Pyoderma gangrenosum: a review

The Histopathology of Leg Ulcers

Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.

Profile of Nonvenereal Female Genital Dermatoses: A Cross-Sectional Study From Eastern India

OBJECTIVE

Nonvenereal genital dermatoses may be a reason for considerable concern to the patient and often pose diagnostic dilemma to the treating physicians. The objective of the present study was to find out the demographical and clinical profile of nonvenereal genital dermatoses including systemic comorbidities in a tertiary care hospital.

MATERIALS AND METHODS

This was an observational study, carried out at the outpatient department of dermatology of a tertiary care hospital of Eastern India over a period of 12 months. Female patients with genital lesions were included in the study after excluding venereal disease. Results were tabulated and analyzed.

RESULTS

A total of 189 female patients were evaluated having 39 different dermatoses. The age ranged from 2 months to 72 years with most patients belonged to the fourth decade and 70.4% patients were from reproductive age group. Most of the patients were literate (81%) and hailing from rural areas. Most of them were homemakers and belonged to lower socioeconomic status (42.3%). Itching (77.3%) was the most common presenting complaint followed by burning sensation (9.5%). Common dermatoses encountered were vulval candidiasis (40.7%), lichen sclerosus (15.3%), tinea cruris (13.8%), lichen planus (4.2%), vitiligo (3.2%), irritant contact dermatitis (2.6%), psoriasis (2.6%), lichen simplex chronicus (2.1%), among others. Most common associated comorbidity was diabetes mellitus.

CONCLUSIONS

This study provides important data on the spectrum of vulvar diseases in Eastern Indian patients and emphasizes the importance of proper and timely diagnosing nonvenereal vulvar dermatoses.

Pyoderma gangrenosum - a guide to diagnosis and management

Pyoderma gangrenosum (PG) is a reactive non-infectious inflammatory dermatosis falling under the spectrum of the neutrophilic dermatoses. There are several subtypes, with 'classical PG' as the most common form in approximately 85% cases. This presents as an extremely painful erythematous lesion which rapidly progresses to a blistered or necrotic ulcer. There is often a ragged undermined edge with a violaceous/erythematous border. The lower legs are most frequently affected although PG can present at any body site. Other subtypes include bullous, vegetative, pustular, peristomal and superficial granulomatous variants. The differential diagnosis includes all other causes of cutaneous ulceration as there are no definitive laboratory or histopathological criteria for PG. Underlying systemic conditions are found in up to 50% of cases and thus clinicians should investigate thoroughly for such conditions once a diagnosis of PG has been made. Treatment of PG remains largely anecdotal, with no national or international guidelines, and is selected according to severity and rate of progression. Despite being a well-recognised condition, there is often a failure to make an early diagnosis of PG. This diagnosis should be actively considered when assessing ulcers, as prompt treatment may avoid the complications of prolonged systemic therapy, delayed wound healing and scarring.

A rare case of adult scalp pyoderma gangrenosum with cranial osteolysis

Pyoderma gangrenosum (PG) is a rare and painful idiopathic skin condition that has one or more areas of chronic ulceration with well demarcated and undermined borders. Bone osteolysis (the pathological destruction of bone tissue) secondary to PG is a rare phenomenon with limited cases reported in children only. This is the first case report of scalp PG with cranial osteolysis in an 80-year-old adult, with an initial presentation mimicking skin carcinoma. This case highlights the importance of a multidisciplinary team (MDT) meeting discussion, diagnosis of PG by exclusion and the successful treatment of this patient's PG eroding to the bone.

Pyoderma Gangrenosum Associated with Acute Megakaryoblastic Leukemia

Pyoderma gangrenosum (PG) is an unusual ulcerating cutaneous process frequently representing a dermatologic manifestation of a systemic disease including myeloproliferative disorders. This article describes the first case of PG associated with acute megakaryoblastic leukemia (AML-M7). This case determined that the morphology of blast forms present within the lesion represented by PG, including elongated cytoplasmic projections, frayed shaggy cytoplasm, and appearance of adhesion of blasts to each other, are suggestive, though not diagnostic, of megakaryoblast. Identification of microthrombi within PG, suggestion of adhesion of circulating megakaryoblasts, and previous reported cases of patients with AML-M7 and patients with PG associated with myeloproliferative disorders exhibiting thrombotic or coagulopathies suggest that a localized microangiopathic consumptive coagulopathy or microthrombotic ischemic process might be considered in the etiology and pathogenesis of PG.

