Cutaneous manifestations in patients with inflammatory bowel diseases: pathophysiology, clinical features, and therapy

Immune cell trafficking: a novel perspective on the gut-skin axis

Immune cell trafficking, an essential mechanism for maintaining immunological homeostasis and mounting effective responses to infections, operates under a stringent regulatory framework. Recent advances have shed light on the perturbation of cell migration patterns, highlighting how such disturbances can propagate inflammatory diseases from their origin to distal organs. This review collates and discusses current evidence that demonstrates atypical communication between the gut and skin, which are conventionally viewed as distinct immunological spheres, in the milieu of inflammation. We focus on the aberrant, reciprocal translocation of immune cells along the gut-skin axis as a pivotal factor linking intestinal and dermatological inflammatory conditions. Recognizing that the translation of these findings into clinical practices is nascent, we suggest that therapeutic strategies aimed at modulating the axis may offer substantial benefits in mitigating the widespread impact of inflammatory diseases.

Sweet or Not? Azathioprine-Induced Sweet Syndrome Mimicking Erythema Nodosum in a Patient With Inflammatory Bowel Disease

This case report highlights the clinical challenge and need to distinguish Sweet syndrome and erythema nodosum (EN) in a 50-year-old woman with newly initiated azathioprine for inflammatory bowel disease. While she initially presented with clinical features concerning for drug-induced Sweet syndrome, a subsequent histopathological examination confirmed early-stage EN. Both Sweet syndrome and EN share common triggers and therapeutic responses, but have distinctive clinical characteristics. Subtle histologic differences also exist in lesion distribution and depth of infiltration. This case underscores the need for accurate differentiation in patients with inflammatory bowel disease to initiate appropriate management and avoid potential complications.

Investigating the shared genetic architecture between primary sclerosing cholangitis and inflammatory bowel diseases: a Mendelian randomization study

BACKGROUND

Several studies have found that primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) are closely associated. However, the direction and causality of their interactions remain unclear. Thus, this study employs Mendelian Randomization to explore whether there are causal associations of genetically predicted PSC with IBD.

METHODS

Genetic variants associated with the genome-wide association study (GWAS) of PSC were used as instrumental variables. The statistics for IBD, including ulcerative colitis (UC), and Crohn's disease (CD) were derived from GWAS. Then, five methods were used to estimate the effects of genetically predicted PSC on IBD, including MR Egger, Weighted median (WM), Inverse variance weighted (IVW), Simple mode, and Weighted mode. Last, we also evaluated the pleiotropic effects, heterogeneity, and a leave-one-out sensitivity analysis that drives causal associations to confirm the validity of the analysis.

RESULTS

Genetically predicted PSC was significantly associated with an increased risk of UC, according to the study (odds ratio [OR] IVW= 1.0014, P<0.05). However, none of the MR methods found significant causal evidence of genetically predicted PSC in CD (All P>0.05). The sensitivity analysis results showed that the causal effect estimations of genetically predicted PSC on IBD were robust, and there was no horizontal pleiotropy or statistical heterogeneity.

CONCLUSIONS

Our study corroborated a causal association between genetically predicted PSC and UC but did not between genetically predicted PSC and CD. Then, we identification of shared SNPs for PSC and UC, including rs3184504, rs9858213, rs725613, rs10909839, and rs4147359. More animal experiments and clinical observational studies are required to further clarify the underlying mechanisms of PSC and IBD.

Local neutrophil and eosinophil extracellular traps formation in pyodermatitis pyostomatitis vegetans

Pyodermatitis pyostomatitis vegetans is a rare inflammatory condition, affecting the skin and/or mucous membrane. Some cases include both skin and mucous involvement, whereas others develop either skin or mucous lesions only. The typically affected areas are the scalp, face, trunk and extremities, including the flexural areas and umbilicus. Clinical features show erosive granulomatous plaques, keratotic plaques with overlying crusts and pustular lesions. Among mucous lesions, oral mucosa is most frequently involved, and gingival erythema, shallow erosions, cobblestone-like papules on the buccal mucosa or upper hard palate of the oral cavity are also observed. Some of the lesions assume a 'snail track' appearance. Although there are several similarities between pyodermatitis pyostomatitis vegetans and other diseases, that is pyoderma gangrenosum, pemphigus vegetans and pemphigoid vegetans, the histopathological features of pyodermatitis pyostomatitis vegetans are unique in that epidermal hyperplasia, focal acantholysis and dense inflammatory infiltrates with intraepidermal and subepidermal eosinophilic microabscesses are observed. Direct immunofluorescence findings are principally negative. Activated neutrophils are supposed to play an important role in the pathogenesis of pyodermatitis pyostomatitis vegetans. The expression of IL-36 and neutrophil extracellular traps (NETs) was observed in the lesional skin, and additionally, eosinophil extracellular traps (EETs) was detected in pyodermatitis pyostomatitis vegetans. A possible pathogenic role of NETs and EETs in the innate immunity and autoinflammatory aspects of pyodermatitis pyostomatitis vegetans was discussed.

Ulcerative Colitis Diagnosed through Evaluation of Underlying Diseases in a Pyoderma Gangrenosum Adolescent without Gastrointestinal Symptoms

Pyoderma gangrenosum (PG) is a rare, non-infectious, neutrophilic dermatosis characterized by painful ulcers with indistinct borders and peripheral erythema. The diagnosis of PG requires the exclusion of other causes of similar appearing skin manifestations, including vasculitis and infections. The pathogenesis of PG is not clear; however, dysregulation of the immune system has been suggested in previous studies. More than half of the PG patients have underlying diseases; the most common being inflammatory bowel disease (IBD). The progression of PG in IBD patients is seen after the onset of IBD, usually during its exacerbation. On the other hand, PG may follow a course independent of the intestinal disease. We present a case of an 18-year-old young male with PG that presented before being diagnosed with ulcerative colitis as an associated condition. He had a painful ulcerative lesion on his right shin with no previous gastrointestinal symptoms. This case suggests that investigating for underlying disorders is essential in PG patients despite the lack of symptoms other than the skin lesions.

