Pyoderma gangrenosum in infancy: the youngest reported patient

Pyoderma Gangrenosum: An Update on Pathophysiology, Diagnosis and Treatment

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic disorder with prototypical clinical presentations. Its pathophysiology is complex and not fully explained. Recent information regarding the genetic basis of PG and the role of auto-inflammation provides a better understanding of the disease and new therapeutic targets. PG equally affects patients of both sexes and of any age. Uncontrolled cutaneous neutrophilic inflammation is the cornerstone in a genetically predisposed individual. Multimodality management is often required to reduce inflammation, optimize wound healing, and treat underlying disease. A gold standard for the management of PG does not exist and high-level evidence is limited. Multiple factors must be taken into account when deciding on the optimum treatment for individual patients: location, number and size of lesion/ulceration(s), extracutaneous involvement, presence of associated disease, cost, and side effects of treatment, as well as patient comorbidities and preferences. Refractory and rapidly progressive cases require early initiation of systemic therapy. Newer targeted therapies represent a promising pathway for the management of PG, and the main focus of this review is the management and evidence supporting the role of new targeted therapies in PG.

Pediatric pyoderma gangrenosum: a systematic review and update

Pyoderma gangrenosum (PG) is a sterile neutrophilic disorder that rarely affects children. Clinical, epidemiological, and therapeutic data on pediatric PG is poor as there are many newly reported associated diseases and drugs. This paper aims to review all recent available data on pediatric PG. A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. A total of 132 articles were included in the review. The most commonly reported underlying diseases in pediatric PG are inflammatory bowel diseases followed by hematologic disorders, vasculitis, immune deficiencies and Pyogenic Arthritis, Pyoderma gangrenosum and Acne (PAPA) syndrome. More than half of the cases occur with no underlying disease. The most frequently reported clinical presentation is multiple disseminated ulcers. Treatment should be tailored according to the underlying etiology. It includes systemic steroids, corticosteroid sparing agents such as dapsone and cyclosporine, and TNF-alpha inhibitors such as adalimumab and infliximab. Response to treatment is high with cure rates reaching 90%. A high index of suspicion and a thorough workup are mandatory in the management of pediatric PG.

Patients with pyoderma gangrenosum - analyses of the German DRG data from 2012

Pyoderma gangrenosum (PG) is a rarely diagnosed non-infectious neutrophil ulcerative dermatosis with only limited knowledge on the underlying auto-inflammatory process. To unravel common cofactors and comorbidities in patients with PG we analysed Diagnosis Related Groups (DRG) cases of all inpatients diagnosed with PG in German hospitals in 2012. We received data of 1227 inpatient cases having PG as primary diagnosis and 985 inpatient cases with PG as secondary diagnosis. The ratio of women to men was 2:1, and the most often registered age was 75-79 years. Common comorbidities were arterial hypertension (50·3%), non-insulin-dependent diabetes mellitus (25·1%) and dysfunction of lipid metabolism (10·8%). In sum, 94·8% of the patients suffered from aspects of metabolic syndrome. Other comorbidities were Crohn's disease (4·5%), ulcerative colitis (4·2%), chronic polyarthritis (5·2%), monoclonal gammopathy or myelodysplastic syndrome (2·5%), leukaemia (1·1%) and lymphoma (0·4%). DRG data do not reflect individual patients, but rather patient cases. We described the worldwide largest PG population and confirmed a wide range of potentially relevant and partly not yet described cofactors and comorbidities such as metabolic syndrome.

Idiopathic infantile pyoderma gangrenosum with stridor responsive to infliximab

A 4-month-old female infant presented with widespread pyoderma gangrenosum associated with stridor, presumed secondary to tracheal involvement. No underlying cause was revealed despite extensive investigation. Treatment with immunosuppressive agents only partially suppressed disease activity. Complete resolution followed treatment with infliximab. We review this rare condition in infants and discuss treatment with infliximab not previously described in this age group.

