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Mastronardi M, Cavalcanti E, Labarile N, Armentano R, Gabriele F, Curlo M. Pyoderma gangrenosum in ulcerative colitis patient treated with vedolizumab: adsorptive granulocyte/monocyte apheresis as a new therapeutic option refractory cases - a case report and literature review. Ther Adv Chronic Dis 2023; 14:20406223231194190. [PMID: 37928629 PMCID: PMC10623906 DOI: 10.1177/20406223231194190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 07/25/2023] [Indexed: 11/07/2023] Open
Abstract
Extraintestinal manifestations occur rather frequently in ulcerative colitis (UC) and Crohn's disease patients and are usually related to an exacerbation of the underlying intestinal bowel disease but sometimes may run a course independent of the inflammatory bowel diseases (IBD). About one-third of patients with IBD develop extraintestinal manifestations, such as pyoderma gangrenosum (PG). PG is an uncommon inflammatory skin disorder of unknown pathogenesis. There are no specific serological or histological markers, and diagnosis is predominantly clinical. Topical and systemic therapies are both vital aspects of treatment and immune modulators have been used with increasing success in recent years, although immunosuppressive drugs raise some concerns due to an increased risk of serious and opportunistic infections and cancer, particularly in elderly and comorbid patients, underlining the unmet need for safer alternative therapies. Thus, in this case report, we highlighted an adsorptive granulocyte/monocyte apheresis (GMA) as a new therapeutic possibility in IBD patients with extraintestinal manifestations. We report a case of a 60-year woman with a history of UC with a Mayo grade 3 score which was associated with a PG. Given that the patients maintained clinical remission with vedolizumab, we preferred not to perform a combined treatment with other antitumor necrosis factor-alpha or ciclosporin, thus avoiding an increased risk of serious infections in the patient. Therefore, we performed the extracorporeal leukocyte apheresis. The patient progressed favorably, with progressive improvement of skin and bowel disease. Therefore, adsorptive GMA has a very favorable safety profile and has been confirmed in numerous studies. In this study, we underlined that an intensive regimen of GMA paves the way to an ideal option for patients with severe and refractory PG complicated with UC.
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Affiliation(s)
- Mauro Mastronardi
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
| | - Elisabetta Cavalcanti
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Via Turi 27, Castellana Grotte, Bari 70013, Italy
| | - Nunzia Labarile
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
| | - Raffaele Armentano
- Histopathology Unit of National Institute of Gastroenterology “S. de Bellis”, Research Hospital, Castellana Grotte, Bari, Italy
| | - Francesco Gabriele
- Intensive Therapy Unit of National Institute of Gastroenterology “S. de Bellis”, Research Hospital, Castellana Grotte, Bari, Italy
| | - Margherita Curlo
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
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Kusraeva DT, Olisova OY, Teplyuk NP, Grabovskaya OV, Kayumova LN, Bobkova AE, Varshavsky VA, Komleva LF, Petrenko EV, Bobrova KY. PYODERMA GANGRENOSUM MIMICKING GRANULOMATOSIS WITH POLYANGIITIS: CACE REPORT AND RIVIEW OF THE LITERATURE. VESTNIK DERMATOLOGII I VENEROLOGII 2023. [DOI: 10.25208/vdv1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Pyoderma gangrenosum is an autoinflammatory neutrophilic dermatosis. Diagnosis of the disease remains a difficult task to date, due to the lack of a gold standard of examination and differential diagnostic signs. The primary elements in the development of PG may be papules, pustules or bullae the dissection of which subsequently leads to the formation of ulcers with irregular, violaceous, undermined borders. In rare cases, the diagnosis of the disease can also be complicated by the rapid development of internal organs damage symptoms, which must be regarded as extracutaneous manifestations of PG. Extracutaneous lesions can occur before, during or after the appearance of skin rashes, and the detection of sterile neutrophil infiltrates in the defeat of internal organs confirm the concept of PG as a multisystemic disease. The presented case of a rare course of PG with multiple skin lesions and extracutaneous manifestations, simulating systemic vasculitis, emphasizes the importance of a detailed examination of patients in order to make a correct diagnosis and prescribe timely adequate treatment.
