centers. DISCUSSION Epidemiology, pathogenesis, clinical and histopathologic presentation, and management of post-surgical pyoderma gangrenosum are discussed with a review of the literature. CONCLUSION Post-surgical pyoderma gangrenosum (PSPG) can mimic ulcerative disorders including bacterial infection. The diagnosis should be suspected in post-operative wounds with negative bacterial cultures which progress despite broad-spectrum antibiotics and surgical debridement. Recognizing the clinical features of PSPG is fundamental to prevent severe destruction and deformity.
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Affiliation(s)
- Rawaa Almukhtar
- Department of Dermatology, Louisiana State University, New Orleans, LA, USA.
| | - Andrew M Armenta
- Department of Dermatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Julie Martin
- Department of Dermatology, Ochsner Medical Center, New Orleans, LA, USA
| | - Brandon P Goodwin
- Department of Dermatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Bethany Vincent
- Department of Dermatology, Ochsner Medical Center, New Orleans, LA, USA
| | - Brain Lee
- Department of Dermatology, Louisiana State University, New Orleans, LA, USA
| | - Mara M Dacso
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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50
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Progrediente Ulzerationen der Periorbita. Ophthalmologe 2018; 115:157-160. [DOI: 10.1007/s00347-017-0512-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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