Pyoderma gangrenosum

The Pathophysiology and Treatment of Pyoderma Gangrenosum-Current Options and New Perspectives

Pyoderma gangrenosum (PG) is an uncommon inflammatory dermatological disorder characterized by painful ulcers that quickly spread peripherally. The pathophysiology of PG is not fully understood; however, it is most commonly considered a disease in the spectrum of neutrophilic dermatoses. The treatment of PG remains challenging due to the lack of generally accepted therapeutic guidelines. Existing therapeutic methods focus on limiting inflammation through the use of immunosuppressive and immunomodulatory therapies. Recently, several reports have indicated the successful use of biologic drugs and small molecules administered for coexisting diseases, resulting in ulcer healing. In this review, we summarize the discoveries regarding the pathophysiology of PG and present treatment options to raise awareness and improve the management of this rare entity.

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

BACKGROUND AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnosis and management of parastomal pyoderma gangrenosum

Parastomal pyoderma gangrenosum (PPG) is an unusual neutrophilic dermatosis characterized by painful, necrotic ulcerations occurring in the area surrounding an abdominal stoma. It typically affects young to middle-aged adults, with a slight female predominance. The underlying etiology for PPG remains enigmatic but aberrant immune response to injury may play a pivotal role. The reported risk factors for the development of PPG include the presence of extra-intestinal manifestations, autoimmune disorders and obesity, along with local factors, such as the presence of parastomal hernia or pressure ulcer. PPG can develop at any time after the stoma construction. The histopathological features of PPG are not pathognomonic and its diagnosis is mainly based on clinical features. The management of PPG often requires a multidisciplinary approach, with a combination of local wound care and systemic medications.

Etiology and management of pyoderma gangrenosum: a comprehensive review

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful, necrotic ulceration. It typically affects patients in the third to sixth decades of life, with almost equal incidence in men and women. PG occurs most frequently on the lower extremities. Five clinical variants are currently recognized: classic, bullous, pustular, vegetative, and peristomal types. Half of PG cases are seen in association with systemic disease. Mimickers include infection, vascular insufficiency ulcers, systemic vasculitides, autoimmune disease, cancer, and exogenous tissue injury, among others. PG is often a diagnosis of exclusion, as there are no specific laboratory or histopathologic findings to confirm the diagnosis. PG thus presents many clinical challenges: it is difficult to diagnose, is frequently misdiagnosed, and often requires a work-up for underlying systemic disease. Successful management of PG typically requires multiple modalities to reduce inflammation and optimize wound healing, in addition to treatment of any underlying diseases. Prednisone and cyclosporine have been mainstays of systemic treatment for PG, although increasing evidence supports the use of biologic therapies, such as tumor necrosis factor-α inhibitors, for refractory cases of PG. Here, we review the clinical presentation and pathophysiology of PG, as well as its associated conditions, diagnostic work-up, and management.

Pyoderma gangrenosum: uncommon presentations

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

Management of peristomal pyoderma gangrenosum

PURPOSE

This study was designed to evaluate the presentation, management, and outcome of peristomal pyoderma gangrenosum at a specialist colorectal unit and develop a strategy for therapy.

METHODS

Patients with peristomal pyoderma gangrenosum were identified from a prospectively accrued Institutional Review Board-approved stoma database. Data were collected regarding demographics, disease status, history of illness, time to healing, and treatments used from the database and by chart review.

RESULTS

Sixteen patients presented between 1997 and 2002 with peristomal ulceration consistent with a diagnosis of peristomal pyoderma gangrenosum. Diagnosis was predominantly clinically based on a classic presentation of painful, undermined peristomal ulceration. The underlying diagnosis was Crohn's disease in 11 patients, ulcerative colitis in 3, indeterminate colitis in 1, and posterior urethral valves in 1. At the time of development of peristomal pyoderma gangrenosum, the underlying disease was active in 69 percent of patients. Stoma care, ulcer debridement with unroofing of undermined edges, and intralesional corticosteroid injection was associated with a 40 percent complete response rate and further 40 percent partial response rate. Of five patients who received infliximab, four (80 percent) responded to therapy. Complete response after all forms of therapy, including stoma relocation in seven patients, was 87 percent.

CONCLUSIONS

Local wound management and enterostomal therapy are extremely important for patients with peristomal pyoderma gangrenosum. Infliximab may provide a useful option for those failing other forms of medical therapy. Relocation of the stoma is reserved for persistent ulceration failing other therapies, because peristomal pyoderma gangrenosum may recur at the new stoma site.

Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria

Pyoderma gangrenosum is a rare but significant cause of ulcerations. It is a diagnosis of exclusion. Herein, we suggest diagnostic criteria and some historical perspectives on the diagnosis of pyoderma gangrenosum.