Hereditary Ichthyosis With Gastrointestinal Manifestations: A Case Report

Gut inflammation and defect in the gut mucosal barrier appear to have a correlation with skin diseases and vice versa. The coexistence of hereditary ichthyosis with active colitis has never been reported. We present a 17-year-old female with ichthyosis since birth, abdomen pain for 3 months, with acute colitis. After the initial diagnosis, the patient was started on antituberculous therapy (ATT), steroids, and mesalamine. She followed up with us for 1 year where there was resolution of symptoms. Steroids were stopped after 16 weeks, mesalamine was stopped after 20 weeks in view of low absolute neutrophil counts and ATT was stopped after 1 year. She was asymptomatic post 18 months of stopping ATT.

Cutaneous manifestations of inflammatory bowel disease: basic characteristics, therapy, and potential pathophysiological associations

Inflammatory bowel disease (IBD) is a chronic inflammatory disease typically involving the gastrointestinal tract but not limited to it. IBD can be subdivided into Crohn's disease (CD) and ulcerative colitis (UC). Extraintestinal manifestations (EIMs) are observed in up to 47% of patients with IBD, with the most frequent reports of cutaneous manifestations. Among these, pyoderma gangrenosum (PG) and erythema nodosum (EN) are the two most common skin manifestations in IBD, and both are immune-related inflammatory skin diseases. The presence of cutaneous EIMs may either be concordant with intestinal disease activity or have an independent course. Despite some progress in research on EIMs, for instance, ectopic expression of gut-specific mucosal address cell adhesion molecule-1 (MAdCAM-1) and chemokine CCL25 on the vascular endothelium of the portal tract have been demonstrated in IBD-related primary sclerosing cholangitis (PSC), little is understood about the potential pathophysiological associations between IBD and cutaneous EIMs. Whether cutaneous EIMs are inflammatory events with a commonly shared genetic background or environmental risk factors with IBD but independent of IBD or are the result of an extraintestinal extension of intestinal inflammation, remains unclear. The review aims to provide an overview of the two most representative cutaneous manifestations of IBD, describe IBD's epidemiology, clinical characteristics, and histology, and discuss the immunopathophysiology and existing treatment strategies with biologic agents, with a focus on the potential pathophysiological associations between IBD and cutaneous EIMs.

Unmet Challenges in Patients with Crohn's Disease

Patients with Crohn's disease can present with a variety of clinical manifestations; treatment strategies should focus on long-term remission and improvement of quality of life. There is no standardized process of diagnosing, predicting prognosis, and treating the disease. This narrative review was based on a literature search using PubMed, Embase, and Science Direct. Data on unmet challenges in patients with Crohn's disease were extracted from identified manuscripts. The aim was to discuss present research on standardized processes in the management of patients with Crohn's disease and to identify the unmet needs in clinical evaluation and treatment approaches. There is no consensus on standardized diagnostic, treatment, and surveillance algorithms, particularly in assessing complications of Crohn's, such as stricturing disease, intestinal cancer risk, and cutaneous manifestations. Complications and treatment failure rates of conventional, interventional, and surgical therapy place emphasis on the need for standardized treatment algorithms, particularly in the case of acute complications of the disease. Research on standardized clinical approaches, reliable biomarkers for disease diagnosis and therapy monitoring, and new treatment agents is necessary to improve therapy and reduce complications in patients with Crohn's disease.

Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review

Background

Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition.

Case Presentation

Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab.

Conclusion

PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.

Bowel-Associated-Dermatosis-Arthritis Syndrome (BADAS) as early presentation of ulcerative colitis in an adolescent girl

A 14-year-old girl presented with fevers, joint pain, leukocytosis, and painful, fluctuant skin lesions, preceded by a 2-week history of abdominal cramping and diarrhea. Workup revealed bowel-associated-dermatosis-arthritis syndrome (BADAS) in the setting of ulcerative colitis, a rare finding in the pediatric population.

Efficacy of Ustekinumab in Crohn's Disease With and Without Concurrent Autoimmune Skin Disease

BACKGROUND

Approximately 33% of Crohn's disease (CD) patients have associated autoimmune skin disease. The pathophysiology of the latter frequently involves interleukin-12/interleukin-23 signaling pathways that may also impact gut inflammation. Ustekinumab is an anti-IL-12/23 FDA-approved biologic for psoriasis and inflammatory bowel disease. However, its relative efficacy has never been studied in CD with autoimmune skin disease (CD-ASD) vs CD without autoimmune skin disease (CD-none).

METHODS

This is a retrospective, single-center, case-control study comparing markers of disease activity between CD-ASD and CD-none. Biomarkers (fecal calprotectin [FCP], C-reactive protein [CRP]) prior to drug initiation and after at least 5 months of standard IBD dose ustekinumab therapy were extracted from the medical record. In addition, 2 blinded observers performed 5-point Likert scoring before and after endoscopic, pathologic, and imaging reports.

