Diagnosing pyoderma gangrenosum

Pyoderma Gangrenosum Associated With Seronegative Arthritis: A Rural Tertiary Care Experience

Pyoderma gangrenosum (PG) is a rare ulcerating inflammatory skin condition, the cause of which remains idiopathic. A 35-year-old female presented to our outpatient department (OPD) with initial findings of multiple non-healing ulcers that developed suddenly with a symmetric bilateral pattern on the dorsal aspect of hands, elbows, and inner knees. Lesions initially developed as a pustule that progressed to burst and leave behind a raw area that turned into an ulcer. Polyarthralgia preceded these symptoms. Extensive investigations were done for the varied differentials that were postulated; this led to finally declaring PG associated with seronegative arthritis as a diagnosis of exclusion. Initial treatment with antibiotics showed little results, and thus, the patient was started on a systemic corticosteroid which proved to be successful.

Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatoses

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The second article in this continuing medical education series reviews the epidemiology, clinical characteristics, histopathologic features, diagnosis, and management of pyoderma gangrenosum as well as bowel-associated dermatosis-arthritis syndrome and the arthritis-associated neutrophilic dermatoses rheumatoid neutrophilic dermatitis and adult Still disease.

Postoperative Pyoderma Gangrenosum in Children: The Case Report of a 13-Year-Old Boy With Pyoderma Gangrenosum After Hip Reconstruction Surgery and a Review of the Literature

BACKGROUND

Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis and pathergic reaction at surgical sites. Reports of children with postoperative PG are rare in the literature.

METHODS

We report the case of a 13-year-old boy without any known preexisting illnesses, who developed severe systemic response and wound deterioration after elective hip reconstruction surgery. The working diagnosis of necrotizing fasciitis was later determined to be postoperative PG.

RESULTS

The patient was successfully treated by the systemic application of corticosteroids.

CONCLUSIONS

Postoperative PG is a very rare complication after surgery, especially in children. If mistaken for necrotizing fasciitis, it can substantially mutilate a patient because PG is worsened by surgical debridement. It can be treated successfully only by corticosteroids and other immunosuppressive drugs.

LEVEL OF EVIDENCE

Level IV-this is a case report.

Pediatric pyoderma gangrenosum: a systematic review and update

Pyoderma gangrenosum (PG) is a sterile neutrophilic disorder that rarely affects children. Clinical, epidemiological, and therapeutic data on pediatric PG is poor as there are many newly reported associated diseases and drugs. This paper aims to review all recent available data on pediatric PG. A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. A total of 132 articles were included in the review. The most commonly reported underlying diseases in pediatric PG are inflammatory bowel diseases followed by hematologic disorders, vasculitis, immune deficiencies and Pyogenic Arthritis, Pyoderma gangrenosum and Acne (PAPA) syndrome. More than half of the cases occur with no underlying disease. The most frequently reported clinical presentation is multiple disseminated ulcers. Treatment should be tailored according to the underlying etiology. It includes systemic steroids, corticosteroid sparing agents such as dapsone and cyclosporine, and TNF-alpha inhibitors such as adalimumab and infliximab. Response to treatment is high with cure rates reaching 90%. A high index of suspicion and a thorough workup are mandatory in the management of pediatric PG.

A Review of the Use of Infliximab to Manage Cutaneous Dermatoses

Background:

Infliximab is a chimeric monoclonal antibody that binds specifically to human tumor necrosis factor-alpha (TNF-α), decreasing the effect of the cytokine in inflammatory diseases.

Objective:

The aim of this study was to review the efficacy and safety of infliximab in the treatment of dermatological diseases.

Methods:

A MEDLINE search (1966–January 2003), using the keyword “infliximab” was performed to find relevant articles pertaining to the use of infliximab in dermatology.

Results:

Infliximab has been used in the following dermatological diseases: psoriasis, Behçet's disease, graft versus host disease, hidradenitis suppurativa, panniculitis, pyoderma gangrenosum, SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome, sarcoidosis, subcorneal pustular dermatosis, Sweet's syndrome, toxic epidermal necrolysis, and Wegener's granulomatosis. There is a generally good safety profile for infliximab, which is similar to that when it is used to treat Crohn's disease and rheumatoid arthritis.

Conclusion:

Although not approved for use in dermatological diseases, there have been numerous reports of the efficacy of infliximab in cutaneous inflammatory diseases. The most promise lies in those diseases that have increased amounts of TNF-α in the cutaneous lesions, such as psoriasis.

