Managing Pyoderma Gangrenosum: A Synergistic Approach Combining Surgical D??bridement, Vacuum-Assisted Closure, and Hyperbaric Oxygen Therapy

Assessing the role of wound debridement in pyoderma gangrenosum-A retrospective cohort study

The role of wound debridement in pyoderma gangrenosum (PG) is controversial, largely due to concerns regarding pathergy. This study sought to evaluate the clinical outcomes and utility of wound debridement in PG management. We conducted a retrospective cohort study of 104 patients diagnosed with PG at a single tertiary referral centre, stratified into two treatment groups: those receiving debridement in conjunction with immunosuppressive therapy (n = 38) and those treated with immunosuppression alone (control group, n = 66). The primary outcomes measured were remission (absence of active PG lesions without necessitating additional treatment), time to remission and disease progression (new lesions or expansion of existing ones). Remission was achieved by 60.53% (n = 23) in the debridement group versus 87.88% (n = 58) in the control group (p = 0.003). The mean time to remission was 12.3 months for the debridement group versus 8.67 months for the control group (p = 0.2). Multivariate Cox regression analysis indicated that debridement significantly decreased the likelihood of disease remission (adjusted hazards ratio [HR]: 0.45, 95% confidence interval [CI]: 0.26-0.78, p = 0.005). Disease progression was significantly higher in the debridement group (68.42%, n = 26) compared to the control group (15.15%, n = 10) (p < 0.001). Additionally, 28.95% (n = 11) of patients in the debridement group required repeated procedures, and 10.53% (n = 4) underwent amputations due to deteriorating conditions. The timing and duration of immunosuppressive therapy relative to the procedure did not mitigate the risk of post-surgical exacerbations. These findings suggest that debridement is associated with poorer healing outcomes in PG, advocating for its contraindication in the management of this condition.

Pyoderma Gangrenosum Post-Breast Surgery: A Case Report and Comprehensive Review of Management Strategies

Background/Objectives: Pyoderma gangrenosum (PG) is a rare, autoimmune skin condition characterized by painful, rapidly progressing ulcers, often associated with autoimmune dysregulation. Managing PG following breast surgery presents unique challenges due to its pathergy phenomenon, which complicates surgical interventions. This article outlines the case of PG in a 48-year-old female post-breast surgery and reviews management strategies through a systematic analysis of the literature. Methods: A systematic literature review from 2018 to 2023 identified 24 relevant articles on PG management post-breast surgery. The studies were analyzed to compare the efficacy and complications of conservative versus combined (conservative and surgical) treatment strategies. Results: Results indicate that while conservative management, primarily with corticosteroids, remains preferred, combined strategies, including systemic therapies, vacuum-assisted closure, and surgery, offer significant benefits in select cases. Conclusions: Our findings suggest that a personalized, multifaceted treatment plan is crucial for managing PG effectively, emphasizing the need for early detection, meticulous planning, and comprehensive care to optimize patient outcomes.

Wound Debridement in Pyoderma Gangrenosum

BACKGROUND

Wound debridement improves healing in a variety of acute and chronic ulcers. However, there is concern that debridement may trigger pathergy and worsen pyoderma gangrenosum (PG).

OBJECTIVE

To determine whether published evidence supports conservative wound debridement for PG.

DATA SOURCES

The authors reviewed the literature published in MEDLINE through January 2023 using the search germs "pyoderma gangrenosum" and "debridement."

STUDY SELECTION

Articles reporting sharp surgical debridement or maggot debridement for PG were included in the review. The authors also searched the reference sections of the reviewed articles for additional reports on debridement for PG.

DATA EXTRACTION

Clinical data regarding patient status, procedures performed, and patient outcomes were extracted from the selected articles.

DATA SYNTHESIS

There are multiple reports of uncontrolled, active-phase PG wounds worsening after aggressive excisional debridement of viable inflamed tissues. In contrast, there is no evidence indicating that conservative debridement of nonviable necrotic tissue worsens PG wounds, regardless of the disease activity. There are multiple reports of successful debridement and surgical grafting for PG in remission.