Pyoderma gangrenosum in an infant

Pyoderma gangrenosum is rare in children and very rare in infants less than 1 year of age. We report Pyoderma gangrenosum in a 6-month-old girl without any associated disorders, which was well controlled with oral prednisone. This entity in infants usually presents with multiple lesions, mainly located on the face, buttocks, thighs, and extremities, which in some instances are associated with pathergy. Pyoderma gangrenosum in infants has a good response to therapy, and healing is usually achieved.

Pyoderma gangrenosum: uncommon presentations

Pyoderma gangrenosum (PG) is a rare, inflammatory, noninfective, nonneoplastic skin disorder, which is often associated with systemic diseases. These include inflammatory bowel disease, rheumatoid arthritis, paraproteinaemia, or hematologic malignancy, which can be found in up to 50% of patients with some variants of PG. Brunsting et al (Arch Dermatol 1930;22:655-80) first described PG as a disease entity in 5 patients who had painful, enlarging necrotic ulcers with bluish undermined borders surrounded by advancing zones of erythema. Four of these patients had chronic ulcerative colitis. They felt that the condition might be associated with bacterial infection (pyoderma) and considered it as linked to the underlying bowel disease. Although the cause of PG remains obscure, bacterial infection seems to be unrelated to its causation, rendering the term pyoderma redundant. In addition, the number of conditions reported in association with PG has markedly expanded in recent years, showing clearly that this is not solely a cutaneous manifestation of inflammatory bowel disease. The clinical concept of PG has also been broadened, and certain clinical variants of PG have been linked with different types of associated disease seen in these patients.

Anogenital and buttock ulceration in infancy

Rashes in the anogenital and buttock region are some of the commonest dermatological problems occurring in infancy. The most frequent causes seen in clinical practice are ulcerating haemangiomas, bullous impetigo and severe irritant contact dermatitis. Other causes include nutritional deficiencies, bullous diseases, trauma, Langerhans cell histiocytoses and inflammatory disorders such as pyoderma gangrenosum and Crohn's disease. This review presents a brief overview of these causes and outlines the recommended management strategies.

Pyoderma gangrenosum in two siblings: a familial predisposition

We report pyoderma gangrenosum in two siblings with onset during childhood and no associated systemic abnormalities. The patients were born of nonconsanguineous, healthy parents. Treatment with oral corticosteroids produced an excellent clinical response, followed by recurrence after cessation of therapy. Steroids were restarted in combination with dapsone to prevent further recurrence.

The use of high-dose immunoglobulin in the treatment of pyoderma gangrenosum

BACKGROUND

Immunosuppressive medications such as corticosteroids and cyclosporin are the most commonly employed therapies in pyoderma gangrenosum. We describe a patient with multiple ulcers of pyoderma gangrenosum on the lower extremities in whom immunosuppressive therapy caused serious side effects and had to be discontinued but who was subsequently treated successfully with high dose intravenous immunoglobulin (IVIG).

METHODS

IVIG was given intravenously at a dose of 400 mg/kg per day for 5 consecutive days. After 1 week there was an arrest in the progression of the ulcers and a marked reduction in pain. Two weeks later clinical improvement of the ulcers was observed. Subsequently, IVIG was given at a dose of 1 g/kg per day for 2 consecutive days.

RESULTS

The treatment induced a dramatic clinical improvement of one ulcer and healing of the others. Side effects were minimal and well tolerated, and consisted of chills and a slight fever, which resolved with the administration of acetaminophen.

CONCLUSION

We feel that IVIG can be used in patients with pyoderma gangrenosum in whom conventional therapies are ineffective or produce serious side effects.

Split skin grafts in the treatment of pyoderma gangrenosum. A report of four cases

BACKGROUND

Pyoderma gangrenosum (PG) is an uncommon necrotising, non-infective ulceration of the skin. The management of PG is aimed at limiting tissue destruction, promoting the healing of the wound, and providing an acceptable cosmetic result. However, skin grafting is normally avoided because of the potential risk of pathergy-the localization of skin damaged by trauma.

REPORT

We describe the use of split skin grafts in the management of ulcerative pyoderma gangrenosum in 4 patients.

RESULTS

Our cases demonstrate that split skin grafts are a useful treatment modality in patients with ulcerative PG, producing a good cosmetic result. One case illustrates the importance of ensuring the disease is quiescent prior to grafting, to avoid pathergy. The other cases emphasise the need for prolonged immunosuppressive therapy to minimise the chance of reactivation of the disease process.