Skin Signs of Rheumatoid Arthritis and its Therapy-Induced Cutaneous Side Effects

Rheumatoid arthritis (RA) is a systemic inflammatory disorder that primarily affects the joints, but may exhibit extra-articular, including cutaneous, manifestations such as rheumatoid nodules, rheumatoid vasculitis, granulomatous skin disorders, and neutrophilic dermatoses. A large burden of cutaneous disease may be an indication of RA disease activity and the need for more aggressive treatment. Many of the therapeutic agents used to treat RA can also result in cutaneous adverse effects, which pose their own diagnostic and therapeutic challenges. Anti-TNFα agents, in particular, have a wide variety of adverse effects including psoraisiform eruptions, granulomatous conditions, and cutaneous connective tissue disorders. Herein we provide an update on the clinical presentations and management of RA-associated cutaneous findings as well as drug-induced cutaneous effects, with particular attention to the adverse effects of biologic disease-modifying agents.

Pyoderma Gangrenosum in a Patient with Hereditary Spherocytosis

Pyoderma gangrenosum (PG) is a rare, relapsing cutaneous disease with 4 distinctive clinical manifestations: ulcerative, bullous, pustular, and vegetative lesions. It mainly occurs in adults and is frequently associated with systemic diseases, most commonly inflammatory bowel disease, rheumatologic disease, or hematological dyscrasias. However, there have been no previous reports of PG in a patient with hereditary spherocytosis, a common inherited hemolytic anemia. We report here a unique case of PG in a 15-year-old boy with underlying hereditary spherocytosis.

Pyoderma gangrenosum following a routine caesarean section: Pseudo-infection in a caesarean wound

A 22-year-old booked primigravida underwent lower segment caesarean section for breech presentation. She developed signs and symptoms of wound infection by the fourth postoperative day. This was initially managed with antibiotics and wound dressing, but debridement was later undertaken after consulting surgeons. This resulted in an alarming worsening of the wound with sudden and fast increase in its size along with systemic symptoms. Wound biopsy established the diagnosis of pyoderma gangrenosum. The patient's management included oral medication with prednisolone, cyclosporin and dapsone and wound care. There was a dramatic response to this treatment. The wound completely healed by the eighth postoperative month. The oral medications were tapered off slowly and stopped by that time.

Risk factors for peristomal pyoderma gangrenosum complicating inflammatory bowel disease

BACKGROUND AND AIMS

Risk factors for peristomal pyoderma gangrenosum (PPG) are not well defined. The aim of this study was to evaluate risk factors associated with development of PPG.

METHODS

Both PPG patients and controls were obtained by searching a database of the Cleveland Clinic using the ICD-9 code from March 2005 to May 2011. The control group was selected by matching for underlying diseases and type of stoma in a ratio of 3:1. Univariate and multivariate analyses were performed.

RESULTS

A total of 15 PPG cases and 45 controls were included. The mean age at the time of PPG diagnosis was 46.0 ± 14.4 years. The underlying disease was Crohn's disease in 7 patients (46.7%), ulcerative colitis in 7 (46.7%) and indeterminate colitis in 1 (6.7%). Eleven patients (73.3%) had end ileostomy, 3 (20.0%) had loop ileostomy and 1 (6.7%) had colostomy. Eleven patients (73.3%) had active intestinal disease. In multivariate analysis, female gender, the presence of concurrent autoimmune disorders, and a high body mass index (BMI) were significantly associated with the presence of PPG, with odds ratios of 8.385 (95% confidence interval [CI]: 1.496-46.982, p=0.015), 6.882 (95% CI:1.438-32.941, p=0.016), and 9.895 (95% CI: 1.970-43.704, p=0.005), respectively. After a median follow-up of 12.8 (interquartile range: 7.9-20.1) months with appropriate therapy, PPG healed in 8 patients (53.3%) and improved in 7 (46.7%) patients, after treatment.