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Rick J, Gould LJ, Marzano AV, Garg A, Chen D, Oakes DL, Dissemond J, Herfarth H, Friedman MA, Alavi A, Yamamoto T, Gerbens LAA, Thomas KS, Ortega-Loayza AG. The “Understanding Pyoderma Gangrenosum, Review and Assessment of Disease Effects (UPGRADE)” Project: a protocol for the development of the core outcome domain set for trials in pyoderma gangrenosum. Arch Dermatol Res 2022; 315:983-988. [PMID: 36305958 DOI: 10.1007/s00403-022-02424-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 04/22/2022] [Accepted: 10/13/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that affects approximately 0.3-6 out of every 100,000 people worldwide. Clinical trials are scarce but there is growing interest in using newer and more targeted therapeutics to achieve disease remission. However, there are no standardized instruments to measure outcomes in PG and, therefore, future clinical trials are hampered by the absence of established and accurate means of assessment and comparison. Therefore, we aim to produce an internationally accepted core outcome set (COS) that will overcome this obstacle. This protocol outlines our intended approach to achieve the first part of this process, establishing a core outcome domain set. METHODS An international team of PG stakeholders, consisting of physicians, wound care nurses, patients, scientists and industry representatives, has been assembled for the purpose of building a comprehensive and universally established set of core outcome domains. During the first step, we will generate items of relevance using a nominal process from all stakeholders. Items will be distilled and collapsed into potential domains and subdomains. A systematic review of current methods for reporting PG has already been published and domains identified in this work will be considered in the generation of the core domains set. During the second step, after the potential domains and subdomains are identified, stakeholders will participate in an e-Delphi exercise to rate the importance of (sub)domains. A final consensus meeting will be organized with the goal of establishing a core domain set. CONCLUSION Pyoderma gangrenosum lacks an established COS and previously published clinical trials have used inconsistent measures established from similarly inconsistent domains. As a first step this study seeks to create a core domain set within the COS, to build the foundation for future core outcome work for PG.
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Affiliation(s)
- Jonathan Rick
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Lisa J Gould
- South Shore Health Center for Wound Healing, Weymouth, MA, USA
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Amit Garg
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Diana Chen
- Genentech Incorporated, South San Francisco, CA, USA
| | - Debbie L Oakes
- South Shore Health Center for Wound Healing, Weymouth, MA, USA
| | - Joachim Dissemond
- Department of Dermatology, University of Essen-Duisburg, Essen, Germany
| | - Hans Herfarth
- Department of Internal Medicine, Division of Gastroenterology, University of North Carolina, Chapel Hill, NC, USA
| | - Marcia A Friedman
- Department of Internal Medicine, Division of Rheumatology, Oregon Health and Science University, Portland, OR, USA
| | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Louise A A Gerbens
- Department of Dermatology, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Kim S Thomas
- School of Medicine, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
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A rare complication after coronary bypass surgery: Incisional pyoderma gangrenosum. North Clin Istanb 2021; 8:395-397. [PMID: 34585076 PMCID: PMC8430364 DOI: 10.14744/nci.2020.73554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/15/2020] [Indexed: 11/20/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a non-infectious, necrotizing, destructive skin disease which is rarely seen after cardiac surgery. This report presents a PG case after coronary bypass surgery.