RESULTS

In all, 395 CD patients received ustekinumab therapy (79 CD-ASD, 316 CD-none). Patients were similar in age; gender; ethnicity; CD severity, phenotype, and duration; tobacco, immunomodulator, and steroid use. Ustekinumab had greater efficacy in CD-ASD when evaluated by FCP (P = .0337) and CRP (P = .078). The CD-ASD group also showed better outcomes in Likert scores of endoscopy (P = .016), histopathology (P = .074), and imaging (P = .094). In all Likert parameters, CD-ASD had more patients with complete resolution of moderate/severe disease (P < .05). Additional subanalyses for surgeries, ulcers, abscesses, fistulas, and colitis were conducted, with colitis reaching statistical significance (P = .0011).

CONCLUSIONS

Concurrent autoimmune skin disease in CD is associated with greater ustekinumab effectiveness in controlling intestinal inflammation.

Intestinal inflammation alters the antigen-specific immune response to a skin commensal

Resident microbes in skin and gut predominantly impact local immune cell function during homeostasis. However, colitis-associated neutrophilic skin disorders suggest possible breakdown of this compartmentalization with disease. Using a model wherein neonatal skin colonization by Staphylococcus epidermidis facilitates generation of commensal-specific tolerance and CD4⁺ regulatory T cells (Tregs), we ask whether this response is perturbed by gut inflammation. Chemically induced colitis is accompanied by intestinal expansion of S. epidermidis and reduces gut-draining lymph node (dLN) commensal-specific Tregs. It also results in reduced commensal-specific Tregs in skin and skin-dLNs and increased skin neutrophils. Increased CD4⁺ circulation between gut and skin dLN suggests that the altered cutaneous response is initiated in the colon, and resistance to colitis-induced effects in Cd4^creIl1r1^fl/fl mice implicate interleukin (IL)-1 in mediating the altered commensal-specific response. These findings provide mechanistic insight into observed connections between inflammatory skin and intestinal diseases.

Cutaneous Manifestations of Inflammatory Bowel Disease: A Basic Overview

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal (GI) tract that is subdivided into Crohn's disease (CD) and ulcerative colitis (UC). CD is characterized by involvement of the entire GI tract, while UC mainly affects the distal GI tract. Moreover, both CD and UC can present with extraintestinal manifestations (EIMs) of the disease affecting multiple organ systems including the hepatobiliary tract, kidney, bones, eyes, joints, and skin. These complications can cause significant morbidity and negatively impact the quality of life for IBD patients. Although the pathogenesis of EIMs is not clearly elucidated, it is postulated that the diseased GI mucosa similarly stimulates excess immune responses at the extraintestinal sites. Cutaneous EIMs occur in up to 15% of patients with IBD, often predating their IBD diagnosis. They are categorized into (1) specific, (2) reactive, (3) associated, and (4) treatment-induced. Here, we review the epidemiological, clinical, diagnostic, and histologic features of the most commonly described cutaneous EIMs of IBD along with their respective treatment options.

Advanced Regenerative Medicine Strategies for Treatment of Perianal Fistula in Crohn's Disease

Regenerative medicine is an emerging therapeutic method that aims to reconstruct tissues and organs. This advanced therapeutic approach has demonstrated great potential in addressing the limitations of medical and surgical procedures for treating perineal fistula in patients with Crohn's disease. Recent developments in stem cell technology have led to a massive good manufacturing practices (GMPs) production of various stem cells, including mesenchymal and embryonic cells, along with induction of pluripotent stem cells to repair damaged tissues in the fistula. The recent advances in separation and purification of exosomes, as biologic nanovesicles carrying anti-inflammatory and regenerative agents, have made them powerful tools to treat this inflammatory disease. Further, tremendous advances in nanotechnology, biomaterials, and scaffold fabrication methods enable tissue engineering methods to synthesize tissue-like structures to assist surgical techniques. This review focuses on advanced regenerative-based methods including stem cell therapy, exosome therapy, and tissue engineering used in the treatment of perianal fistula. Relevant in vitro and in vivo studies and the latest innovations in implementation of regenerative medicine for this disease are also separately reviewed. Additionally, current challenges regarding implementation of g stem cells, exosomes, and tissue engineering methods for bridging the gaps between laboratory findings and clinic application will be discussed.

Clinical approach to skin eruptions induced by anti-TNF agents among patients with inflammatory bowel diseases: insights from a multidisciplinary IBD-DERMA clinic

BACKGROUND AND AIMS

Skin eruptions are prevalent among patients with inflammatory bowel diseases (IBD), often associated with therapies and frequently leading to dermatological consults and treatment interruptions. We aimed to assess the impact of joint shared decision-making in a multidisciplinary (MDT) IBD-DERMA clinic.

METHODS

This retrospective cohort study assessed a consecutive group of patients with IBD who were referred for consultation in an MDT clinic at a tertiary referral center in Israel.

RESULTS

Over 1 year, 118 patients were evaluated in the MDT-IBD-DERMA clinic: 68 (57.6%) males; age - 35.2 ± 13.5 years, disease duration - 7.1 (interquartile range: 3.7-13.9) years; Crohn's disease - 94/118 (79.6%). Skin eruption induced by an anti-tumor necrosis factor (TNF) were the most common diagnoses [46/118 (39%)], including psoriasiform dermatitis (PD) - 31/46 (67.4%) and inflammatory alopecia (IA) - 15/46 (32.6%). Of these, 18 patients (39.1%) continued the anti-TNF agent concomitantly with a topical or systemic anti-inflammatory agent to control the eruption. The remaining 28 patients (60.9%) discontinued the anti-TNF, of whom 16/28 (57.1%) switched to ustekinumab. These strategies effectively treated the majority [38/46 (82.6%)] of patients. Continuation of the anti-TNF was possible in a significantly higher proportion of patients with PD: 12/31 (38.7%) than only one in the IA group, p = 0.035. There was a higher switch to ustekinumab among the IA 7/15 (46.6%) compared with the PD 7/31 (22.6%) group, P = .09. Following IBD-DERMA advised intervention, IBD deteriorated in 9/4 6(19.5%) patients, 5/9 on ustekinumab (PD versus IA, P = NS).