CONCLUSIONS

Female gender, the presence of autoimmune disorders and a high BMI appeared to be associated with an increased risk for the development of PPG in IBD patients.

Pyoderma gangrenosum--a review of 24 cases observed over 10 years

BACKGROUND AND OBJECTIVES

  Pyoderma gangrenosum (PG) is a disorder, included in the spectrum of neutrophilic and auto-inflammatory dermatoses, whose clinical aspects and outcome we intend to characterize.

MATERIALS AND METHODS

  In a retrospective study based on files of patients diagnosed during a 10-year period (2000-2009), we evaluated demographic data, anatomic locations, number of lesions, clinical variants, associated diseases, treatment regimens, healing time, and recurrence.

RESULTS

  A total of 24 patients were included, 19 women and five men (F/M = 3.8/1), aged between 17 and 89 years (mean 58.3 ± 24.6 years) with a diagnosis of PG. Lesions, single in 15 patients (62.5%) and multiple in nine (37.5%), were localized in the lower limbs in 19 patients (79.2%), upper limbs (4), abdomen (4), face (2) and genital area (1). Clinical variants observed were ulcerative (17 patients), pustular (4), bullous (2) and superficial granulomatous (1). Associated systemic diseases were observed in 18 patients (75%), gastrointestinal in seven patients (29.2%), hematological in seven (25%), autoimmune inflammatory in three (12%), and solid tumors in two (8.3%). Systemic steroids were used in the treatment, either alone in 10 patients (41.7%) or combined with cyclosporine in eight (33.3%). Complete healing was achieved in 20 patients, on average five months after diagnosis, but lesions recurred one or more times in four patients (16.7%).

CONCLUSIONS

  As reported in the literature, PG is a rare disorder, more common in females, frequently associated with systemic disease, which compromises the prognosis.

Comorbidities of hidradenitis suppurativa (acne inversa)

Comorbidities of hidradenitis suppurativa (acne inversa) were reviewed by extracting original and review publications included in MEDLINE, EMBASE and COCHRANE libraries using the terms "hidradenitis," "Verneuil" and "acne inversa." Follicular occlusion disorders, inflammatory bowel diseases, especially Crohn disease, spondylarthropathy, other hyperergic diseases, genetic keratin disorders associated with follicular occlusion and squamous cell carcinoma were the most common hidradenitis suppurativa comorbid diseases. A first classification of these major comorbidities and their possible genetic background reveals a list of chromosome loci and genes, which could be hidradenitis suppurativa candidates. Most of these diseases belong to the group of autoinflammatory disorders, where th17 cell cytokines seem to play a central role.

Acne fulminans: explosive systemic form of acne

Acne fulminans (AF) is a rare severe form of acne vulgaris associated with systemic symptoms. It primarily affects male adolescents. Although the aetiology of AF remains unknown, many theories have been advanced to explain it. There have been reported associations with increased androgens, autoimmune complex disease and genetic pre-disposition. The disease is destructive, with the acute onset of painful, ulcerative nodules on the face, chest and back. The associated systemic manifestations such as fever, weight loss and musculoskeletal pain are usually present at the onset. The patients are febrile, with leucocytosis and an increased erythrocyte sedimentation rate. They may require several weeks of hospitalization. The treatment of AF has been challenging; the response to traditional acne therapies is poor. The recommended treatment is aggressive and consists of a combination of oral steroids and isotretinoin. To avoid the relapses, duration of such treatment should not be less than 3-5 months. Although the prognosis for patients treated appropriately is good, these acute inflammatory nodules often heal with residual scarring.

Mucocutaneous manifestations in inflammatory bowel disease

BACKGROUND

The aim of this study was to evaluate the prevalence and features of the major cutaneous manifestations (erythema nodosum [EN] and pyoderma gangrenosum [PG]) and to determine the associations between cutaneous manifestations and other extraintestinal manifestations in patients with inflammatory bowel disease (IBD).

METHODS

The mucocutaneous manifestations of patients with IBD were studied between December 2002 and June 2007. All patients underwent a detailed whole body examination by a gastroenterologist and dermatologist.