CONCLUSIONS

There is no evidence in favor of or against using conservative debridement of nonviable necrotic tissue for a PG wound. Therefore, it should not be considered contraindicated, even in the active phase of the disease.

Postoperative Pyoderma Gangrenosum in a Laparoscopic Gastrectomy Port Site: A Case Report

Background

Postoperative pyoderma gangrenosum (PPG) is a rare inflammatory skin disease of unknown etiology characterized by blistering and ulcerative lesions in postoperative wounds. Untreated pyoderma gangrenosum (PG) is potentially life-threatening; therefore, immediate and appropriate treatment is essential. Although PPG and surgical site infection (SSI) present similar clinical findings, they should be differentiated because of their conflicting treatment modalities.

Case presentation

An 82-year-old man with comorbidities of pulmonary tuberculosis, chronic obstructive pulmonary disease, and diabetes underwent laparoscopic gastrectomy for gastric cancer. On postoperative day 6, fever exceeding 39°C, port wound redness, and pain was observed. Laboratory tests revealed severe inflammatory reactions: white blood cell, 42,800/μL and C-reactive protein, 30.2 mg/mL. The patient was diagnosed with SSI and treatment with antibiotics and drainage was started; however, his general and wound conditions also worsened. Therefore, he was diagnosed with PG because painful skin findings were exacerbated by external stimuli and no significant bacteria were detected in the culture test. Treatment with oral prednisolone was started, which significantly improved his skin and inflammatory conditions.

Conclusion

We managed a rare case of PPG that occurred in a port wound after laparoscopic gastrectomy. If atypical clinical findings of postoperative SSI are observed, general surgeons should recognize and consider PPG as a differential diagnosis.

Case Report of Two Patients With COVID-19 and Sacral Pressure Injuries Associated with Pyoderma Gangrenosum

ABSTRACT

During the COVID-19 pandemic, an increasing number of patients have been admitted to the ICU with severe respiratory complications requiring prolonged supine positioning. Recently, many case reports have been published regarding dermatologic manifestations associated with COVID-19. However, there is little information about the clinical features of these manifestations. Pyoderma gangrenosum (PG) is an ulcerative noninfectious inflammatory disease of the skin. In at least 50% of the cases, the etiology is unknown. Nevertheless, PG is associated with many systemic diseases. In this article, the authors report two critically ill patients with COVID-19 who developed sacral ulcers during their recovery in the ICU. These ulcers had an atypical course and were exacerbated by surgical debridements. Accordingly, providers suspected PG, which was confirmed by the clinical evolution of the ulcers and biopsies taken from the wounds. To the best of the authors' knowledge, no previous articles have reported sacral pressure injuries associated with PG in patients with COVID-19. Providers should suspect PG in patients with COVID-19 who develop nonhealing pressure injuries.

Pyoderma Gangrenosum: A Rare Disease With Dire Consequences in Facial Aesthetic Surgery Patients

Pyoderma gangrenosum (PG) is a rare, inflammatory dermatologic condition characterized by painful cutaneous ulcerations. Herein, we describe the third documented case of PG arising in an elective plastic surgery patient who had undergone an otherwise uncomplicated facelift. We describe the course of her diagnosis and management of PG, which involved her face and neck and then progressed to her lower extremities. Although the etiology remains unknown, PG often arises in a host with another autoimmune disease. In the case described, the patient was diagnosed with an immunoglobulin A gammopathy shortly after she developed PG. Following the case report, the pathogenesis, diagnosis, and treatment strategy of PG is briefly reviewed. Level of Evidence: 5.

The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: A systematic review and personal experience