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Kayishunge D, Rick J, Ahmed A, Akunna T, Wong H. Progression of pyoderma gangrenosum with angioinvasive fungus. JAAD Case Rep 2021; 11:41-43. [PMID: 33912634 PMCID: PMC8063694 DOI: 10.1016/j.jdcr.2021.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Jonathan Rick
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Aadil Ahmed
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Tara Akunna
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Henry Wong
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that presents with rapidly developing, painful skin ulcers hallmarked by undermined borders and peripheral erythema. Epidemiological studies indicate that the average age of PG onset is in the mid-40s, with an incidence of a few cases per million person-years. PG is often associated with a variety of other immune-mediated diseases, most commonly inflammatory bowel disease and rheumatoid arthritis. The cause of PG is not well understood, but PG is generally considered an autoinflammatory disorder. Studies have focused on the role of T cells, especially at the wound margin; these cells may support the destructive autoinflammatory response by the innate immune system. PG is difficult to diagnose as several differential diagnoses are possible; in addition to clinical examination, laboratory tests of biopsied wound tissue are required for an accurate diagnosis, and new validated diagnostic criteria will facilitate the process. Treatment of PG typically starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) to reduce inflammation followed by the addition of more slowly acting immunosuppressive drugs with superior adverse event profiles, including biologics (in particular, anti-tumour necrosis factor (TNF) agents). Appropriate wound care is also essential. Future research should focus on PG-specific outcome measures and PG quality-of-life studies.
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Kawabe S, Iwata N, Nishida E, Kohagura T, Abe N, Nakaseko H, Morita A. Combination immunosuppressant therapy for rapidly progressive pyoderma gangrenosum in a child. Mod Rheumatol Case Rep 2020; 5:137-140. [PMID: 33016252 DOI: 10.1080/24725625.2020.1749359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
An 8-year-old girl was presented to our clinic with fever, arthritis in her left knee, a necrotic right fifth toe, and multiple large deep-seated ulcerations. She was diagnosed with pyoderma gangrenosum. Treatment with corticosteroids alone was ineffective for her skin lesions, and therefore combination immunosuppressant therapy was administered. Her skin lesions rapidly improved, enabling discontinuation of the corticosteroid therapy and avoiding systemic infection through the ulcers. Combination immunosuppressant therapy may be a treatment option for patients with severe, rapidly progressive pyoderma gangrenosum.
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Affiliation(s)
- Shinji Kawabe
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Emi Nishida
- Department of Dermatology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan.,Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Toaki Kohagura
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Naoki Abe
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Haruna Nakaseko
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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Shibuya T, Haga K, Saeki M, Haraikawa M, Tsuchihashi H, Okahara K, Nomura O, Fukushima H, Murakami T, Ishikawa D, Ikeda S, Nagahara A. Pyoderma gangrenosum in an ulcerative colitis patient during treatment with vedolizumab responded favorably to adsorptive granulocyte and monocyte apheresis. J Clin Apher 2020; 35:488-492. [PMID: 32767842 DOI: 10.1002/jca.21821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 12/31/2022]
Abstract
Pyoderma gangrenosum (PG) is an extra-intestinal skin lesion in inflammatory bowel disease (IBD) as is erythema nodosum. Vedolizumab (VED) is a monoclonal antibody that targets α4β7 integrin and has an intestinal selective mechanism. Despite good therapeutic effects on colitis, the effect on extra-intestinal manifestations (EIMs) remains unclear. Here we report a case of ulcerative colitis complicated by PG during treatment with VED, which was successfully treated with prednisolone in combination with adsorptive granulocyte and monocyte apheresis (GMA). The patient was a 50-year-old woman with a past medical history of extensive ulcerative colitis managed by golimumab (GLM). She developed flare symptoms due to loss of response to GLM, and treatment was switched to VED. Her gastrointestinal symptoms were improved with VED treatment with less frequent bowel movements. However, infiltrative erythema with pain appeared on the right lower leg and right knee, and expanded and gradually ulcerated. Her skin lesions were treated with corticosteroid, but showed poor improvement. Therefore, granulocyte and monocyte apheresis (GMA) treatment was administered in combination with prednisolone. After 3 months, the ulcer gradually improved, and at the time of this writing, the eruptions were nearly replaced by epithelial tissue. This case study showed that patients with UC and EIMS may respond well to combination therapy of VED and GMA. GMA has a very favorable safety profile. On the other hand, the causal connection between VED and PG is still unclear. We believe that a combination therapy involving VED and GMA in IBD patients with EIMs warrants consideration.