RESULTS

In all, 352 patients were included in this study; 34 patients (9.3%) presented with at least 1 major cutaneous manifestation. The prevalence of EN (26 patients) and PG (8 patients) in IBD was 7.4% and 2.3%, respectively. EN was more common in Crohn's disease (16/118) than ulcerative colitis (10/234) (P = 0.002). EN was found to be related to disease activity of the bowel (P = 0.026). The prevalence of arthritis was significantly higher in the IBD patients with EN (11/26) than in IBD patients without EN (53/326) (P = 0.006). Arthritis was more common in IBD patients with PG (7/8) than in IBD patients without PG (57/344) (P = 0.00). IBD patients with PG were significantly more likely to have uveitis (1/8) compared with IBD patients without PG (5/344) (P = 0.017).

CONCLUSIONS

We found the prevalence of 2 important cutaneous manifestations to be 9.3% in IBD in Turkish patients. EN was found to be more common in Crohn's disease and is associated with an active episode of bowel disease and peripheral arthritis. In addition, PG was connected with uveitis and peripheral arthritis.

Skin manifestations of inflammatory bowel disease

Ulcerative colitis (UC) is an inflammatory disorder of the colon that is associated with several extraintestinal manifestations in multiple organs. Several mucous membrane and skin disorders occur in patients with UC. These disorders are not unique to UC and often occur secondary to other causes or in the absence of an apparent cause. One or more such disorders may occur together in association with UC. Mucous membrane and skin disorders may antedate, occur with, or postdate the onset of UC. The dermatologist plays an important role in suspecting the diagnosis of UC that presents with associated mucous membrane or skin disorders. This review covers the clinical presentation, differential diagnosis, workup, and management of selected mucocutaneous manifestations in UC.

Dermatopathology for the surgical pathologist: a pattern-based approach to the diagnosis of inflammatory skin disorders (part II)

The accurate diagnosis of inflammatory conditions in dermatopathology requires integrating the histopathologic findings with the clinical features. This second part of a 2-part review of inflammatory cutaneous conditions presents a pattern-based approach to the diagnosis of dermatologic disorders and reviews the salient clinical and histologic features.

Pyoderma gangrenosum--a review

Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis. Clinically it starts with sterile pustules that rapidly progress and turn into painful ulcers of variable depth and size with undermined violaceous borders. The legs are most commonly affected but other parts of the skin and mucous membranes may also be involved. Course can be mild or malignant, chronic or relapsing with remarkable morbidity. In many cases PG is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatic or haematological disease and malignancy. Diagnosis of PG is based on history of an underlying disease, typical clinical presentation, histopathology, and exclusion of other diseases that would lead to a similar appearance. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. Aetiology has not been clearly determined yet.

The treatment of PG is a challenge. Randomized, double-blinded prospective multicenter trials for PG are not available. The best documented treatments are systemic corticosteroids and ciclosporin A. Combinations of steroids with cytotoxic drugs are used in resistant cases. The combination of steroids with sulfa drugs or immunosuppressants has been used as steroid-sparing modalities. Anti-tumor necrosis alpha therapy in Crohn's disease showed a rapid response of PG. Skin transplants and the application of bioengineered skin is useful in selected cases as a complement to the immunosuppressive treatment. Topical therapy with modern wound dressings is useful to minimize pain and the risk of secondary infections. Despite recent advances in therapy, the prognosis of PG remains unpredictable.

Pyoderma gangrenosum related to a new granulocyte colony-stimulating factor

A 23-year-old Caucasian man diagnosed with stage IVB Hodgkin's disease was referred to a university oncology section after completing 1.5 cycles of chemotherapy. His chemotherapy consisted of doxorubicin HCL, bleomycin, dacarbazine, and vinblastine, with prophylactic administration of a granulocyte colony stimulating factor. He had developed postchemotherapy complications of possible cellulitis and necrotizing fasciitis that required wound debridement. The wound and tissue cultures were negative. Biopsies taken at the time revealed a dense inflammatory infiltrate consistent with an abscess. Over the course of 2 months, the wound healed with systemic antibiotics. The patient was reluctant to resume chemotherapy for his Hodgkin's disease because of his previous presumed skin infections. However, positive emission tomographic scanning revealed disease progression. Doxorubicin, bleomycin, dacarbazine, and prophylactic pegfilgrastim (a granulocyte colony-stimulating factor), were administered. Vinblastine was excluded from the new regimen. Shortly after chemotherapy and an injection of pegfilgrastim, the patient developed poorly defined, rapidly progressive erythema, edema, and pain in his right forearm. He presented to the emergency room, was evaluated by the orthopedics service, and taken to the operating room for debridement of suspected necrotizing fasciitis. When the dermatology service consulted the following day, the patient had developed an erythematous, edematous, tender plaque on his chest. After developing two additional lesions that began to ulcerate despite treatment with imipenem, vancomycin, clindamycin, rifampin, and gentamicin, the patient consented to a skin biopsy. His wound cultures continued to be negative.