Pyoderma gangrenosum (PG) is a rare painful ulcerative neutrophilic inflammatory skin disease, necessitating a high level of diagnostic suspicion associated with appropriate treatment to avoid progression. Negative pressure wound therapy (NPWT) has been efficiently used in the treatment of different types of wounds. However, the role of NPWT in the management of PG is still controversial, due to the risk of the pathergy phenomenon. In this article, we conducted a systematic review (according to the PRISMA guidelines) on the use of NPWT in the treatment of PG, and we report our personal experience with two patients treated with this device. The result of the review showed that articles on the topic are, in their entirety, of low levels of evidence, such as case series, case reports, and reviews. Improvement in wound healing with the use of NPWT was observed in 85.1% of the patients studied. Besides, a significant association between improvement in wound healing with NPWT and immunosuppressive therapy was observed. Regarding the cases reported here, both showed good outcomes with the use of NPWT and skin graft during the treatment of PG injuries. Due to the rarity of PG, there is a scarcity of studies with robust evidence for standardization and comparison between treatments, which consequently makes it difficult to select therapeutic options. However, based on this systematic review and reported cases, we consider NPWT a safe option for adjuvant treatment of wounds caused by PG if combined with systemic immunosuppression, which plays a key role in greater chances of successful treatment. This approach should be recommended, whenever possible, associated with skin grafting to accelerate wound closure. The role of negative pressure wound therapy (NPWT) on the treatment of pyoderma gangrenosum: a systematic review and personal experience.

Hyperbaric oxygen therapy for refractory pyoderma gangrenosum: a salvage treatment

A 42-year-old woman with left-side ulcerative colitis (E2 - rectum to splenic flexure) was diagnosed with pyoderma gangrenosum (PG) on a persistent ulcerated wound with peripheral erythema, in the left leg's gemelar surface, associated with tenderness and pain. Due to incomplete response to wound care and oral prednisolone, treatment with infliximab was initiated. As PG remained unresponsive after 12 weeks, the patient was switched to adalimumab with concomitant oral prednisolone. Before the second induction dosage of adalimumab, the refractory PG complicated with a superinfection by Pseudomonas aeruginosa A course of wide spectrum antibiotic therapy, daily wound care including negative pressure bandages and a physiotherapy rehabilitation programme controlled the infection, but the pyoderma persisted non-healed, with visible deep muscle layers and tendons. We proposed hyperbaric oxygen therapy in addition to weekly adalimumab, achieving full remission of the PG and recovering of the left foot's function.

Efficacy and safety of skin grafting in treatment of vasculitic ulcer and pyoderma gangrenosum-A systematic review

Chronic painful ulcers caused by pyoderma gangrenosum (PG) and cutaneous vasculitis remain to be a therapeutic challenge. Skin grafts have been used with success in selected cases but are generally avoided due to the fear of pathergy. The aim of this study was to investigate the safety and efficacy of skin grafting in the treatment of primary vasculitic ulcer (PVU) and PG. MEDLINE, Embase, the Cochrane Library, Clinicaltrial.gov, and WHO International Clinical Trials Registry Platform (ICTRP) were searched from inception to March 2020. A search for grey literature was conducted in May 2020. We included studies assessing the efficacy and safety of skin grafting in the treatment of PG and PVU. Studies were only included if skin grafting was performed after establishment of PG or PVU diagnosis. A total of 721 articles was identified through the database search of which 92 were included in this study. Ten articles were identified by handsearching the reference list of included studies. Finally, 102 articles describing 212 wounds in 153 patients were included. Complete healing was found in 75.5% of the wounds. The average time to complete was 10.8 weeks (95% CI 6.1-15.6). The mean donor site healing time was 1.9 weeks (95% CI 0.52-3.20). Pathergy was reported in 8 (5.2%) patients. One patient had severe infection related to skin grafting. A statistically significant difference in the number of patients receiving preoperative (P = .0079) and postoperative (P = .002) immunosuppressive therapy was found between the groups with complete healing/reduction and no improvement/aggravation. This systematic review finds the current evidence on efficacy and safety of skin grafting in treatment of PG and PVU to be promising but limited to the size and lack of studies superior to case reports and case series. Future placebo-controlled trials are required to draw a stronger conclusion.

Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines

INTRODUCTION

Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery.

METHODS

This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included.

RESULTS

Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days.

