Peristomal pyoderma gangrenosum: An exceedingly rare and overdiagnosed entity?

Postsurgical Pyoderma Gangrenosum Requiring Plastic Surgical Intervention: A Practical Review

Pyoderma gangrenosum is a neutrophilic dermatosis characterized by immune dysfunction and pathergy. Thus, it is frequently seen in patients with underlying systemic illnesses or postoperatively. For the performance of the debridement or closure of the resultant defect, plastic surgeons are often involved in the care of pyoderma patients. However, both procedures may exacerbate the injury. Therefore, plastic surgeons must be familiar with the presentation of postsurgical pyoderma to avoid further damage and safely repair related soft tissue defects. A systematic search of the PubMed/Medline database was performed using the following keywords: "pyoderma gangrenosum" and "surgery." This online database search has identified 656 studies published between 1958 and 2022. Only reconstructed cases of postsurgical pyoderma gangrenosum were selected. Twenty-eight patients who developed pyoderma after dermatologic, plastic, orthopedic, cardiovascular, general, or obstetric surgery were included in this study. The average time to the PG presentation and diagnosis was 5.5 and 17 days, respectively. Diagnostic scoring tools were not used, and the diagnosis was primarily based on histopathology after repeated treatment failures. The patients received split- or full-thickness skin grafts, local, pedicled, and free flaps. An estimated 82.1% underwent skin grafting, whereas 42.9% underwent flap reconstruction. In addition, 21.4% got both the graft and flap. Accurate diagnosis of PSPG, prevention of further surgical injury, and timely medical management are vital for improving patient outcomes. Reconstruction can be performed, if required. However, despite the availability of different reconstructive techniques, there is no standard approach to the management of the PSPG.

Assessment, diagnosis and treatment of peristomal skin lesions by remote imaging: An expert validation study

BACKGROUND

Prevention and treatment of peristomal skin problems should be a priority for nurses caring for ostomates, even when the assessment of lesions must be done remotely.

OBJECTIVE

To measure the level of agreement on assessment, diagnosis and care indications for peristomal skin lesions using remote imaging among nurses in Spain.

DESIGN

Prospective observational multicentre study to assess the diagnostic validity and inter- and intraobserver agreement between nurses in peristomal skin lesions. Data were collected between March and October 2019.

SETTINGS AND PARTICIPANTS

The research sample consisted of a group of 39 nurses with expertise in the care of ostomates.

METHODS

A panel of experts established a list of 24 common signs/findings, 15 diagnostic options and 35 treatment approaches for peristomal skin lesions. Three expert stoma therapy nurses compiled the clinical cases, which they described thoroughly and documented with photographs. The 39 participating nurses evaluated the cases in two rounds to measure inter and intraobserver agreement.

RESULTS

A high or very high level of agreement (κ > 0.61) was observed for the following signs: encrustation, nodules, mucocutaneous separation and varicose veins; for the following diagnoses: mucocutaneous dehiscence, allergic contact dermatitis, encrustation and varicose veins (caput medusae); for the following treatments: recommending a diet rich in vitamin C/blueberries, applying acetic acid dressings, applying cold and topical tacrolimus treatment.

CONCLUSIONS

The most easily identifiable lesions were those most prevalent and with visible signs. There was a lower level of agreement in identifying lesions for which photographs required additional information (laboratory data, description of signs and symptoms, type of diet and level of self-care). It is important to train nurses caring for ostomates to correctly describe ostomy-related lesions, which is important for nursing records, continuity of care and telehealth care.

A Wound Care Specialist's Approach to Pyoderma Gangrenosum

Significance: Pyoderma gangrenosum (PG) is a rare neutrophilic ulcerative dermatosis that poses a high burden of morbidity due to underdiagnosis, resistance to therapy, and limited therapeutic options. Optimization of wound care strategies and multimodal anti-inflammatory approaches are necessary to mitigate multiple converging pathways of inflammation leading to delayed healing, which is further complicated by additional factors such as pathergy. Recent Advances: PG treatment typically involves reducing inflammation, controlling pain, promoting wound healing, and treating the underlying etiology. Recent advances have been made with regard to targeted therapies for PG with topical, intralesional, and systemic medications. Wound management includes gentle cleansing without sharp debridement, limited topical antibacterial use, and maintenance of a moist environment to promote epithelial migration. Critical Issues: Wound dressings and compression therapy, in particular, introduce a wide variety of therapeutic options. Dressings should aim to target the specific PG wound type, depending on the depth and exudative nature of the wound, as well as local secondary factors. Superficial wounds, eschar, exudative wounds, granulating wounds, and colonized wounds are managed with variable approaches to the same underlying principles of pathergy avoidance, moisture balance, and reduction of immunogenic inflammatory stimuli. The importance of compression therapy to decrease edema and overgranulation fits within this treatment paradigm. Future Directions: As each of these treatment modalities offers a complex mixture of advantages and limitations, development of a systematic treatment algorithm in the future can help direct a more tailored path toward wound healing.

Pyoderma gangrenosum

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.