Important cutaneous manifestations of inflammatory bowel disease

Inflammatory bowel disease (IBD) has many extraintestinal manifestations. Cutaneous manifestations are usually related to the activity of the bowel disease but may have an independent course. Anyone presenting with IBD should be examined for cutaneous manifestations. Pyoderma gangrenosum is a severe painful ulcerating disease that requires moist wound management and, in the absence of secondary infection, systemic corticosteroids, cyclosporine, or both. Infliximab may also be used. Erythema nodosum is a common cause of tender red nodules of the shins. Management includes leg elevation, NSAIDs, and potassium iodide. Oral manifestations of IBD include aphthous stomatitis, mucosal nodularity (cobblestoning), and pyostomatitis vegetans. Treatment should be directed both at the cutaneous lesions and at the underlying systemic condition.

Pyoderma gangrenosum associated with hidradenitis suppurativa

Pyoderma gangrenosum (PG) is associated with a number of systemic diseases. PG in association with hidradenitis suppurativa (HS) has been rarely reported. We describe six patients (three men, three women; aged 35--51 years), who developed PG on a background of HS. The onset of PG occurred only after HS had been present for at least two decades. No relationship in disease activity between the two conditions was observed. Three patients described previous severe adolescent acne vulgaris, one had concurrent systemic lupus erythematosus and another had chronic iron-deficiency anaemia. The course of PG was severe and refractory in four patients, who required treatment including high-dose oral corticosteroids, ciclosporin, intravenous immunoglobulin and intravenous cyclophosphamide.

Could your case of necrotising fascitis be Pyoderma gangrenosum?

Necrotising fascitis is a fulminant infective process which can result in significant morbidity and can indeed be life threatening. It needs to be recognised early and managed aggressively with extensive surgical debridement followed by appropriate antibiotics. On the other hand, Pyoderma gangrenosum is a disease process that needs to be managed non-surgically. We present one such case, the diagnosis of which had treaded along the thin line between the two.

Pyoderma gangrenosum outside the context of inflammatory bowel disease treated successfully with infliximab

A 63-year-old man with chronic lymphocytic leukaemia developed pyoderma gangrenosum following minor trauma to the leg. He required intensive inpatient management with a multitude of treatments including larval therapy, surgical debridement, ciclosporin, methotrexate, thalidomide, pulsed intravenous methylprednisolone and high-dose intravenous immunoglobulin, clofazamine and high dose oral corticosteroids, none of which were helpful. Treatment complications included steroid-induced diabetes, Cushing's syndrome and perforated peptic ulcer. The pyoderma remained refractory to treatment and continued to extend until he received intravenous infliximab 5 mg/kg at weeks 0, 2 and 6.

Anticorpo anticitoplasma de neutrófilos (ANCA) em pioderma gangrenoso, um marcador sorológico para associação com doenças sistêmicas: estudo de oito casos