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Affiliation(s)
- Tomoyoshi Shibuya
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Keiichi Haga
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Michio Saeki
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Mayuko Haraikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hitoshi Tsuchihashi
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Koki Okahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Osamu Nomura
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hirofumi Fukushima
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Takashi Murakami
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Dai Ishikawa
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shigaku Ikeda
- Department of Dermatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihito Nagahara
- Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan
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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: 28] [Impact Index Per Article: 7.0] [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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Tominaga K, Kamimura K, Sato H, Ko M, Kawata Y, Mizusawa T, Yokoyama J, Terai S. Cytapheresis for pyoderma gangrenosum associated with inflammatory bowel disease: A review of current status. World J Clin Cases 2020; 8:2092-2101. [PMID: 32548138 PMCID: PMC7281039 DOI: 10.12998/wjcc.v8.i11.2092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/27/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis clinically characterized by the presence of painful skin ulcerations with erythematous. As it is frequently associated with inflammatory bowel diseases, including ulcerative colitis, gastroenterologists should be familiar with the disease including therapeutic options. Therefore, we have conducted a review focusing on the cytapheresis for PG in cases of inflammatory bowel diseases. A literature search was conducted to extract studies published in the last 20 years, with information on demographics, clinical symptoms, treatment, and the clinical course from a total of 22 cases reported and our recent case. In most patients, cytapheresis was associated with improvement or resolution of PG after failure of conventional therapeutic options such as corticosteroids, antibiotics, immunosuppressive agents and immunoglobulin. Based on the information summarized, cytapheresis is helpful in the majority of patients with PG refractory to medical treatment associated with inflammatory bowel diseases and could be further studied in a multicenter, randomized trial.
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Affiliation(s)
- Kentaro Tominaga
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Masayoshi Ko
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Yuzo Kawata
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Takeshi Mizusawa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata 951-8510, Japan
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Barton V, Le S, Wang J, Toussi A, Sood A, Maverakis E. Peristomal ulcers misdiagnosed as pyoderma gangrenosum: a common error. J Eur Acad Dermatol Venereol 2020; 34:e108-e110. [DOI: 10.1111/jdv.16034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- V.R. Barton
- Department of Dermatology University of California Davis Medical Center Sacramento CA USA
| | - S.T. Le
- Department of Dermatology University of California Davis Medical Center Sacramento CA USA
| | - J.Z. Wang
- Department of Dermatology University of California Davis Medical Center Sacramento CA USA
| | - A. Toussi
- Department of Dermatology University of California Davis Medical Center Sacramento CA USA
| | - A. Sood
- Department of Dermatology University of California Davis Medical Center Sacramento CA USA
| | - E. Maverakis
- Department of Dermatology University of California Davis Medical Center Sacramento CA USA
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Antoni A, Trautinger F, Heinz T, Hajdu S. Hemiarthroplasty in a patient with femoral neck fracture and pyoderma gangrenosum: a case report and review of the literature. J Med Case Rep 2020; 14:8. [PMID: 31931877 PMCID: PMC6958711 DOI: 10.1186/s13256-019-2329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 12/02/2019] [Indexed: 11/10/2022] Open
Abstract
Background Pyoderma gangrenosum is a rare ulcerating skin disease of unknown etiology, making its coincidence with orthopedic trauma a rare challenge. Patients are at risk of progression of the existing lesions and development of new lesions upon skin injury when surgical procedures are performed. To our knowledge, this is the first report in the literature of disease unrelated surgery during active pyoderma gangrenosum. Case presentation We present a case of femoral neck fracture in a Caucasian patient with concurrent pyoderma gangrenosum localized in the axilla. Hemiarthroplasty was safely performed after disease activity was reduced with systemic corticosteroids. Tissue-protective wound closure was used together with perioperative corticosteroids and antibiotics. No signs of pyoderma gangrenosum developed at the surgical wound site, and the axillary lesions showed constant improvement until healing with scar tissue. Conclusions In our patient, the preoperative steroid treatment, perioperative antibiotics, and soft tissue protective surgical technique led to successful management of this rare coincidence.