CONCLUSION

Shared decision-making in an integrated IBD-DERMA clinic allowed successful control of skin eruptions while preserving control of the underlying IBD in more than 80% of cases. Patients with IA profited from a switch to ustekinumab.

Leukocytoclastic Vasculitis as an Extraintestinal Manifestation of Crohn's Disease

Cutaneous involvement is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). More commonly, pyoderma gangrenosum and erythema nodosum are noted, but psoriasis, aphthous stomatitis, Sweet's syndrome, and vasculitis may also occur. Leukocytoclastic vasculitis (LCV) is a rare cutaneous manifestation, characterized by the appearance of palpable purpura, urticaria, and ulcer-necrotic lesions predominantly in the lower extremities that improve with immunosuppressive therapy. In this case, we report a patient with CD and LCV. We also searched the literature on the diagnosis and treatment of LCV in patients with CD. Female, 31, presented with diarrhea containing mucus and blood, abdominal pain, arthralgia, and enanthematous plaques and ulcers with a hematinic background in the lower extremities. The results of the colonoscopy were compatible with CD and skin biopsy showed signs of LCV. Systemic autoimmune disease and primary vasculitis were ruled out. The patient received treatment with a systemic corticosteroid and the skin lesions improved. Outpatient treatment with antitumor necrosis factor therapy was initiated to promote skin healing and IBD clinical remission. As LCV is a rare manifestation of IBD, it is necessary to distinguish this dermatopathy from other systemic vasculitis. The engagement of a multidisciplinary team is essential for the correct diagnosis and management.

Mucocutaneous Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic and incurable disease, of unknown etiology, associated with an unregulated immune response to environmental triggers in a genetically predisposed host. IBD affects mainly the gastrointestinal (GI) tract and includes Crohn's disease (CD) and ulcerative colitis (UC). However, a large percentage of patients may present with extraintestinal manifestations, including mucocutaneous ones (which are the most common) and dermatologic findings, such as erythema nodosum, pyoderma gangrenosum, and aphthous stomatitis (which are the most frequently occurring). According to pathophysiologic mechanisms, mucocutaneous manifestations of IBD are classified into five categories, namely, specific manifestations, associated manifestations, reactive manifestations, adverse effects of IBD therapy, and malabsorption manifestations. Recognizing such manifestations should not be performed only by a dermatologist but also other specialties such as internal medicine, gastroenterology, among others. This is because these manifestations can present before the IBD diagnosis, even in the absence of GI symptoms. Therefore, these skin lesions could be a fundamental tool for the earlier diagnosis of IBD. This review provides a comprehensive overview of the most common cutaneous manifestations of IBD with a focus on their epidemiology, diagnostic criteria, clinical presentation, and available medical treatment.

The surgical approach to Pyoderma gangrenosum: A retrospective monocenter study

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

Rapidly Progressing Aseptic Abscesses in a Patient with Ulcerative Colitis

Aseptic abscesses (AAs) are extraintestinal manifestations of inflammatory bowel disease (IBD). IBD-associated AAs are rare in Japan. We treated a 45-year-old man with ulcerative colitis (UC)-associated AAs. During remission, multiple progressive abscesses were detected in the spleen; he underwent splenectomy because an infectious disease was suspected. Although his condition improved temporarily after splenectomy, a large liver abscess was noted, and a diagnosis of UC-associated AAs was made. Granulocytapheresis (GCAP) and infliximab (IFX) administration resolved the abscess. This is the first reported case of UC-associated AAs in a Japanese patient treated by splenectomy, GCAP, and IFX.

Various skin manifestations related to inflammatory bowel disease: A nationwide cross-sectional study on the Korean population

Inflammatory bowel disease (IBD) presents with various extraintestinal manifestations. As part of them, various skin diseases are suggested to be related to IBD. We aimed to identify the epidemiology and risk of developing skin manifestations in patients with IBD. We used Korean insurance claims data and selected patients with IBD and age/sex-matched non-IBD subjects between 2013 and 2017 using the diagnosis code and prescription records of IBD-specific medications. The prevalence and risk of concurrent skin diseases were estimated. We identified 64 837 patients with IBD. Reactive skin eruptions including pyoderma gangrenosum and erythema nodosum were associated with IBD with highest odds ratios among three categories of reactive, inflammatory, and autoimmune skin diseases. Inflammatory skin diseases including rosacea, psoriasis, atopic dermatitis, hidradenitis suppurativa, and acne conglobata were significantly associated with IBD, but the association was less marked compared to reactive skin eruptions. The patients with IBD also had a higher risk of autoimmune skin diseases including vitiligo and alopecia areata than non-IBD subjects. We determined that IBD was related to various skin diseases including reactive, inflammatory, and autoimmune skin diseases. Considering these relationships can allow better management of patients with IBD and comorbid skin diseases.