CONCLUSIONS

Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

Surgical Treatment of Pyoderma Gangrenosum with Negative Pressure Wound Therapy and Skin Grafting, Including Xenografts: Personal Experience and Comprehensive Review on 161 Cases

Significance: Pyoderma gangrenosum (PG) is a rare debilitating autoinflammatory ulcerative skin disease. No gold standard has been established for the treatment of PG. The role of surgical interventions and negative pressure wound therapy (NPWT) was discussed controversially until recently as these procedures might pose a trigger to further aggravate the condition. Recent Advances: Recent advances confirm the paradigm change that a surgical approach of PG with split thickness skin grafting (STSG) secured by NPWT is a safe and valuable treatment if performed under adequate immunosuppression. We elaborate this on the hand of a broad literature search retrieving 101 relevant articles describing 138 patients complemented with our personal experience on 23 patients, including 2 patients treated with a porcine xenodressing. Critical Issues: A wide range of surgical approaches have been reported, including xenografts. Treatment was finally successful in 86%, including the xenotransplant cases. Ten percent improved and failures were mainly reported without immunosuppression. Despite halting the inflammatory process, NPWT alone, without skin grafting, does not much accelerate healing time. The best surgical approach appears to be STSG fixed with NPWT as this leads to higher skin graft take. There remains the problem of the chronic nature of PG and the recurrence after tapering of immunosuppression or trauma; therefore, a sustained immunosuppressive treatment is suggested. Future Directions: While surgical treatment is supported by the published data, the exact immunosuppression is still evolving. Due to deeper insights into pathogenesis and growing clinical reports, a broader utilization of biologic treatments and a shift from tumor necrosis factor (TNF)-alpha to interleukin (IL)-12/23 or IL-23 antibodies alone are predictable, as IL-12/23 antibodies show good clinical responses with fewer side effects. The positive results with porcine xenodressings might be due to immunological effects of the xenomaterial; they appear promising, but are preliminary and should be confirmed in a larger patient collective.

Hemiarthroplasty in a patient with femoral neck fracture and pyoderma gangrenosum: a case report and review of the literature

Background

Pyoderma gangrenosum is a rare ulcerating skin disease of unknown etiology, making its coincidence with orthopedic trauma a rare challenge. Patients are at risk of progression of the existing lesions and development of new lesions upon skin injury when surgical procedures are performed. To our knowledge, this is the first report in the literature of disease unrelated surgery during active pyoderma gangrenosum.

Case presentation

We present a case of femoral neck fracture in a Caucasian patient with concurrent pyoderma gangrenosum localized in the axilla. Hemiarthroplasty was safely performed after disease activity was reduced with systemic corticosteroids. Tissue-protective wound closure was used together with perioperative corticosteroids and antibiotics. No signs of pyoderma gangrenosum developed at the surgical wound site, and the axillary lesions showed constant improvement until healing with scar tissue.

Conclusions

In our patient, the preoperative steroid treatment, perioperative antibiotics, and soft tissue protective surgical technique led to successful management of this rare coincidence.

Pyoderma gangrenosum after orthopaedic or traumatologic surgery: a systematic revue of the literature

INTRODUCTION

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by a painful ulceration mimicking infection of the operative site. To this day, there is still no general agreement on the medical and surgical treatment of PG. This systematic review of the literature aims to summarise recent studies about post-operative PG in orthopaedic surgery to improve its medical and surgical management.

METHOD

In April 2017, we carried out an exhaustive review of the literature in MEDLINE, PubMed and Cochrane databases. Key words were pyoderma gangrenosum, orthopaedic surgery, and surgical wound infection. We identified 183 articles. After excluding articles reporting idiopathic PG, cases secondary to non-orthopaedic surgery, and cases about other subtypes of dermatosis, 30 studies were identified. We only included articles reporting PG after orthopaedic or trauma surgery.

RESULTS

Thirty-one cases of PG have been reported, 58% (18) of which were in women, whose mean age was 56.5 years. Clinical signs were constant, the most frequently affected site was lower limbs [77.4% (24)] and delay of symptom onset was two to 17 days. Systemic corticosteroid therapy was systematic, polyvalent immunoglobulins were used in two cases and immunosuppressive drugs in one. Negative pressure therapy was used in seven cases and hyperbaric oxygen in three.

DISCUSSION

Delayed diagnosis leads to one or more surgical revisions, which could have been avoided by using early and adapted medical treatment. Early onset of a painful and infected ulcer at the operating site in a patient at risk of PG is an indicator that dermatologist advice is recommended before surgical debridement. Surgical revision, outside the inflammatory phase and/or covered by a systemic corticosteroid therapy, does not lead to PG relapse.