FUNDAMENTOS: A etiopatogenia da retocolite ulcerativa inespecífica (RCUI) e de suas manifestações extra-intestinais permanece em discussão, embora o envolvimento do sistema imune seja enfatizado, e uma possível participação dos neutrófilos é demonstrada pela detecção do anticorpo anticitoplasma de neutrófilo (ANCA) nessa doença inflamatória intestinal. O pioderma gangrenoso (PG) é considerado manifestação cutânea rara da retocolite ulcerativa, e o Anca também tem sido detectado nessa dermatose. OBJETIVOS: Investigar a relação entre o comportamento clínico da RCUI e o aparecimento do PG e sua associação com ANCA. CASUÍSTICA E MÉTODOS: Anca foi pesquisado nos soros de oito pacientes com PG, quatro apresentando RCUI, e os outros, PG não associado a doenças sistêmicas. RESULTADOS: Não se detectou o Anca nos soros dos portadores exclusivamente de pioderma gangrenoso. Dois casos de pancolite em atividade inflamatória acompanhada de pioderma e colangite esclerosante primária (CEP) apresentaram positividade para ANCA, enquanto os soros de dois outros pacientes com RCUI e PG tiveram resultados negativos. CONCLUSÕES: A Presença de ANCA nos soros de pacientes com PG associado a RCUI e CEP sugere que a associação com CEP seja responsável pela positividade do ANCA na presente amostra.

Clinical management of pyoderma gangrenosum

Pyoderma gangrenosum is a noninfectious neutrophilic dermatosis that usually starts with sterile pustules which rapidly progress to painful ulcers of variable depth and size with undermined violaceous borders. In 17 to 74% of cases, pyoderma gangrenosum is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatological or hematological disease or malignancy. Diagnosis of pyoderma gangrenosum is based on a history of an underlying disease, typical clinical presentation and histopathology, and exclusion of other diseases that would lead to a similar appearance. Randomized, double-blinded prospective multicenter trials investigating the treatment of pyoderma gangrenosum are not available. The treatments with the best clinical evidence are systemic corticosteroids (in the initial phase usually 100 to 200 mg/day) and cyclosporine (mainly as a maintenance treatment). Combinations of corticosteroids with cytotoxic drugs such as azathioprine, cyclophosphamide or chlorambucil are used in patients with disease that is resistant to corticosteroids. The combination of corticosteroids with sulfa drugs, such as dapsone, or clofazimine, minocycline and thalidomide, has been used as a corticosteroid-sparing alternative. Limited experience has been documented with methotrexate, colchicine, nicotine, and mycophenolate mofetil, among other drugs. Alternative treatments include local application of granulocyte-macrophage colony-stimulating factor, intravenous immunoglobulins and plasmapheresis. Skin transplants (split-skin grafts or autologous keratinocyte grafts) and the application of bioengineered skin is useful in selected cases in conjunction with immunosuppression. Topical therapy with modern wound dressings is useful to minimize pain and the high risk of secondary infection. The application of topical antibacterials cannot be recommended because of their potential to sensitize and their questionable efficacy, but systemic antibacterial therapy is mandatory when infection is present. Despite recent advances in therapy, the prognosis of pyoderma gangrenosum remains unpredictable.

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.

Pyoderma gangrenosum associated with sclerosing cholangitis, type 1 diabetes mellitus and ulcerative colitis

We describe the case of a 22-year-old black female with type 1 diabetes mellitus diagnosed when she was 12 years old. She first presented (March 1994) with pustules and ulcerations on the upper and lower limbs, trunk and scalp at the age 17. The diagnosis of pyoderma gangrenosum was made. Since presentation, changes in liver function were detected and subsequent study led to the diagnosis of sclerosing cholangitis. The diagnosis of ulcerative colitis was made after colonoscopy. Partial response was obtained with minocycline and clofazimine, but treatment with 5-aminosalicylic acid achieved no improvement of the ulcerations. Liver transplantation, followed by immunosuppressive therapy led to complete regression of the cutaneous lesions.

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.

Cavitating pulmonary infiltrate in an adolescent with pyoderma gangrenosum: a rarely recognized extracutaneous manifestation of a neutrophilic dermatosis

Neutrophilic dermatoses such as pyoderma gangrenosum are characterized by sterile, neutrophilic cutaneous infiltrates. Extracutaneous neutrophilic infiltrates can occur, primarily in the joints, lungs, heart, central nervous system, gastrointestinal tract, and eyes. Pulmonary disease is the most frequently reported extracutaneous manifestation of pyoderma gangrenosum and is characterized by patchy infiltrates or interstitial pneumonitis. We describe an adolescent with typical pyoderma gangrenosum who presented with cavitary pneumonia and responded completely to oral corticosteroids. In patients with inflammatory ulcers, extracutaneous neutrophilic disease should be considered, once an infectious process has been excluded.