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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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2
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Hrin ML, Bashyam AM, Huang WW, Feldman SR. Mycophenolate mofetil as adjunctive therapy to corticosteroids for the treatment of pyoderma gangrenosum: a case series and literature review. Int J Dermatol 2021; 60:e486-e492. [PMID: 33739458 DOI: 10.1111/ijd.15539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/10/2020] [Accepted: 02/26/2021] [Indexed: 01/08/2023]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that is commonly treated with systemic corticosteroids; however, their potent side effects may warrant tapering, and non-steroidal systemic immunosuppressants may help maintain or bolster disease clearance during weaning. Although cyclosporine is regarded as a favorable corticosteroid-sparing agent, it is associated with several side effects, such as renal toxicity and hypertension, that may limit its feasibility. Mycophenolate mofetil is a well-tolerated alternative with limited data. Institutional review board approval was obtained to review patients from a single institution who received mycophenolate mofetil for pyoderma gangrenosum between January 1, 2010, and December 31, 2019. A systematic MEDLINE (PubMed) review was performed of articles containing linked keywords: "mycophenolate mofetil" and "pyoderma gangrenosum". Patient demographics, presentation details, and treatment regimen characteristics were recorded. Fourteen of our pyoderma gangrenosum patients were treated with mycophenolate mofetil concomitantly with prednisone. Ninety-three percent of our patients achieved improvement within 12 months (mean 4.5 months), including five patients who experienced complete healing. Outcomes in literature patients were comparable; 77% either improved or maintained clearance with mycophenolate mofetil. Greater than 80% of total patients experienced healing or adequate disease control at a median dose of 2000 mg daily. The most common side effects of mycophenolate mofetil were myelosuppression and gastrointestinal upset, which were both seen in 18% of patients. Although this study is subject to publication bias, mycophenolate mofetil appears to be an efficacious and well-tolerated adjunctive therapy option for pyoderma gangrenosum.
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Affiliation(s)
- Matthew L Hrin
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Arjun M Bashyam
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - William W Huang
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Dermatology, University of Southern Denmark, Odense, Denmark
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3
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Eisendle K, Thuile T, Deluca J, Pichler M. Surgical Treatment of Pyoderma Gangrenosum with Negative Pressure Wound Therapy and Skin Grafting, Including Xenografts: Personal Experience and Comprehensive Review on 161 Cases. Adv Wound Care (New Rochelle) 2020; 9:405-425. [PMID: 32320362 DOI: 10.1089/wound.2020.1160] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Significance: Pyoderma gangrenosum (PG) is a rare debilitating autoinflammatory ulcerative skin disease. No gold standard has been established for the treatment of PG. The role of surgical interventions and negative pressure wound therapy (NPWT) was discussed controversially until recently as these procedures might pose a trigger to further aggravate the condition. Recent Advances: Recent advances confirm the paradigm change that a surgical approach of PG with split thickness skin grafting (STSG) secured by NPWT is a safe and valuable treatment if performed under adequate immunosuppression. We elaborate this on the hand of a broad literature search retrieving 101 relevant articles describing 138 patients complemented with our personal experience on 23 patients, including 2 patients treated with a porcine xenodressing. Critical Issues: A wide range of surgical approaches have been reported, including xenografts. Treatment was finally successful in 86%, including the xenotransplant cases. Ten percent improved and failures were mainly reported without immunosuppression. Despite halting the inflammatory process, NPWT alone, without skin grafting, does not much accelerate healing time. The best surgical approach appears to be STSG fixed with NPWT as this leads to higher skin graft take. There remains the problem of the chronic nature of PG and the recurrence after tapering of immunosuppression or trauma; therefore, a sustained immunosuppressive treatment is suggested. Future Directions: While surgical treatment is supported by the published data, the exact immunosuppression is still evolving. Due to deeper insights into pathogenesis and growing clinical reports, a broader utilization of biologic treatments and a shift from tumor necrosis factor (TNF)-alpha to interleukin (IL)-12/23 or IL-23 antibodies alone are predictable, as IL-12/23 antibodies show good clinical responses with fewer side effects. The positive results with porcine xenodressings might be due to immunological effects of the xenomaterial; they appear promising, but are preliminary and should be confirmed in a larger patient collective.