LEVEL OF EVIDENCE

IV: Systematic revue of the literature.

Nonhealing Wounds Caused by Brown Spider Bites: Application of Hyperbaric Oxygen Therapy

BACKGROUND

Bites by Loxosceles spiders (also known as recluse spiders or brown spiders) can cause necrotic ulcerations of various sizes and dimensions. The current standard of care for brown spider bites includes analgesics, ice, compression, elevation, antihistamines, and surgical debridement. Hyperbaric oxygen therapy (HBOT) in the treatment of brown spider bites has been administered in the early stage of ulceration, or 2 to 6 days after the bite. Unfortunately, the diagnosis of spider bite-related ulcers is often delayed and weeks or months may elapse before HBOT is considered.

OBJECTIVE

To evaluate the effect of HBOT on nonhealing wounds caused by brown spider bites in the late, chronic, nonhealing stage.

METHODS

Analysis of 3 patients with brown spider-bite healing wounds treated at The Sagol Center for Hyperbaric Medicine and Research in Israel. Patients presented 2 to 3 months after failure of other therapies including topical dressings, antibiotics, and corticosteroids. All patients were treated with daily 2 ATA (atmospheres absolute) with 100% oxygen HBOT sessions.

RESULTS

All 3 patients were previously healthy without any chronic disease. Their ages were 30, 42, and 73 years. They were treated once daily for 13, 17, and 31 sessions, respectively. The wounds of all 3 patients healed, and there was no need for additional surgical intervention. There were no significant adverse events in any of the patients.

CONCLUSIONS

Microvascular injury related to brown spider bites may culminate in ischemic nonhealing wounds even in a relatively young, healthy population. Hyperbaric oxygen therapy should be considered as a valuable therapeutic tool even months after the bite.

Pyoderma Gangrenosum after Deep Inferior Epigastric Perforator Breast Reconstruction: Systematic Review and Case Report

BACKGROUND

Pyoderma gangrenosum (PG) is a rare skin disorder of the neutrophilic dermatoses spectrum that can mimic wound infections in surgical patients. PG after breast surgery has been reported but in limited amounts in autologous breast reconstruction patients. We present the first case of PG after a delayed bilateral deep inferior epigastric perforator flap breast reconstruction in the setting of systemic disease along with a systematic review.

METHODS

PubMed, Ovid, and Web of Science were systematically searched to obtain cases of PG after autologous breast reconstruction. Sixty articles were identified but only 16 were relevant to this study.

RESULTS

Systemic disease was present in 2 patients (13%). Wound onset occurred typically 5 days after surgery. Fever and/or leukocytosis was observed in 10 patients (63%). Wound cultures were positive in 2 patients (13%). Donor-site wounds were present in 9 patients (56%). Bilateral breast wounds were present in 67% of bilateral cases. Debridement was performed in 10 cases (63%). Skin graft or substitute was performed in 6 cases (38%). Resection of autologous flap was performed in 3 cases (19%). All patients were treated with systemic steroids (81%) and/or immunosuppressive medications (50%). Complete wound healing occurred by 4 months on average.

CONCLUSION

If early ulcerative wounds develop at multiple sites after autologous breast reconstruction with worsening after debridement and antibiotic therapy, then PG should be considered. It is imperative that an early diagnosis and subsequent treatment with steroids and/or immunosuppressive medications be initiated so further surgical procedures, flap loss, and scarring can be minimized.

Pyoderma gangrenosum with pathergy: A potentially significant complication following breast reconstruction

The failure of postoperative surgical site infection to resolve after appropriate antibiotic therapy should alert the clinician to other diagnoses. Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that is typically characterized by necrotizing ulceration. PG can be exacerbated by minor trauma leading to exaggerated skin injury, a condition known as pathergy. We present a case series of PG arising after immediate reconstruction for breast oncological surgery from 1st January 2006 to 1st September 2014. 395 immediate breast reconstructions were performed in 335 patients. Three cases of post-surgical PG were identified (0.9%), all in the setting of mastectomy for breast cancer. Two cases underwent immediate reconstruction with pedicled transverse rectus abdominus myocutaneous flaps, and one underwent submuscular expander insertion. A mean delay of 6.3 days was observed from first presentation of symptoms to diagnosis of PG. Immunosuppressants commonly used included methylprednisolone, prednisone, and ciclosporin, with good success at halting disease progress. Significant scarring affected all three women. Once the disease was deemed quiescent, intravenous immunoglobulin used in the perioperative period for further surgical procedures provided favorable results. A diagnostic algorithm is suggested to guide surgeons in investigations and management when post-surgical PG is suspected.