Dermatological Manifestations in Inflammatory Bowel Diseases

Inflammatory bowel diseases (IBDs) may be associated with extra-intestinal manifestations. Among these, mucocutaneous manifestations are relatively frequent, often difficult to diagnose and treat, and may complicate the course of the underlying disease. In the present review, a summary of the most relevant literature on the dermatologic manifestations occurring in patients with inflammatory bowel diseases has been reviewed. The following dermatological manifestations associated with IBDs have been identified: (i) specific manifestations with the same histological features of the underlying IBD (occurring only in Crohn's disease); (ii) cutaneous disorders associated with IBDs (such as aphthous stomatitis, erythema nodosum, psoriasis, epidermolysis bullosa acquisita); (iii) reactive mucocutaneous manifestations of IBDs (such as pyoderma gangrenosum, Sweet's syndrome, bowel-associated dermatosis-arthritis syndrome, aseptic abscess ulcers, pyodermatitis-pyostomatitis vegetans, etc.); (iv) mucocutaneous conditions secondary to treatment (including injection site reactions, infusion reactions, paradoxical reactions, eczematous and psoriasis-like reactions, cutaneous infections, and cutaneous malignancies); (v) manifestations due to nutritional malabsorption (such as stomatitis, glossitis, angular cheilitis, pellagra, scurvy, purpura, acrodermatitis enteropathica, phrynoderma, seborrheic-type dermatitis, hair and nail abnormalities). An accurate dermatological examination is essential in all IBD patients, especially in candidates to biologic therapies, in whom drug-induced cutaneous reactions may assume marked clinical relevance.

Vedolizumab and Extraintestinal Manifestations in Inflammatory Bowel Disease

In Crohn's disease and ulcerative colitis, inflammation is not limited to the digestive tract. Extraintestinal manifestations (EIMs), which affect up to 50% of patients, can substantially impair quality of life. EIMs may parallel luminal disease activity or have an independent course. They most commonly involve the musculoskeletal system (e.g., peripheral or axial arthritis) and skin (e.g., erythema nodosum and pyoderma gangrenosum). Less commonly, the hepatobiliary tract (e.g., primary sclerosing cholangitis [PSC]) and the eye (e.g., episcleritis, scleritis, and uveitis) are involved. Although the pathophysiology of EIMs is poorly understood, they are likely either manifestations of a primary systemic immune disease with variable expression amongst organs, or secondary phenomena to bowel inflammation. Additional pathophysiologic mechanisms may include aberrant lymphocyte homing mediated by ectopic expression of gut-specific chemokines and adhesion molecules, cross-reactivity between microbial and self-antigens, autoantibodies against epitopes shared by the intestine and extraintestinal tissues, elevated serum concentrations of cytokines, and alterations in innate immunity. Many EIMs independent of intestinal disease activity can be successfully treated with tumor necrosis factor (TNF) antagonists. The efficacy of vedolizumab-a monoclonal antibody targeting the α4β7 integrin-for the treatment of EIMs is uncertain, but data are emerging from post hoc analyses of randomized controlled trials, prospective and retrospective cohort studies, and case series. Vedolizumab may be effective in treating EIMs related to luminal disease activity (e.g., type 1 peripheral arthritis and erythema nodosum) but has not shown biochemical improvement in PSC. Its postulated role in the development of de novo EIMs is heavily confounded by the high proportion of patients previously exposed to TNF antagonists; new EIMs could result from TNF antagonist treatment cessation rather than being caused by vedolizumab. A common limitation of clinical studies is the lack of multidisciplinary involvement in the diagnosis and monitoring of EIMs, which may lead to misdiagnosis and overreporting. Future studies should rigorously measure EIMs in parallel with objective measures of luminal disease activity to provide more robust data on the relative efficacy of new drugs, especially as increasing numbers of gut-selective compounds enter clinical development.

Prevalence of pyoderma gangrenosum and Sweet´s syndrome in inflammatory bowel disease at a tertiary healthcare center

BACKGROUND AND AIM

dermatological manifestations are normally found in one third of patients with inflammatory bowel disease. In this study, the prevalence, clinical characteristics, intestinal disease activity, and treatment response of neutrophilic dermatoses (pyoderma gangrenosum and Sweet´s syndrome) were determined in patients with inflammatory bowel disease.

METHODS

a retrospective, observational study was performed in patients with inflammatory bowel disease and neutrophilic dermatoses between March 2012 and March 2018.

RESULTS

of 444 patients analyzed, 10 complied with the inclusion criteria. Seven had pyoderma gangrenosum and three presented Sweet's syndrome; and one patient developed both pathologies. The prevalence of neutrophilic dermatoses was 2.3 % (10/444), comprising 1.6 % with pyoderma gangrenosum and 0.7 % with Sweet's syndrome. Six out of seven patients with pyoderma gangrenosum were female and had ulcerative colitis. The most frequent clinical presentation of pyoderma gangrenosum was the ulcerative subtype. Active moderate-to-severe intestinal disease was found in 71.4 % of patients. Biological therapy was prescribed to three patients with partial response to corticosteroids and persistent intestinal disease activity. This therapy was not indicated for cutaneous manifestations only. Three patients with moderate-to-severe Crohn´s disease presented classical (n = 2) and pustular (n = 1) Sweet's syndrome. A complete response was achieved in all Sweet's syndrome cases treated with corticosteroids. Biological therapy was prescribed to control intestinal disease activity.

CONCLUSIONS

pyoderma gangrenosum was the most frequent cutaneous manifestation of neutrophilic dermatoses, predominantly in females with ulcerative colitis, and highly associated with intestinal disease activity. Anti-tumor necrosis factor was effective in patients with partial cutaneous and intestinal disease response.

Rare Presentation of Postsurgical Pyoderma Gangrenosum Presenting as Necrotizing Soft Tissue Infection

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis believed to be mediated by an autoimmune reaction. Typical treatment includes autolytic debridement, management of exudate, protection from trauma, and steroid therapy. A diagnosis of exclusion, PG is frequently mistaken for a wound infection, but antibiotics do not alleviate the condition. Incision and debridement has been observed to cause further spread of the lesions because of pathergy resulting from the additional trauma. This case report describes a patient who was misdiagnosed with necrotic soft tissue infection that was actually postsurgical PG.