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Affiliation(s)
- Klaus Eisendle
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
- IMREST Interdisciplinary Medical Research Center South Tyrol, Claudiana, College of Health-Care Professions, Bolzano/Bozen, Italy
| | - Tobias Thuile
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
| | - Jenny Deluca
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
| | - Maria Pichler
- Department of Dermatology, Venereology and Allergology, Academic Teaching Department of Medical University Innsbruck, Central Teaching Hospital Bolzano/Bozen, Bolzano/Bozen, Italy
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4
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Fazel M, Merola JF, Kurtzman DJB. Inflammatory arthritis and crystal arthropathy: Current concepts of skin and systemic manifestations. Clin Dermatol 2018; 36:533-550. [PMID: 30047436 DOI: 10.1016/j.clindermatol.2018.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic inflammatory disorders frequently involve the skin, and when cutaneous disease develops, such dermatologic manifestations may represent the initial sign of disease and may also provide valuable prognostic information about the underlying disorder. Familiarity with the various skin manifestations of systemic disease is therefore paramount and increases the likelihood of accurate diagnosis, which may facilitate the implementation of an appropriate treatment strategy. An improvement in quality of life and a reduction in the degree of morbidity may also be a realized benefit of accurate recognition of these skin signs. With this context in mind, this review highlights the salient clinical features and unique dermatologic manifestations of rheumatoid arthritis, adult-onset Still's disease, and the crystal arthropathy, gout.
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Affiliation(s)
- Mahdieh Fazel
- Division of Dermatology, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Joseph F Merola
- Division of Rheumatology and Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Drew J B Kurtzman
- Division of Dermatology, The University of Arizona College of Medicine, Tucson, Arizona, USA.
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Vallini V, Andreini R, Bonadio A. Pyoderma Gangrenosum: A Current Problem as Much as an Unknown One. INT J LOW EXTR WOUND 2017; 16:191-201. [DOI: 10.1177/1534734617710980] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic inflammatory skin disease, characterized by recurrent skin ulcers, which in almost 50% of cases are associated with systemic autoimmune disorders, including rheumatoid arthritis, chronic hepatitis, inflammatory bowel disease, paraproteinemias and hematological malignancies. A systematic search of literature for PG was carried out using the PubMed, Embase, and Google Scholar databases for the purpose of this review and 2780 articles were retrieved up to February 2017. Inflammation represents the predominant aspect of the disease, but its pathophysiological mechanisms are not completely clear yet, since there are many studies showing only one or more isolated findings of the disease. The goal of PG treatment is to reduce inflammation in order to promote ulcer healing by minimizing side effects of therapy. Several systemic and local treatments are available, but the lack of large randomized double-blind studies results in an absence of a uniform therapeutic standard: thus, more clinical studies are required in order to make head-to-head comparisons between combination and single-drug therapies and to identify specific combination therapies for distinctive clinical patterns of PG.
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Affiliation(s)
- Valerio Vallini
- Ospedale Santa Maria Maddalena–Volterra, Azienda Usl Nordovest, Toscana, Italy
| | - Roberto Andreini
- Ospedale Santa Maria Maddalena–Volterra, Azienda Usl Nordovest, Toscana, Italy
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Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive drug the efficiency of which has been established in renal transplantation. Recent studies suggest that it may also be effective in the treatment of variant skin diseases especially if the skin lesions are triggered by lymphocytes. Studies have shown efficacy in autoimmune bullous dermatoses, atopic dermatitis and psoriasis. However, there are no placebo-controlled trials that support the use of MMF as first line therapy in these skin diseases.
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Affiliation(s)
- M Hartmann
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - A Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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7
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Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive drug the efficiency of which has been established in renal transplantation. Recent studies suggest that it may also be effective in the treatment of variant skin diseases especially if the skin lesions are triggered by lymphocytes. Studies have shown efficacy in autoimmune bullous dermatoses, atopic dermatitis and psoriasis. However, there are no placebo-controlled trials that support the use of MMF as first line therapy in these skin diseases.
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Affiliation(s)
- M Hartmann
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany.