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Affiliation(s)
- Anna Antoni
- Department of Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Franz Trautinger
- Karl Landsteiner Institute of Dermatological Research, Karl Landsteiner Society, Franziskanergasse 4a, 3100, St. Pölten, Austria
| | - Thomas Heinz
- Department of Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Stefan Hajdu
- Department of Trauma Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Plumptre I, Knabel D, Tomecki K. Pyoderma Gangrenosum: A Review for the Gastroenterologist. Inflamm Bowel Dis 2018; 24:2510-2517. [PMID: 29788368 DOI: 10.1093/ibd/izy174] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Indexed: 12/20/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative skin disease of unknown etiology often associated with systemic inflammatory conditions, most commonly inflammatory bowel disease (IBD). The most common presentation of PG is spontaneous rapid formation of an extremely painful ulcer on the extremities, associated with significant morbidity and mortality. Rarely, PG can also occur as a chronic peristomal complication or as an acute postoperative complication of a surgical wound. The clinical course is unpredictable; it may not correlate with IBD activity and may even precede a diagnosis of IBD. Pyoderma gangrenosum is a diagnosis of exclusion. Treatment is challenging, often involving a variety of immunosuppressive therapies. This review aims to provide an update for the gastroenterologist on the pathogenesis, presentation, diagnosis, and management of PG, a rare complication of IBD.
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Affiliation(s)
- Isabella Plumptre
- London North West University Healthcare NHS Trust, London, United Kingdom
| | - Daniel Knabel
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth Tomecki
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
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Partridge ACR, Bai JW, Rosen CF, Walsh SR, Gulliver WP, Fleming P. Effectiveness of systemic treatments for pyoderma gangrenosum: a systematic review of observational studies and clinical trials. Br J Dermatol 2018; 179:290-295. [PMID: 29478243 DOI: 10.1111/bjd.16485] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a neutrophilic dermatosis with substantial morbidity. There is no consensus on gold-standard treatments. OBJECTIVES To review the effectiveness of systemic therapy for PG. METHODS We searched six databases for 24 systemic therapies for PG. Primary outcomes were complete healing and clinical improvement; secondary outcomes were time to healing and adverse effects. RESULTS We found 3326 citations and 375 articles underwent full-text review; 41 studies met the inclusion criteria. There were 704 participants in 26 retrospective cohort studies, three prospective cohort studies, seven case series, one case-control study, two open-label trials and two randomized controlled trials (RCTs). Systemic corticosteroids were the most studied (32 studies), followed by ciclosporin (21 studies), biologics (16 studies) and oral dapsone (11 studies). One RCT (STOP-GAP, n = 121) showed that prednisolone and ciclosporin were similar: 15-20% of patients showed complete healing at 6 weeks and 47% at 6 months. Another RCT (n = 30) found that infliximab was superior to placebo at 2 weeks (46% vs. 6% response), with a 21% complete healing rate at 6 weeks. Two uncontrolled trials showed 60% and 37% healing within 4 months for canakinumab and infliximab, respectively; other data suggest that patients with concurrent inflammatory bowel disease may benefit from biologics. The remaining studies were poor quality and had small sample sizes but supported the use of corticosteroids, ciclosporin and biologics. CONCLUSIONS Systemic corticosteroids, ciclosporin, infliximab and canakinumab had the most evidence in treating PG. However, current literature is limited to small and lower-quality studies with substantial heterogeneity.