Ten-year follow-up study of linear immunoglobulin A dermatosis complicated with ulcerative colitis

Linear immunoglobulin A dermatosis (LAD) is rarely complicated in patients with ulcerative colitis (UC), though the long-term prognosis in those with concurrent LAD and UC is not fully understood. Here, we report findings obtained in follow-up examinations performed over a 10-year period of a UC patient initially complicated with LAD. We treated an 18-year-old male for relapse of UC with deteriorating blisters diagnosed as LAD. Following successful induction therapy for both UC and LAD with oral prednisolone, the patient was followed for 10 years. Skin condition remained good at each examination, even with second and third relapses of UC. Our findings in this case indicate that LAD is rarely complicated with UC, while it has no association with colitis disease activity. Furthermore, adequate treatment following an initial diagnosis of LAD is important for management of affected UC patients.

Diagnosis and treatment of dermatologic diseases in inflammatory bowel disease

PURPOSE OF REVIEW

Dermatologic manifestations in patients with inflammatory bowel disease (IBD) are increasingly recognized as related disorders, secondary to specific therapies used to treat IBD, or complications of IBD itself. These dermatologic manifestations can be difficult to manage.

RECENT FINDINGS

We summarize three categories of dermatologic manifestations in this review: extraintestinal cutaneous disorders, paradoxical manifestations to biologic therapies, and other drug-induced cutaneous manifestations. In particular, we provide current data surrounding clinical characteristics, epidemiology, and treatment modalities for individual cutaneous manifestations.

SUMMARY

Many extraintestinal cutaneous manifestations can be managed by optimized treatment of IBD itself, as shared treatment pathways exist. Paradoxical reactions to biologic agents may be driven by the individual biologic therapy. In these instances, if topical therapies or immunomodulators are not effective in treating the paradoxical cutaneous reaction, a change of class may be required. Nonmelanoma and melanoma skin cancers have been linked to specific therapies for IBD (including thiopurines and antitumor necrosis factor alpha agents, respectively). Therefore, optimizing preventive efforts towards skin cancer is warranted. Recognition of these cutaneous disorders by the practicing gastroenterologist is important, as is collaboration with dermatology for management of many cutaneous disorders.

Extraintestinal manifestations in inflammatory bowel disease - epidemiology, genetics, and pathogenesis

Inflammatory bowel disease (IBD) is a chronic inflammatory disorder, primarily of, but not restricted to the gut. Extraintestinal manifestations (EIMs) are frequently observed and involve the joints, eyes, hepatobiliary tract, and skin. Areas covered: In this review, we discuss classical EIM focusing on epidemiology, genetics, and pathogenesis, highlighting recent advances in the understanding of EIM. We further discuss treatment-induced immunological phenomena, which are increasingly recognized and might challenge IBD-treating physicians in the era of biological treatment. Expert opinion: EIM considerably contributes to morbidity and mortality. Genetic studies have revealed a common genetic background between EIM and IBD and among specific EIM. Identified protein interactions have been shown to cluster in shared biological pathways. However - despite these recent advances - pathogenesis of EIM is at best partially understood. Several pathogenic mechanisms have been proposed such as upregulation of tumor necrosis factor, aberrant lymphocyte homing, and cross-reactive antigen presentation. It still remains unclear whether EIM is a direct result of the inflammatory process in the gut or rather a consequence of a shared genetic background leading to dysfunctional immune responses to environmental stimuli. Exploration and understanding of EIM genetics and pathophysiology will pave the road for better and more efficacious treatment options in the future.

Current clinical issue of skin lesions in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) is associated with a number of extraintestinal complications, including skin lesions. Most reports have shown that skin lesions are found in 10-15% of IBD cases, although this depends on the definition of skin lesions. The representative skin lesions in patients with IBD are erythema nodosum, pyoderma gangrenosum, Sweet's syndrome, and so on. These lesions are often associated with IBD progression, and intestinal lesions in particular require appropriate treatment. Recently, another clinical issue regarding skin lesions in patients with IBD, a so-called paradoxical reaction, during the treatment with anti-tumor necrosis factor (TNF)-α agents has emerged. These reactions are termed paradoxical reactions because the skin lesions sometimes resemble psoriasis, although the anti-TNF-α agents have been historically used to treat psoriasis. Paradoxical reactions are reportedly found in approximately 5-10% of patients using anti-TNF-α agents and are no longer rare. Now that the use of biologics is at its culmination, reports regarding paradoxical reactions are predicted to increase in number; thus, we must recognize skin lesions with IBD patients including this type of adverse events and manage them appropriately while consulting with dermatologists.

Is probiotic use beneficial for skin lesions in patients with inflammatory bowel disease?

Background: Inflammatory bowel diseases (IBDs) are associated with extraintestinal manifestations including skin lesions. The intestinal microflora plays a key role in the development and course of IBD. Aim: To examine the efficacy of probiotics and the occurrence of skin lesions in patients with IBD. Methods: The occurrence of cutaneous lesions in IBD patients from Northern Sardinia was analyzed according to demographic, anthropometrics, clinical features, treatments, and probiotic use expressed as the ratio of disease duration under probiotic treatment and the total disease duration. Results: In 170 IBD patients (59.4% women; UC: 61.2%) at least one skin lesion was present (8.2%) at diagnosis and in 30.6% developed during the follow-up. Psoriasis, erythema nodosum, and pyoderma gangrenosum were the most frequent. An inverse trend was observed between probiotics use and skin lesions occurrence after adjusting for confounders, including conventional treatment for IBD. The risk of developing at least one skin lesion was 1.40 for probiotic use between 5-19% of disease duration and 0.3 for probiotic use > 50%. Body mass index, Crohn phenotype, marriage, and potency of IBD-treatment were significant predictors for developing skin lesions. Conclusion: These findings suggest that probiotics may be an additional tool in the treatment of IBD.