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Shin YC, Shin DM, Lee EJ, Lee JH, Kim JE, Song SH, Hwang DY, Lee JJ, Kim B, Lim D, Hyon SH, Lim YJ, Han DW. Hyaluronic Acid/PLGA Core/Shell Fiber Matrices Loaded with EGCG Beneficial to Diabetic Wound Healing. Adv Healthc Mater 2016; 5:3035-3045. [PMID: 27805803 DOI: 10.1002/adhm.201600658] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/02/2016] [Indexed: 01/13/2023]
Abstract
During the last few decades, considerable research on diabetic wound healing strategies has been performed, but complete diabetic wound healing remains an unsolved problem, which constitutes an enormous biomedical burden. Herein, hyaluronic acid (HA)/poly(lactic-co-glycolic acid, PLGA) core/shell fiber matrices loaded with epigallocatechin-3-O-gallate (EGCG) (HA/PLGA-E) are fabricated by coaxial electrospinning. HA/PLGA-E core/shell fiber matrices are composed of randomly-oriented sub-micrometer fibers and have a 3D porous network structure. EGCG is uniformly dispersed in the shell and sustainedly released from the matrices in a stepwise manner by controlled diffusion and PLGA degradation over four weeks. EGCG does not adversely affect the thermomechanical properties of HA/PLGA-E matrices. The number of human dermal fibroblasts attached on HA/PLGA-E matrices is appreciably higher than that on HA/PLGA counterparts, while their proliferation is steadily retained on HA/PLGA-E matrices. The wound healing activity of HA/PLGA-E matrices is evaluated in streptozotocin-induced diabetic rats. After two weeks of surgical treatment, the wound areas are significantly reduced by the coverage with HA/PLGA-E matrices resulting from enhanced re-epithelialization/neovascularization and increased collagen deposition, compared with no treatment or HA/PLGA. In conclusion, the HA/PLGA-E matrices can be potentially exploited to craft strategies for the acceleration of diabetic wound healing and skin regeneration.
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Affiliation(s)
- Yong Cheol Shin
- Department of Cogno-Mechatronics Engineering; College of Nanoscience & Nanotechnology; Pusan National University; Busan 46241 Korea
| | - Dong-Myeong Shin
- Research Center for Energy Convergence Technology; Pusan National University; Busan 46241 Korea
| | - Eun Ji Lee
- Department of Cogno-Mechatronics Engineering; College of Nanoscience & Nanotechnology; Pusan National University; Busan 46241 Korea
| | - Jong Ho Lee
- Department of Cogno-Mechatronics Engineering; College of Nanoscience & Nanotechnology; Pusan National University; Busan 46241 Korea
| | - Ji Eun Kim
- Department of Biomaterials Science; College of Natural Resources and Life Science; Life and Industry Convergence Research Institute; Pusan National University; Miryang 50463 Korea
| | - Sung Hwa Song
- Department of Biomaterials Science; College of Natural Resources and Life Science; Life and Industry Convergence Research Institute; Pusan National University; Miryang 50463 Korea
| | - Dae-Youn Hwang
- Department of Biomaterials Science; College of Natural Resources and Life Science; Life and Industry Convergence Research Institute; Pusan National University; Miryang 50463 Korea
| | - Jun Jae Lee
- Department of Prosthodontics; Dental Research Institute; School of Dentistry; Seoul National University; Seoul 03080 Korea
| | - Bongju Kim
- Dental Life Science Research Institute; Seoul National University Dental Hospital; Seoul 03080 Korea
| | - Dohyung Lim
- Department of Mechanical Engineering; Sejong University; Seoul 05006 Korea
| | - Suong-Hyu Hyon
- Center for Fiber and Textile Science; Kyoto Institute of Technology; Kyoto 606-8585 Japan
| | - Young-Jun Lim
- Department of Prosthodontics; Dental Research Institute; School of Dentistry; Seoul National University; Seoul 03080 Korea
| | - Dong-Wook Han
- Department of Cogno-Mechatronics Engineering; College of Nanoscience & Nanotechnology; Pusan National University; Busan 46241 Korea
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Clinical features, causes, treatments, and outcomes of peristomal pyoderma gangrenosum (PPG) in 44 patients: The Mayo Clinic experience, 1996 through 2013. J Am Acad Dermatol 2016; 75:931-939. [DOI: 10.1016/j.jaad.2016.05.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/09/2016] [Accepted: 05/31/2016] [Indexed: 12/15/2022]
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Abstract
Dermatologists face a wide range of pain control challenges in daily practice, from the transient pain of dermatologic surgery to the persistent pain that plagues some chronic dermatologic conditions. Although the pathophysiology of pain is well described and the profound impact of dermatological pain on patients' quality of life is well appreciated, there is an identified need for clear therapeutic plans for providing symptomatic pain relief of common painful dermatoses. In this paper, we will review and clearly outline approaches to pain management of a number of common painful dermatoses such as herpes zoster and post-herpetic neuralgia, ulcers, oral dermatoses, dysesthesias, and many others.