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Affiliation(s)
- A C R Partridge
- MD Program, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - J W Bai
- MD Program, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - C F Rosen
- Division of Dermatology, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - S R Walsh
- Division of Dermatology, University of Toronto, Toronto, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - W P Gulliver
- Department of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - P Fleming
- Division of Dermatology, University of Toronto, Toronto, Canada
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16
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Alavi A, French LE, Davis MD, Brassard A, Kirsner RS. Pyoderma Gangrenosum: An Update on Pathophysiology, Diagnosis and Treatment. Am J Clin Dermatol 2017; 18:355-372. [PMID: 28224502 DOI: 10.1007/s40257-017-0251-7] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Russo I, Miotto S, Colpo A, Marson P, Tison T, Ferrazzi A, Alaibac M. Successful treatment of pyoderma gangrenosum with granulocyte and monocyte adsorption apheresis. Int Wound J 2016; 14:282-284. [PMID: 27790848 DOI: 10.1111/iwj.12684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/07/2016] [Indexed: 12/14/2022] Open
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis clinically characterised by the presence of painful skin ulcerations with erythematous and undetermined borders and histologically by the presence of neutrophilic infiltrates in the dermis. Granulocyte and monocyte adsorption apheresis, also called granulocytapheresis, is a therapeutic strategy for extracorporeal immunomodulation that selectively removes activated granulocytes and monocytes/macrophages from the peripheral blood. Here, we report a case of a 73-year-old patient affected by a severe form of pyoderma gangrenosum presenting with multiple painful ulcers and pustules on his trunk and extremities. The disease was resistant to high doses of methylprednisolone and methotrexate and successfully treated by granulocyte and monocyte adsorption apheresis. To the best of our knowledge, this is the first report on the efficacy of granulocyte and monocyte adsorption apheresis in pyoderma gangrenosum in Europe.
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Affiliation(s)
- Irene Russo
- Unit of Dermatology, University of Padua, Padua, Italy
| | - Serena Miotto
- Unit of Dermatology, University of Padua, Padua, Italy
| | - Anna Colpo
- Apheresis Unit, University of Padua, Padua, Italy
| | - Piero Marson
- Apheresis Unit, University of Padua, Padua, Italy
| | | | - Anna Ferrazzi
- Unit of Dermatology, University of Padua, Padua, Italy
| | - Mauro Alaibac
- Unit of Dermatology, University of Padua, Padua, Italy
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Pyoderma gangrenosum—a novel approach? Wien Med Wochenschr 2016; 167:58-65. [DOI: 10.1007/s10354-016-0472-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/30/2016] [Indexed: 12/20/2022]
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Anuset D, Reguiai Z, Perceau G, Colomb M, Durlach A, Bernard P. Caractéristiques cliniques et traitement du pyoderma gangrenosum dans la Marne. Ann Dermatol Venereol 2016; 143:108-17. [DOI: 10.1016/j.annder.2015.10.593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/15/2015] [Accepted: 10/28/2015] [Indexed: 11/28/2022]
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Gameiro A, Pereira N, Cardoso JC, Gonçalo M. Pyoderma gangrenosum: challenges and solutions. Clin Cosmet Investig Dermatol 2015; 8:285-93. [PMID: 26060412 PMCID: PMC4454198 DOI: 10.2147/ccid.s61202] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare disease, but commonly related to important morbidity. PG was first assumed to be infectious, but is now considered an inflammatory neutrophilic disease, often associated with autoimmunity, and with chronic inflammatory and neoplastic diseases. Currently, many aspects of the underlying pathophysiology are not well understood, and etiology still remains unknown. PG presents as painful, single or multiple lesions, with several clinical variants, in different locations, with a non specific histology, which makes the diagnosis challenging and often delayed. In the classic ulcerative variant, characterized by ulcers with inflammatory undermined borders, a broad differential diagnosis of malignancy, infection, and vasculitis needs to be considered, making PG a diagnosis of exclusion. Moreover, there are no definitively accepted diagnostic criteria. Treatment is also challenging since, due to its rarity, clinical trials are difficult to perform, and consequently, there is no “gold standard” therapy. Patients frequently require aggressive immunosuppression, often in multidrug regimens that are not standardized. We reviewed the clinical challenges of PG in order to find helpful clues to improve diagnostic accuracy and the treatment options, namely topical care, systemic drugs, and the new emerging therapies that may reduce morbidity.
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Affiliation(s)
- Ana Gameiro
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal
| | - Neide Pereira
- Dermatology Department, Centro Hospitalar Cova da Beira, Covilhã, Portugal
| | | | - Margarida Gonçalo
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal
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