The Impact of Inflammatory Bowel Disease in Canada 2018: Extra-intestinal Diseases in IBD

The burden of extra-intestinal disease is high in patients with IBD, some of whom respond to or are prevented by treating the bowel inflammation, whereas others require specific treatment because they are independent of the underlying bowel inflammation. Among the most common extra-intestinal manifestations are other chronic immune-mediated diseases such as erythema nodosum, ankylosing spondylitis and primary sclerosing cholangitis. Patients with IBD are at higher risk of complications in other organ systems such as osteoporosis, venous thromboembolism and cardiovascular disease. In addition, patients with IBD have a higher risk of cancer, including colon cancer. Mental health comorbidity is important and common in IBD though not always recognized and managed. Consequently, patients and care providers need to be vigilant in the surveillance of extra-intestinal manifestations and complications of IBD.

Highlights

The burden of extra-intestinal disease is high in patients with IBD.

Immune-mediated inflammatory diseases (IMIDs) commonly coexist with patients with IBD and the activity of IMIDs can be either dependent or independent of bowel inflammation.

Patients with IBD can be diagnosed with coexisting diseases that affect every organ, including bones, blood, heart, liver, and others.

Patients with IBD are at increased risk of cancer, including colon cancer, caused by their bowel inflammation, cholangiocarcinoma due to primary sclerosing cholangitis, and rarely lymphoma related to immunosuppressive medications.

The best way to prevent or reduce the burden of many of the extra-intestinal disease is to treat the inflammation of IBD, however some extra-intestinal inflammatory diseases run courses that are independent of the intestinal disease activity.

Key Summary Points

Patients with IBD are often burdened with extra-intestinal manifestations, some of which respond to or are prevented by treating the bowel inflammation whereas others require specific treatment because they are independent of the underlying bowel inflammation.

Other immune-mediated inflammatory diseases (IMIDs) can coexist with IBD.

Some IMIDs run an independent course from the bowel inflammation of IBD, such as ankylosing spondylitis, iritis, and primary sclerosing cholangitis.

Immune-mediated inflammatory diseases that often have courses that match the bowel inflammation of IBD include erythema nodosum and peripheral arthritis.

Immune-mediated inflammatory diseases such as multiple sclerosis and psoriasis have been associated with IBD. However, these conditions may also emerge as complications of therapy for IBD.

Patients with IBD are at risk for venous thromboembolic disease, which occurs at a rate of one per 200 person-years.

Venous thromboembolic disease can be reduced by treating patients admitted to hospital with an IBD diagnosis with venous thromboembolism prophylaxis.

Arterial vascular disease is also increased in IBD patients, including both coronary artery disease and cerebrovascular disease.

Osteoporosis is more prevalent in IBD patients and translates to a 40% increased risk of fracture. While corticosteroids increase the risk of osteoporosis, patients with IBD can also develop metabolic bone disease independent of corticosteroid use.

Persons with IBD are more likely to be infected with Clostridium difficile than community controls and often without prior antibiotic exposure.

Mental health comorbidity is important in IBD. Depression may antedate a diagnosis of IBD by several years and increase post-diagnosis. High stress can exacerbate symptoms in IBD but does not necessarily increase bowel inflammation.

Fatigue is a common symptom in IBD and is not always explained by depression, active inflammatory disease or other apparent factors.

The risk of colorectal cancer is increased twofold in Crohn’s colitis and in ulcerative colitis and 10-fold in persons with primary sclerosing cholangitis with colitis.

Primary sclerosing cholangitis runs a course independent of IBD and can progress to cirrhosis, liver transplantation or death. Patients with IBD and primary sclerosing cholangitis are at higher risk of cholangiocarcinoma, which is often fatal.

The risk of lymphoma may be increased in older males with Crohn’s disease and in patients using thiopurines or anti-TNF therapy.

The risk for intensive care unit admission is nearly twofold higher for patients with IBD and higher in Crohn’s disease than in ulcerative colitis. Risk factors for intensive care unit admission from the year before admission included cumulative corticosteroid use and IBD-related surgery.

Gaps in Knowledge and Future Directions

Patients with IBD are often burdened with extra-intestinal disease. Future research should determine the collective frequency and added costs of living with extra-intestinal disease.

Immune-mediated inflammatory diseases are commonly codiagnosed with IBD. Future research should focus on the pathogenesis connecting coexisting IMIDs with IBD.

Care pathways that support the investigation and mitigation of extra-intestinal disease are needed. For example, when and how ambulatory patients with IBD should receive prophylaxis against venous thromboembolic disease is unknown.

With an aging IBD population, the burden of extra-intestinal disease should be studied in the context of comorbidities of advancing age.

Increasing mental health screening and access to mental health care should be a goal of IBD management.

Low Rates of Dermatologic Care and Skin Cancer Screening Among Inflammatory Bowel Disease Patients

BACKGROUND

Dermatologic manifestations of inflammatory bowel disease (IBD) are common, and certain IBD medications increase the risk of skin cancer.

AIMS

To define the rates of care and factors associated with dermatologic utilization with a focus on skin cancer screening.

METHODS

We utilized a prospective, natural history IBD research registry to evaluate all outpatient healthcare encounters from 2010 to 2016. Gastrointestinal, dermatologic and primary care visits per individual were identified. We calculated the proportion of patients obtaining care, categorized primary indications for dermatologic visits, determined the incidence of melanoma and non-melanoma skin cancers, and used logistic regression to determine factors associated with dermatology utilization.