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Wollina U, Tchernev G. Pyoderma gangrenosum: pathogenetic oriented treatment approaches. Wien Med Wochenschr 2014; 164:263-73. [DOI: 10.1007/s10354-014-0285-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 05/01/2014] [Indexed: 01/10/2023]
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12
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Li J, Kelly R. Treatment of pyoderma gangrenosum with mycophenolate mofetil as a steroid-sparing agent. J Am Acad Dermatol 2013; 69:565-9. [DOI: 10.1016/j.jaad.2013.05.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 05/27/2013] [Accepted: 05/30/2013] [Indexed: 10/26/2022]
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Abstract
Neutrophilic dermatoses, including Sweet's syndrome, pyoderma gangrenosum, and rheumatoid neutrophilic dermatitis, are inflammatory conditions of the skin often associated with underlying systemic disease. These are characterized by the accumulation of neutrophils in the skin. The associated conditions, potential for systemic neutrophilic infiltration, and therapeutic management of these disorders can be similar. Sweet's syndrome can often be effectively treated with a brief course of systemic corticosteroids. Pyoderma gangrenosum, however, can be recurrent, and early initiation of a steroid-sparing agent is prudent. Second-line treatment for both of these conditions includes medications affecting neutrophil function, in addition to immunosuppressant medications.
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Affiliation(s)
- Courtney R Schadt
- Division of Dermatology, University of Louisville, 310 East Broadway, Louisville, KY 40202, USA.
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Bonamigo RR, Razera F, Olm GS. Dermatoses neutrofílicas: parte I. An Bras Dermatol 2011; 86:11-25; quiz 26-7. [DOI: 10.1590/s0365-05962011000100002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Indexed: 12/16/2022] Open
Abstract
Os autores apresentam uma revisão das dermatoses neutrofílicas que possuem grande repercussão à saúde dos pacientes: síndrome de Sweet, pioderma gangrenoso, doença de Behçet e urticária neutrofílica. São discutidos, baseados nos resultados e conclusões de estudos relevantes publicados recentemente e na experiência dos autores, os principais aspectos clínicos, as importantes alterações histopatológicas e as opções para o manejo.
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Postoperative Pyoderma Gangrenosum After Elective Abdominoplasty: A Case Report and Review of the Literature. J Burn Care Res 2010; 31:959-63. [DOI: 10.1097/bcr.0b013e3181f93ab1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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[Management of pyoderma gangrenosum. An update on clinical features, diagnosis and therapy]. Hautarzt 2010; 61:345-53; quiz 354-5. [PMID: 20361320 DOI: 10.1007/s00105-009-1909-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pyoderma gangrenosum is a rare neutrophilic inflammatory skin disease, mostly observed in middle-aged adults. Etiology and pathogenesis remain unclear. Autoimmune mechanisms including immune complex-mediated neutrophilic vascular reactions have been suggested. The hallmark finding in pyoderma gangrenosum is painful ulcers with sharply circumscribed and demarcated, frequently undermined, livid borders and a necrotic base. Pyoderma gangrenosum has been described in association with a great variety of systemic disorders, ranging from inflammatory bowel diseases to myeloproliferative disorders. The diagnosis of pyoderma gangrenosum is based primarily on the clinical presentation and course. It is usually a diagnosis of exclusion. Histopathological and laboratory findings in pyoderma gangrenosum are nonspecific. The aims of therapy are the complete suppression of inflammatory disease activity, promotion of wound healing and control of pain. Frequently, successful treatment of associated diseases leads to an improvement or complete remission of pyoderma gangrenosum. Surgical interventions, including aggressive ulcer excision, recipient site preparation and autologous skin grafting have to be avoided during the active phase of the disease because the likely occurrence of pathergy inducing new lesions at surgical sites and causing a worsening the original lesions.
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Prajapati V, Man J, Brassard A. Pyoderma gangrenosum: common pitfalls in management and a stepwise, evidence-based, therapeutic approach. J Cutan Med Surg 2009; 13 Suppl 1:S2-11. [PMID: 19480746 DOI: 10.2310/7750.2009.00002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Vimal Prajapati
- Division of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, AB
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Abstract
Originally used to treat psoriasis nearly three decades ago, mycophenolic acid, reformulated as mycophenolate mofetil (MMF), has been rediscovered by the world of dermatology. As a relatively well-tolerated immunosuppressive used in organ transplant recipients, MMF has recently been reported to show promise for several dermatologic conditions, including psoriasis, pemphigus vulgaris, pyoderma gangrenosum, bullous lichen planus, and even connective tissue diseases such as lupus erythematosus and dermatomyositis. Although not intended to be exhaustive, this review discusses MMF with regard to its basic pharmacology, its side effects, and its reported efficacy in a variety of dermatologic indications. Relevant literature was retrieved by a Medline search combining the terms "mycophenolate" or "mycophenolic acid" and "skin" or "skin disease" or a number of specific conditions ("psoriasis", "dermatitis", "eczema", "pemphigoid", "pemphigus", "vasculitis", "pyoderma gangrenosum", "Crohn's disease", "graft-versus-host disease", "lichen planus"). As MMF has only been recently re-introduced for dermatologic application, the nature of much of the literature is admittedly that of case reports or case series. Nevertheless, the results are sufficiently promising to warrant further larger, control studies.