A novel approach to the management of pyoderma gangrenosum complicating reduction mammaplasty

Reduction mammaplasty is a common procedure performed by plastic and reconstructive surgeons to relieve chronic back and neck pain associated with macromastia, with the added benefit of an improvement in the aesthetic contour of the ptotic breast. Complications related to this procedure are fortunately uncommon, but include hematoma, infection, and wound breakdown. The authors report an interesting case of reduction mammaplasty complicated postoperatively by pyoderma gangrenosum (PG), which is a rare inflammatory disorder leading to progressive skin necrosis. The destructive process, which involved both breast incisions, was managed successfully with immunosuppressive therapy and intensive wound care, followed by a novel method of coverage with a dermal regeneration template and subsequent epidermal autograft that led to stable coverage of the open wounds. PG is frequently misdiagnosed as a necrotizing infection, leading to improper debridement with exacerbation of the disease process. The mainstay of therapy for PG is still nonoperative and focuses on immunosuppressive medications and local wound care, which allows healing in most cases. However, there are a few indications for surgical intervention, including significantly large wounds that are refractory to medical management. It is important for plastic surgeons and other clinicians to be cognizant of this entity, as a delay in diagnosis and management of PG can lead to serious consequences, with considerable soft tissue loss and disfigurement of the breast.

Pyoderma gangrenosum: an update

Pyoderma gangrenosum (PG) can be differentiated into classic and atypical forms. The classic form is characterized by ulcers and the atypical form by deep erosions with bullous blue-gray margins. Pathergy, the development of cutaneous lesions at sites of trauma, is a common feature of both forms of PG. Approximately 50% of patients who have PG have underlying systemic diseases, most commonly inflammatory bowel disease, myeloproliferative disorders, and various forms of inflammatory arthritis. The diagnosis of PG is one of exclusion. The management of this disorder begins with treatment of any underlying disease and local or systemic glucocorticoids or immunomodulating therapies.

Etanercept for the treatment of refractory pyoderma gangrenosum: a brief series

BACKGROUND

Pyoderma gangrenosum (PG) is a rare ulcerative inflammatory condition of unknown etiology. Therapy for PG involves local wound care along with topical and systemic anti-inflammatory and other immunodulatory agents. Etanercept is one such immunomodulator with activity against the inflammatory cytokine, tumor necrosis factor.

OBJECTIVE

To evaluate the efficacy and safety of etanercept in the treatment of PG ulcers.

METHODS

A retrospective analysis was performed on seven patients with 11 refractory PG ulcers treated with subcutaneous injections of etanercept (25-50 mg twice weekly).

RESULTS

All seven patients with PG responded well to etanercept. Eight of the 11 ulcers (73%) completely healed with the mean time of (12.5 weeks), while the other three ulcers had marked reduction in size (within 8-18 weeks). Etanercept was well tolerated. No serious side-effects were reported. Only one patient discontinued the drug secondary to side-effects.

CONCLUSION

Etanercept is an alternative treatment option for patients with refractory ulcers due to PG.

Clinical treatment options for peristomal pyoderma gangrenosum

Pyoderma gangrenosum is a rare debilitating skin disease of unknown aetiology that manifests itself as painful lesions and is often associated with inflammatory bowel disease. Stoma care nurses will encounter it directly around the stoma as peristomal pyoderma gangrenosum (PPG). There are many case reports of varying methods of treatment for PPG, although none have proven to be efficacious in all circumstances. When these lesions develop in the peristomal area, treatment must be balanced with the need to maintain an intact stoma appliance.

Could your case of necrotising fascitis be Pyoderma gangrenosum?

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

Parasternal Pyoderma Gangrenosum: A Case Report and Literature Review

Parasternal pyoderma gangrenosum (PPG) is an exceedingly rare disease process most often observed in inflammatory bowel disease patients with an ileostomy. Fewer than 50 cases have been reported in the medical literature. The incidence is 0.6 per cent of patients with ileostomy and inflammatory bowel disease. The rarity of the disease leads to misdiagnosis and mistreatment of the lesion. The intense pain and disruption of ostomy function greatly impair affected individuals beyond the limit of their underlying disease. Current best care practices observed in small study series indicate long-term intensive medical therapy aimed at systemic disease suppression to optimize PPG wound healing. Our patient had no signs of active Crohn disease at the time of PPG presentation. She was initially treated with minimal wound debridement and intralesional triamcinolone. Finally under the care of an enterostomal/wound care therapist the patient achieved excellent PPG resolution in 6 months.