RESULTS

Of the 2127 IBD patients included, 452 (21.3%) utilized dermatology over the study period, and 55 (2.6%) had a total body skin examination at least once. The 452 patients incurred 1633 dermatology clinic visits, 278 dermatologic procedures, and 1108 dermatology telephone encounters. The most frequent indication was contact dermatitis or dermatitis. Factors associated with dermatology use were family history of skin cancer, employment, systemic steroids, longer disease duration, emergency room use, and the number of IBD-related clinic visits. Between 8.3 and 11% of IBD patients recommended for skin cancer screening visited dermatology each year, and the resulting incidence of non-melanoma skin cancer was 35.4/10,000 [95% CI 23.3-51.5] and melanoma was 6.56/10,000 [95% CI 2.1-15.3].

CONCLUSIONS

Less than one in ten IBD patients obtain dermatologic care. Given the increased risk of skin cancers among IBD patients, an emphasis on education, prevention, and screening merits attention.

Comparison of Clinical Features between Pyoderma Gangrenosum Concomitant by Inflammatory Bowel Disease and Idiopathic Pyoderma Gangrenosum

Background:

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that is highly associated with inflammatory bowel disease (IBD). Certain PG patients with no systemic disorders have been diagnosed with idiopathic PG. This study sought to clarify the difference between PG with IBD and idiopathic PG based on clinical features, laboratory tests, and medications.

Methods:

Twelve patients with PG and IBD and 24 patients with idiopathic PG, who were hospitalized in Peking Union Medical College Hospital from 2000 to 2017, were retrospectively categorized into the IBD group and control group, respectively. Data of clinical features, laboratory tests, and medications were collected and compared between the two groups.

Results:

Both groups were similar with respect to their clinical features. However, the IBD group had an increased occurrence of arthralgia or arthritis (58.3% vs. 12.5%, P = 0.007), anemia (83.3% and 29.2%, P = 0.004), and an increased percentage of antineutrophilic cytoplasmic antibody (ANCA)-positive patients (85.7% and 0.0%, P < 0.001), compared to the control group.

Conclusion:

PG patients with IBD had increased occurrence rates of arthralgia or arthritis, anemia, and ANCA-positive status compared to idiopathic PG patients.

Health Maintenance in Inflammatory Bowel Disease

PURPOSE OF REVIEW

Patients with inflammatory bowel disease (IBD) are not receiving preventative care services at the same rate as the general population. IBD patients are at increased risk for infections, osteoporosis, and certain malignancies secondary to their disease and as they are on immunosuppressive therapy. They are a younger population and often times consider their gastroenterologist as their primary care physician. In this review, we discuss up-to-date evidence pertaining to vaccine-preventable illnesses in the immunosuppressed IBD patient, screening for bone health, cervical cancer, skin malignancies, psychological wellbeing, and smoking cessation.

RECENT FINDINGS

Vaccinations are recommended in the IBD population as they are immunosuppressed and at increased risk for acquiring influenza and pneumonia. Not only are they at greater risk to acquire it but they also have a much severe complicated course. Ideally, IBD patients should be vaccinated prior to initiating immunosuppression and most inactive vaccines can be administered to them while they are on therapy. All IBD patients should be encouraged to stop smoking and have adequate vitamin D intake along with appropriate applicable cancer screenings. Gastroenterologists must work in collaboration with primary care providers along with other specialists to help provide our patients well-rounded care for their IBD.

Alopecia Universalis Associated with Ulcerative Colitis and The Role of Azathioprine

Skin manifestations can herald, co-exist, or follow the evolution of inflammatory bowel disease (IBD). We report a middle-aged man with recent onset alopecia universalis and a history of intermittent diarrheal attacks for 6 years. Colonscopy and biopsy sampling confirmed ulcerative colitis. Regrowth of hair was achieved by treating the patient with azathioprine and mesalamine. Clinicians have to be aware that a multitude of skin manifestations with history of diarrhea can be an extraintestinal manifestation of IBD such as ulcerative colitis and this warrants further investigation.

Beyond the Bowel: Extraintestinal Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic, relapsing immune-mediated inflammation of the gastrointestinal tract. IBD includes two major disease entities: Crohn disease and ulcerative colitis. Imaging plays an important role in the diagnosis and surveillance of these complex disorders. Computed tomographic and magnetic resonance enterographic techniques have been refined in recent years to provide a superb means of evaluating the gastrointestinal tract for suspected IBD. Although the intestinal imaging manifestations of IBD have been extensively discussed in the radiology literature, extraintestinal imaging manifestations of IBD have received less attention. Multiple extraintestinal manifestations may be seen in IBD, including those of gastrointestinal (hepatobiliary and pancreatic), genitourinary, musculoskeletal, pulmonary, cardiac, ocular, and dermatologic disorders. Although many associations between IBD and extraintestinal organ systems have been well established, other associations have not been fully elucidated. Some extraintestinal disorders may share a common pathogenesis with IBD. Other extraintestinal disorders may occur as a result of unintended treatment-related complications of IBD. Although extraintestinal disorders within the abdomen and pelvis may be well depicted with cross-sectional enterography, other musculoskeletal and thoracic disorders may be less evident with such examinations and may warrant further investigation with additional imaging examinations or may be readily apparent from the findings at physical examination. Radiologists involved in the interpretation of IBD imaging examinations must be aware of potential extraintestinal manifestations, to provide referring clinicians with an accurate and comprehensive profile of patients with these complex disorders. ^© RSNA, 2017.