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Affiliation(s)
- V Liu
- Department of Dermatology, Harvard Medical School, Massachusetts General Hospital Dermatopathology Unit, 55 Fruit Street, Boston, MA 02114, USA.
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Abstract
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.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology & Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Friedrichstrasse Dresden, Germany.
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Abstract
Rheumatoid arthritis (RA) is a chronic progressive disorder characterized by symmetric inflammatory arthritis in association with systemic symptoms. Although considered a "joint disease," RA is associated with involvement in diverse organ systems, including the skin. Common manifestations include Raynaud phenomenon, rheumatoid nodules, and rheumatoid vasculitis. As with other extra-articular manifestations, dermatologic involvement tends to occur in patients with more severe RA. In addition to manifestations related to the disease, there are also sundry dermatologic reactions related to the medications used to treat RA. Understanding the etiology and therapy for cutaneous manifestations of RA will help optimize patient care.
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Affiliation(s)
- Tissa Hata
- Department of Medicine, Division of Dermatology, University of California, San Diego School of Medicine, La Jolla, 92093-0943, USA.
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Reichrath J, Bens G, Bonowitz A, Tilgen W. Treatment recommendations for pyoderma gangrenosum: an evidence-based review of the literature based on more than 350 patients. J Am Acad Dermatol 2006; 53:273-83. [PMID: 16021123 DOI: 10.1016/j.jaad.2004.10.006] [Citation(s) in RCA: 243] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Because the incidence of pyoderma gangrenosum (PG) is low, no prospective randomized controlled trials and only a few studies with case numbers of more than 15 patients have been published. To date no guidelines for treatment of PG have been established far. The aim of the study was to provide an evidence-based review of the literature and an evaluation of recommendations for PG treatment. We performed an electronic search using the PubMed database and the term "pyoderma-gangrenosum." Literature published in the English language during the past two decades was reviewed. All relevant studies that could be obtained regardless of the study design were evaluated for grades of recommendation and levels of evidence. Data on patient characteristics including severity of the disease, localization of lesions, associated diseases, and treatment procedures were abstracted and evaluated for therapeutic outcome. We conclude that therapeutic efficacy of systemic treatment with corticosteroids and cyclosporine is best documented in the literature for disseminated as well as for localized disease and should be considered first-line therapy. In cases that do not respond to this treatment, we recommend alternative therapeutic procedures (eg, systemic treatment with corticosteroids and mycophenolate mofetil; mycophenolate mofetil and cyclosporine; tacrolimus; infliximab; or plasmapheresis), considering additional factors including associated diseases.
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Affiliation(s)
- Jörg Reichrath
- Dermatology Clinic, The Saarland University Hospital, Homburg/Saar, Germany.
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Ehling A, Karrer S, Klebl F, Schäffler A, Müller-Ladner U. Therapeutic management of pyoderma gangrenosum. ACTA ACUST UNITED AC 2004; 50:3076-84. [PMID: 15476233 DOI: 10.1002/art.20559] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
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.
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Affiliation(s)
- Uwe Wollina
- Department of Dermatology, Hospital Dresden-Friedrichstadt, PO Box 120906, 01008 Dresden, Germany.
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Wollina U, Konrad H, Fischer T. Recessive epidermolysis bullosa dystrophicans (Hallopeau-Siemens)--improvement of wound healing by autologous epidermal grafts on an esterified hyaluronic acid membrane. J Dermatol 2001; 28:217-20. [PMID: 11449673 DOI: 10.1111/j.1346-8138.2001.tb00120.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Epidermolysis bullosa dystropicans of the Hallopeau-Siemens type (HS-EBD) is an autosomal-recessive blistering disease. Skin fragility due to mutations in structural proteins is responsible for further development of chronic and painful wounds, skin infections and sepsis. There is no causative treatment available. We present a case report with HS-EBD and longstanding painful wounds treated with autologous keratinocytes on an esterified hyaluronic acid membrane. Two out of three wounds treated showed a complete take of the graft. They improved markedly with a stable result over 12 months until now. Even autologous keratinocyte grafting may have a beneficial effect on chronic wounds in HS-EBD despite the fact that the genetic defects are unchanged.
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Affiliation(s)
- U Wollina
- Department of Dermatology and Dermatological Allergology, Medical School, Friedrich-Schiller-University of Jena, Erfurter Strasse 35, 07740 Jena, Germany
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