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Erduran F, Adışen E, Hayran Y, Aksoy GG, Alpsoy E, Selçuk LB, Günaydın SD, Yazıcı AC, Öktem A, Güngör M, Afacan E, Kuşçu DD, Elmas L, Aydoğan K, Bayramgürler D, Demirsoy EO, Akyol M, Güner RY, Erdoğan HK, Acer E, Ergun T, Yaylı S, Bulut F, Saraç E, Aktaş A. Analysis of clinical characteristics and factors affecting treatment responses in patients with pyoderma gangrenosum: a multicenter study of 239 patients ☆. An Bras Dermatol 2024:S0365-0596(24)00079-5. [PMID: 38735817 DOI: 10.1016/j.abd.2024.02.002] [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: 10/30/2023] [Revised: 02/08/2024] [Accepted: 02/17/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Pyoderma Gangrenosum (PG) is a chronic disease characterized by recalcitrant skin ulcers. OBJECTIVE We aimed to evaluate the demographic, clinical characteristics, treatments and factors affecting the treatment responses of patients with PG. METHODS We performed a multicenter study of 12 tertiary care centers. We analyzed the data of the patients who were followed up with a diagnosis of PG between the years 2012‒2022 retrospectively. RESULTS We included a total of 239 patients of whom 143 were female and 96 were male, with an average age of 54.2 ± 17.4 years. The most common treatment was systemic steroids (n = 181, 75.7%). Among these patients, 50.8% (n = 92) used systemic steroids as the sole systemic agent, while 49.2% (n = 89) used at least one adjuvant immunosuppressive agent. The independent factors determined in regression analysis to influence response to systemic steroids positively were disease onset age ≥ 30-years, negative pathergy, absence of leukocytosis, negative wound culture, presence of a single lesion, and absence of upper extremity involvement. Biological agents were used in 18.4% (n = 44) of the patients in the present study. We also analyzed pathergy positive PG and early onset (onset age < 30) PG separately due to their distinct clinical features which were revealed during statistical analysis. STUDY LIMITATIONS Retrospective nature of the present study. CONCLUSIONS Analyses of the factors influencing treatment responses are addressed in this study. Also, we concluded that investigation for accompanying autoinflammatory diseases of pathergy positive PG and early onset PG is necessary and the patients in these two groups are more resistant to treatment, necessitating more complicated treatments.
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Affiliation(s)
- Funda Erduran
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey.
| | - Esra Adışen
- Department of Dermatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Yıldız Hayran
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Güneş Gür Aksoy
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Erkan Alpsoy
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Leyla Baykal Selçuk
- Department of Dermatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Sibel Doğan Günaydın
- Department of Dermatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ayça Cordan Yazıcı
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Ayşe Öktem
- Ankara University Faculty of Medicine, Department of Dermatology, Ankara, Turkey
| | - Malik Güngör
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Elif Afacan
- Department of Dermatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Deniz Devrim Kuşçu
- Ankara University Faculty of Medicine, Department of Dermatology, Ankara, Turkey
| | - Leyla Elmas
- Department of Dermatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kübra Aydoğan
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Dilek Bayramgürler
- Department of Dermatology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | | | - Melih Akyol
- Department of Dermatology, Sivas Cumhuriyet University Faculty of Medicine, Sivas, Turkey
| | - Rukiye Yasak Güner
- Department of Dermatology, Sivas Cumhuriyet University Faculty of Medicine, Sivas, Turkey
| | - Hilal Kaya Erdoğan
- Department of Dermatology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Ersoy Acer
- Department of Dermatology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Tulin Ergun
- Marmara University Faculty of Medicine, Department of Dermatology, İstanbul, Turkey
| | - Savaş Yaylı
- Department of Dermatology, Koç University Faculty of Medicine, İstanbul, Turkey
| | - Ferhan Bulut
- Marmara University Faculty of Medicine, Department of Dermatology, İstanbul, Turkey
| | - Esra Saraç
- Department of Dermatology, Koç University Faculty of Medicine, İstanbul, Turkey
| | - Akın Aktaş
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey
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2
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Tan MG, Tolkachjov SN. Treatment of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:183-192. [PMID: 38423680 DOI: 10.1016/j.det.2023.12.002] [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
Pyoderma gangrenosum is a rare neutrophilic dermatosis that results in painful cutaneous ulcers and is frequently associated with underlying hematologic disorders, inflammatory bowel disease, or other autoimmune disorders. Pathogenesis involves an imbalance between proinflammatory and anti-inflammatory mediators, leading to tissue damage from neutrophils. First-line treatment options with the greatest evidence include systemic corticosteroids, cyclosporine, and tumor necrosis factor alpha inhibitors. Other steroid-sparing therapies such as dapsone, mycophenolate mofetil, intravenous immunoglobulin, and targeted biologic or small molecule inhibitors also have evidence supporting their use. Wound care and management of underlying associated disorders are critical parts of the treatment regimen.