Topical tacrolimus (FK506) in the treatment of recalcitrant parastomal pyoderma gangrenosum associated with Crohn's disease: report of two cases

INTRODUCTION

Pyoderma gangrenosum is a rare idiopathic skin disorder associated with other diseases, including inflammatory bowel disease. The commonest site is the skin, but sometimes it can occur in the parastomal region. Most of these cases respond to treatment with systemic corticosteroids and cyclosporin or local Kenalog injections.

METHODS

The following are two cases of parastomal pyoderma in patients not responding to the standard measures. These patients were treated with topical tacrolimus.

RESULTS

These patients showed dramatic improvement in one week with complete resolution and re-epithelialization of skin within two weeks.

CONCLUSION

Pyoderma gangrenosum is a difficult problem to manage and its early resolution is important. In these two reported cases, the improvement was dramatic, therefore topical tacrolimus should be considered early in the management.

Culture and immunohistochemical evidence of Chlamydia pneumoniae infection in ulcerative pyoderma gangrenosum

A potentially contributing factor to the development and chronicity of pyoderma gangrenosum is infection with the relatively recently characterized human pathogen, Chlamydia pneumoniae. C pneumoniae is an obligate intracellular bacterium that can infect endothelial, monocyte, and smooth muscle cells and is associated with cardiopulmonary diseases. A case of serologically, polymerase chain reaction-positive, immunohistochemically, and culture-documented viable C pneumoniae organisms in a chronic pyoderma gangrenosum ulcer is reported, a finding that has not been described previously.

Neutrophilic dermatoses

The neutrophilic dermatoses are a group of related cutaneous disorders that frequently have systemic manifestations or associations. While there are distinct clinical differences in the classical lesions of these disorders, there are many patients who have overlapping features. In addition, the associated systemic manifestations or associated diseases are often similar among these disorders. Finally, the management of these disorders with the frequent use of corticosteroids and nonsteroidal immunosuppressive or immunomodulatory agents is common.

Clinical management of pyoderma gangrenosum

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

Pyoderma gangrenosum: a great marauder

Pyoderma gangrenosum is a progressively necrotizing and ulcerative skin disease that mimics a severe bacterial infection. However, the cause is not infectious in nature and the lesions are refractory to local wound care and antibiotic therapy. The etiology of pyoderma remains unknown, although pathogenic mechanisms may involve immunologically mediated cutaneous damage. The authors report a 67-year-old woman in whom a necrotic ulcer developed at a chest tube site. Treated with local wound care and antibiotics, this lesion spread progressively to involve 15% of her body surface area. A septic clinical picture developed despite sterile cultures, and she required several operative debridements. Her disease continued to spread and finally a diagnosis of pyoderma gangrenosum was considered. Treated with systemic steroids, hyperbaric oxygen (HBO), and local wound care, she eventually underwent skin grafts.

Pyoderma gangrenosum of the hand: a case series and review of the literature

Pyoderma gangrenosum is a rapidly developing cutaneous ulcer that is rare in the hand and may mimic a fulminating infection. The correct treatment is nonsurgical; surgery may actually incite a pathergic response worsening the condition. Misdiagnosis results in inappropriate treatment, unnecessary surgery, and even amputations. The records of 7 patients with pyoderma gangrenosum of the hand treated at 2 large academic medical centers between 1992 and 1999 were reviewed. There were 4 men and 3 women with an average age of 58 years (range, 32-81 years). Five patients had bilateral involvement. Minor trauma preceded the appearance of the lesions. An associated systemic disease was found in all patients with ulcerative colitis being the most common (3 patients). All patients initially had a misdiagnosis of infection. Thirteen misdiagnoses (range, 1-3/patient) resulted in 16 unnecessary surgeries (mean, 2.2/patient) including 4 amputations and 2 failed skin grafts. No surgical procedure resulted in clinical improvement. All cultures were negative. Several physicians (mean, 5; range, 3-7) examined each patient before the final diagnosis of pyoderma gangrenosum, which was made by, or in conjunction with, a dermatologist in all cases. The average time to clinical improvement after correct medical treatment was initiated was 5 days.

Surgical management of pyoderma gangrenosum: case report and review

BACKGROUND

Commonly used treatments for pyoderma gangrenosum are medical, with immunosuppressive agents employed most often.

OBJECTIVE

To report a case and discuss the indications for radical surgical treatment of pyoderma gangrenosum.

METHODS

Analysis of a case of Crohn's disease-associated pyoderma gangrenosum treated with immunosuppression followed by amputation, and a review of the literature on surgical management of pyoderma gangrenosum.