CONCLUSION

Our preliminary experience of 4 cases of ulcerative PG indicates that split skin grafts have a role to play in its management. The ultimate cosmetic result is considered to be superior to allowing the wound to heal by secondary intention. To limit the risk of pathergy developing, our experience suggests a role for prolonged courses of immunosuppressive therapy. The most effective dose and duration of immunosuppressive therapy in patients with PG treated with split skin grafts remains to be determined. A controlled study would be of benefit to compare it with other current treatment options.

Familial pyoderma gangrenosum presenting in infancy

Pyoderma gangrenosum (PG) is a rare, poorly understood skin disease that occurs in all age groups. Less than 0.4% of patients are infants and represent a diagnostic challenge as early lesions may resemble other skin disorders. Here we report for the first time three siblings affected with PG all presenting during infancy. Unlike the older age group, the ulcers spared the legs but involved the buttocks, thighs and perianal area in all the infants.

CONCLUSION

This is the first reported family with PG affecting three siblings suggesting autosomal recessive inheritance. The diagnosis may be more difficult in infants due to absence of underlying associated disorders and the tendency of the lesions to appear in areas where infants frequently have other dermatoses. PG characteristically involves the buttocks, thighs and perianal area and spares the legs.

Pyoderma gangrenosum: classification and management

Pyoderma gangrenosum (PG) has four distinctive clinical and histologic variants. Some have morphologic and histologic overlapping features with other reactive neutrophilic skin conditions. PG often occurs in association with a systemic disease, and the specific clinical features of the skin lesion may provide a clue to the associated disease. Management of PG depends on its type and severity and usually requires aggressive local and systemic treatment.

Pyoderma gangrenosum and cranial osteolysis: case report and review of the paediatric literature

Pyoderma gangrenosum is a poorly understood, ulcerating cutaneous disorder which is rarely seen in the paediatric age-group. We report a 3-year-old boy who developed an ulcer over the left frontoparietal scalp at the age of 1 year. A 9-cm area of underlying cranial bone was destroyed. The appearance on radiographs and CT scan was suggestive of eosinophilic granuloma, osteomyelitis, or other destructive processes. Biopsies of the scalp lesion and calvaria showed granulation tissue and degenerating bone. After the biopsies the scalp lesion increased in size, and wound dehiscence occurred. Ulceration developed at the site of a PPD skin test, which on biopsy was consistent with the diagnosis of pyoderma gangrenosum. Pyoderma gangrenosum should be added to the differential diagnosis of cutaneous disorders which can result in osteolytic/osteonecrotic defects.

Pyoderma gangrenosum in infants and children

Pyoderma gangrenosum is an uncommon ulcerative skin disorder that occurs in all age groups. Approximately 4% of patients are infants and children. There are several notable differences between the childhood and adult manifestations of the disease, including the distribution of lesions and associated disorders. We reviewed the childhood cases (< or = 18 yrs of age) of unequivocal pyoderma gangrenosum in the English literature and tabulated the trends in clinical features, associated disorders, and therapy. We report our 3-week-old patient, the youngest documented case. Of the 46 patients, only 4 were less than 1 year of age. A systemic illness was present in 74% of the older children, most commonly, ulcerative colitis. Only one infant had an associated problem (HIV+) at the time of onset. Infants appear to have an unusual distribution of perianal and genital lesions not often described in other age groups. Our review suggests that pyoderma gangrenosum in children has a similar clinical appearance to that in adults. It is associated with some of the same underlying disorders, but with different frequencies. The distribution of lesions in children is similar, often involving the lower extremities, but pyoderma gangrenosum of the head and face appears to be more common in children. Infants may have ulcers in genital and perianal areas. The most frequently prescribed treatment for children is systemic corticosteroids, which generally are very effective.

Infantile pyoderma gangrenosum

A six month old female infant with pyoderma gangrenosum is reported. Pyoderma gangrenosum in an infant is rare. The child responded to pulse therapy with intravenous dexamethasone and intralesional triamcinolone acetonide.