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Affiliation(s)
- Marcus G Tan
- Division of Dermatology, University of Ottawa, 737 Parkdale Avenue, 4th Floor Dermatology, Ottawa, ON K1Y1J8, Canada.
| | - 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, Lewisville, TX 75056, USA
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3
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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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4
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Dissemond J, Marzano AV, Hampton PJ, Ortega-Loayza AG. Pyoderma Gangrenosum: Treatment Options. Drugs 2023; 83:1255-1267. [PMID: 37610614 PMCID: PMC10511384 DOI: 10.1007/s40265-023-01931-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.
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Affiliation(s)
- Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Philip J Hampton
- Department of Dermatology, Newcastle Dermatology, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science, University, Portland, OR, USA
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5
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Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments. Am J Clin Dermatol 2022; 23:615-634. [PMID: 35606650 PMCID: PMC9464730 DOI: 10.1007/s40257-022-00699-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 12/12/2022]
Abstract
Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving cutaneous ulcers with undermined, irregular, erythematous-violaceous edges. Pyoderma gangrenosum pathogenesis is complex and involves a profound dysregulation of components of both innate and adaptive immunity in genetically predisposed individuals, with the follicular unit increasingly recognized as the putative initial target. T helper 17/T helper 1-skewed inflammation and exaggerated inflammasome activation lead to a dysregulated neutrophil-dominant milieu with high levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-1α, IL-8, IL-12, IL-15, IL-17, IL-23, and IL-36. Low-evidence studies and a lack of validated diagnostic and response criteria have hindered the discovery and validation of new effective treatments for pyoderma gangrenosum. We review established and emerging treatments for pyoderma gangrenosum. A therapeutic algorithm based on available evidence is also provided. For emerging treatments, we review target molecules and their role in the pathogenesis of pyoderma gangrenosum.
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6
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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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7
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Gündüz K, Gülbaşaran F, Hasdemir PS, Temiz P, Inanır I. Successful treatment of severe refractory post-cesarean pyoderma gangrenosum with intravenous immunoglobulin. Dermatol Ther 2020; 33:e14121. [PMID: 32743854 DOI: 10.1111/dth.14121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly progressing necrolytic ulceration of the skin. Proper treatment is crucial since it can result in devastating consequences. First-line treatments include systemic corticosteroids or cyclosporine. However, no standardized treatment regimens for refractory cases exist and treatment outcomes are affected by underlying conditions. PG after cesarean section, which is believed to occur in association with underlying pregnancy- and parturition-related immune changes, is extremely rare, and all reported cases in the literature have been successfully treated with systemic or topical corticosteroids. We report a case of a 32-year-old patient with severe PG occurring on her cesarean scar 3 days after the cesarean delivery. Treatment with systemic corticosteroids and first-line immunomodulatory agents resulted in insufficient response and serious complications. Intravenous immunoglobulin (IVIG) was then initiated, and a rapid clinical response was seen. Corticosteroid dose was gradually decreased and ceased. IVIG infusion was continued for 3 months until complete recovery. Reactivation was not observed in a 1-year follow-up period. Due to its cost, IVIG infusion is less suitable as a first-line agent. However, IVIG may be an important therapeutic option in resistant postpartum PG, in which first-line agents have failed or led to complications.