RESULTS

In unstable patients with intractable multiple medical problems, surgical treatment of pyoderma gangrenosum may be indicated by the existence of these life-threatening comorbidities. The recent literature suggests that surgical management of pyoderma gangrenosum may also be appropriate in other special circumstances.

CONCLUSIONS

Surgical management, including amputation, may have a role in the management of pyoderma gangrenosum. Further research is needed to delineate precisely the circumstances and patient factors that are appropriate indications for such surgery.

Pyoderma gangrenosum occurring in a lower limb fasciocutaneous flap--a lesson to learn

Pyoderma gangrenosum is a destructive cutaneous disease characterised by progressive painful ulceration. The occurrence of pyoderma gangrenosum at a surgical site is rare (especially if there is no predisposing illness), but is well recognised. We present a case of a 63-year-old man who developed erythematous ulcerative lesions due to pyoderma gangrenosum in and around a lower limb fasciocutaneous flap used to cover an exposed total knee prosthesis. The lesions were initially confused with postoperative wound infection. No predisposing disorder, other than the rarely reported association with osteoarthritis, was found. The diagnosis is important because its rapid detection not only avoids unnecessary treatment but also allows for prompt intervention with oral steroids. This case is presented to alert surgeons to the presence of pyoderma gangrenosum and its diagnostic confusion with postoperative wound infection.

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

BACKGROUND

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

REPORT

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

RESULTS

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

CONCLUSION

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

Treatment of pyoderma gangrenosum

Critical to the proper management of pyoderma gangrenosum are correct diagnosis, identification and treatment of any underlying disorder, and the proper choice of topical and systemic therapy. Many agents are available for the treatment of pyoderma gangrenosum. We review the current therapeutic options, their efficacy and side effects, and we offer some guidelines for their proper selection.

Pyoderma gangrenosum: classification and management

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

Pyoderma gangrenosum with systemic involvement

We report a case of a patient with pyoderma gangrenosum associated with multisystemic manifestations. The patient showed liver dysfunction, respiratory failure, and aseptic meningeal reaction. Corticosteroid therapy was efficient in treating both the skin lesions and the other systemic disorders.

Pyoderma gangrenosum in association with psoriatic arthritis

We present a patient with psoriasis and psoriatic arthritis who developed multiple large, painful ulcers that were scattered over his anterior lower legs and were characteristic of pyoderma gangrenosum (PG). This association has not previously been described. We review other forms of arthritis that usually occur with PG and discuss them in light of this observation.

Bullous pyoderma gangrenosum

Pyoderma gangrenosum is a necrotizing, ulcerative process commonly associated with inflammatory bowel disease but also occurring in several other systemic illnesses. When associated with myelodysplastic syndromes, its clinical appearance is often atypical. We describe a patient with severe, refractory bullous pyoderma gangrenosum. At autopsy cardiac involvement was demonstrated, a finding not previously reported. Patients with this unusual variant of pyoderma gangrenosum have a grave prognosis.

Pyoderma gangrenosum--a complication of chronic venous leg ulceration?

Three patients whose chronic venous leg ulcers were complicated by pyoderma gangrenosum are reported. Illnesses which may have predisposed to the development of pyoderma gangrenosum included Crohn's colitis, rheumatoid arthritis and small bowel perforation. Pyoderma gangrenosum should be suspected in susceptible patients whose venous leg ulcers undergo inexplicable and painful deterioration.

Minimizing the risk of post-operative pyoderma gangrenosum

A 61-year-old woman with seropositive rheumatoid arthritis developed numerous ulcers due to pyoderma gangrenosum at suture entry/exit sites following an arthroplasty of the right hip when interrupted silk sutures were used to close the skin. When a subsequent arthroplasty was performed on the left hip and subcuticular Dexon sutures were used to close the skin only two small ulcers developed. Sixteen cases of pyoderma gangrenosum developing in surgical wounds have previously been reported. We recommend that surgery in patients with a history of pyoderma gangrenosum is performed when the pyoderma is clinically quiescent, and that subcuticular sutures are used for skin closure, thus avoiding puncturing the skin surface.

Recalcitrant pyoderma gangrenosum--two cases successfully treated with cyclosporin A

The successful use of cyclosporin A (CSA) in organ transplantation is now well established. In recent years its usefulness has extended to the treatment of cutaneous autoimmune disorders, including pyoderma gangrenosum (P.G.). We report two further cases of recalcitrant P.G., both associated with rheumatoid arthritis (R.A.) which responded to low dose CSA.

Pyoderma gangrenosum with cutaneous T-cell lymphoma manifested as lower extremity ulcers--case reports

Patients with extensive lower extremity ulcerations initially thought to be vascular disease were subsequently proved to have pyoderma gangrenosum and malignant lymphoma. Both patients died of sepsis; one patient exhibited hypogammaglobulinemia involving immunoglobulins IgA, IgG, and IgE; in the second patient, a polyclonal excess involving IgA and IgE was present.

Vulvar pyoderma gangrenosum

Pyoderma gangrenosum is an idiopathic dermatologic disease manifested by painful cutaneous ulceration. The ulcers are characterized by their undermined, violaceous borders and necrotic tissue at the ulcer base. The lesions may have an unusual response to physical manipulation known as pathergy, a phenomenon that is manifested by rapid progression following debridement. Pyoderma gangrenosum is frequently associated with systemic diseases such as inflammatory bowel disease, rheumatoid arthritis, chronic active hepatitis and hematologic malignancies. Conservative wound care and systemic corticosteroids are usually effective therapy. We report the second case in the gynecologic literature of a patient with vulvar pyoderma gangrenosum.

Pyoderma gangrenosum in an allogeneic bone marrow transplant recipient

We present the case of a 15-year-old boy who developed facial pyoderma gangrenosum following an allogeneic bone marrow transplantation for the treatment of a 'blast' crisis developing in the course of chronic myelogenous leukaemia. The lesion appeared 7 months before any evidence of relapse. The discussion is focused on both the presentation of pyoderma gangrenosum associated with myelo-proliferative disorders and its pathogenesis via the underlying immunosuppression.

Chlorambucil--an effective corticosteroid-sparing therapy for pyoderma gangrenosum

A 21-year-old man, with a past history of severe aphthosis and arthritis between age 5 and 15 years, presented at age 18 years with a large leg ulceration, which developed after minor trauma. At that time he was otherwise healthy and taking no medications. Between 1983 and 1986 the patient failed to respond to intensive topical care to the ulcer, two attempted skin grafts, oral prednisone (up to 200 mg/day), sulfasalazine, dapsone (200 mg/day), multiple trials of intralesional triamcinolone acetonide, hyperbaric oxygen, azathioprine, methotrexate, clofazimine, minocycline, and three courses of pulse methylprednisolone therapy. Therapy with chlorambucil (4 mg/day) resulted in progressive improvement and complete healing with eventual cessation of all other therapy. The use of chlorambucil in pyoderma gangrenosum may be an effective adjunctive steroid-sparing therapy.

Superficial granulomatous pyoderma: clinicopathologic spectrum

Superficial granulomatous pyoderma is a form of pyoderma gangrenosum characterized by superficial ulceration and a chronic course. Histopathologic examination shows a granulomatous response. We report two new cases of superficial granulomatous pyoderma in detail and briefly review the clinical data of five previous cases included in a recent series. These lesions typically begin as single furunculoid papules that most commonly occur on the trunk and that may arise at sites of surgical treatment or other pathergic stimuli. The lesions progress to superficial ulcers with a relatively clean base and vegetative borders. Tetracycline, minocycline, sulfapyridine, dapsone, and intralesionally administered corticosteroids have been effective anti-inflammatory agents, producing healing and allowing avoidance of the use of systemic corticosteroids in the management of most patients with superficial granulomatous pyoderma.

Neutrophilic vascular reactions

Dermatologic diseases are classified most commonly by morphology, by pathogenesis, or by etiology. Nontraditional classifications may be useful in terms of providing a reassessment of traditional views about disease interrelationships. This review of dermatoses characterized by neutrophilic infiltrates and dermal vessel changes reveals evidence suggesting that these dermatoses result from immune complex-mediated, neutrophil-induced dermal vessel damage. Therapeutic approaches to these heretofore unlinked dermatoses are remarkably similar.

A case study of pyoderma gangrenosum

Pyoderma gangrenosum is a rare neutrophilic dermatosis seen initially as painful pustules or bullae on the skin that rapidly ulcerate and have a characteristic raised, purplish areola surrounding them. It is often associated with inflammatory bowel disease and less commonly with other systemic diseases, such as myelofibrosis, rheumatoid arthritis, and chronic active hepatitis. Pyoderma gangrenosum involving the hand is a rare entity, with only two previous cases reported in the literature. This article describes a patient with myelofibrosis in whom pyoderma gangrenosum of the hand developed after she underwent splenectomy.

Pyoderma gangrenosum: a review

Pyoderma gangrenosum is a poorly understood disease characterized by exacerbations and remissions of morphologically unique skin ulcers. It frequently is thought to be the cutaneous manifestation of an underlying systemic disease. In this review of pyoderma gangrenosum, the characteristics of the disease are described and a differential diagnosis is formulated. Associations with systemic diseases are made through a review of the literature. The pathophysiology of pyoderma gangrenosum and probable causes are considered, and special consideration is given to the immunologic mechanisms that may be operative in the disease. Finally the currently available therapeutic alternatives are reviewed.