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Affiliation(s)
- Kamer Gündüz
- Medical Faculty, Department of Dermatology, Celal Bayar University, Manisa, Turkey
| | - Fatmagül Gülbaşaran
- Medical Faculty, Department of Dermatology, Celal Bayar University, Manisa, Turkey.,Department of Dermatology, Salihli State Hospital, Manisa, Turkey
| | - Pınar Solmaz Hasdemir
- Medical Faculty, Department of Obstetrics and Gynecology, Celal Bayar University, Manisa, Turkey
| | - Peyker Temiz
- Medical Faculty, Department of Pathology, Celal Bayar University, Manisa, Turkey
| | - Işıl Inanır
- Medical Faculty, Department of Dermatology, Celal Bayar University, Manisa, Turkey
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8
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Jin SY, Chen M, Wang FY, Wang F. Applying Intravenous Immunoglobulin and Negative-Pressure Wound Therapy to Treat Refractory Pyoderma Gangrenosum: A Case Report. INT J LOW EXTR WOUND 2020; 20:158-161. [PMID: 32734793 DOI: 10.1177/1534734620940459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare chronic neutrophilic dermatosis that causes undermining ulcers. Unfortunately, standardization of PG treatment remains a challenge. In this article, we describe a case in which a 69-year-old man presented with a painful ulcer on the right lower leg. The diagnosis of PG was made after excluding other diseases. He had a history of PG on his left lower leg 2 years earlier and was cured by the treatment of systemic corticosteroids and cyclosporin A for 43 days. However, such a treatment was not effective this time. Hence, we applied intravenous immunoglobulin and negative-pressure wound therapy, and the patient was cured. Altogether, this case supports the use of intravenous immunoglobulin as an effective adjuvant for refractory PG, and indicates negative-pressure wound therapy as a treatment option to advance ulcer healing under adequate immunosuppression.
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Affiliation(s)
- Shi-Ying Jin
- Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China
| | - Mei Chen
- Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China
| | - Feng-Yuan Wang
- Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China
| | - Fei Wang
- Zhongda Hospital, Southeast University, Nanjing, Jiangsu, China
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9
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Goldust M, Hagstrom EL, Rathod D, Ortega-Loayza AG. Diagnosis and novel clinical treatment strategies for pyoderma gangrenosum. Expert Rev Clin Pharmacol 2020; 13:157-161. [PMID: 31875484 DOI: 10.1080/17512433.2020.1709825] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Pyoderma gangrenosum (PG) is a noninfectious, reactive inflammatory neutrophilic dermatosis that is commonly associated with autoimmune and neoplastic disorders. There are emerging diagnostic tools and treatment options for PG.Area covered: The diagnosis of PG should be seriously considered when managing ulcers to avoid unnecessary medical and surgical complications with prompt and suitable treatment. There are no standardized treatment guidelines for PG, and current therapy largely depends on the severity and progression of the disease. Systemic corticosteroids, immunosuppressant therapy, and biologic agents remain mainstay therapies. In this article, we present a literature review of recent diagnostic and novel treatment options for the management of PG. The literature research considered clinical studies or scientific reviews. Studies were identified by searching electronic databases and reference lists of respective articles till August 2019.Expert opinion: The true diagnosis of PG is challenging, as there is no diagnostic gold standard. PARACELSUS is a novel diagnostic tool. Biologics and small molecules are emerging systemic therapy options that are relatively new in treatment of PG.
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Affiliation(s)
- Mohamad Goldust
- Department of Dermatology, University of Rome Guglielmo Marconi, Rome, Italy.,Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - Erika L Hagstrom
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | | | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
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10
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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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