Successful Treatment of Pyoderma Gangrenosum after Augmentation Mastopexy Using Vacuum Therapy

Supplemental Digital Content is available in the text.

Background:

Pyoderma gangrenosum (PG) is a rare, severe, destructive neutrophilic dermatosis characterized by a progressive, necrotizing process after skin injury. Its cause is still unknown, and diagnosis represents a challenge when ulcers are seen after surgery. Bacterial infection is not found in the wounds. Patients exhibit “pathergy” with the appearance of new lesions after local trauma such as surgical procedures, debridements, and wound care, suggesting altered inflammatory response. The objective of this study was to review the literature and report a case of PG that was satisfactorily treated with vacuum therapy (vacuum-assisted closure [VAC]).

Case Report:

A 19-year-old healthy patient presented with skin ulceration 4 days after augmentation mastopexy, progressing to extensive necrosis. On the eighth day, she underwent debridement and implant removal. Two days later, the necrotic process was again evident and progressed, resulting in a significant increase in wound size, with each wound reaching 20 × 25 cm. Intense and diffuse neutrophilic exudate and areas of necrosis were present. Systemic corticosteroids and VAC under general anesthesia were initiated 5 days after the second surgery. From the fourth VAC session, some adherence between the mammary gland and pectoral muscles was visible, so deep sutures avoiding the dermis were placed to direct wound closure.

Conclusions:

PG is a life-threatening complication with devastating outcomes. Early diagnosis is critical. Although some reported cases needed up to 2 years for wound closure, in this case, VAC therapy allowed the patient to be discharged after only 42 days and permitted wound closure without the need for skin grafts.

Pyoderma gangrenosum following breast reduction: treatment with topical tacrolimus and steroids

Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory dermatosis usually associated with autoimmune disorders. Wounds may mimic a necrotizing infection, and the diagnosis is usually made after antibiotic therapy fails. Debridement may cause even larger wounds because of pathergy, so PG treatment consists of corticosteroids and local wound care. Pyoderma gangrenosum can be a devastating complication of breast and aesthetic surgery. We describe a case of PG following unilateral breast reduction that resulted in systemic inflammatory response; after treatment with prednisone and topical tacrolimus, the PG was resolved. The application of topical tacrolimus may reduce the need for prolonged corticosteroids.

LEVEL OF EVIDENCE

5.

Refractory postsurgical pyoderma gangrenosum in a patient with Beckwith Wiedemann syndrome: response to multimodal therapy

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that may be difficult to diagnose and treat. We presented a 41-year-old woman who required skin grafting following third-degree burns to her left breast. She suffered recurrent graft dehiscence and infections over many years, prompting elective bilateral reduction mammoplasty. She subsequently developed suture margin ulcerations unresponsive to topical therapies and antibiotics. Skin biopsies were non-specific, and a clinical diagnosis of PG was established. Although initially responsive to corticosteroids, wounds promptly recurred following steroid taper. She was treated unsuccessfully with various immunomodulatory agents and underwent elective bilateral mastectomy. Following a mastectomy, she developed progressive deep chest wall ulcerations. She failed numerous immunomodulatory treatments, surgical wound closure and negative pressure wound therapy. Ultimately, treatment with adalimumab, mycophenolate mofetil and prednisone, in addition to hyperbaric oxygen therapy facilitated progressive healing. Our case highlights the role of collaborative multimodal therapy for the treatment of refractory PG.

Gauze-based negative pressure wound therapy: a valid method to manage pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an uncommon ulcerative, non-infective chronic inflammatory skin disorder of unknown aetiology. Systemic therapies are necessary to control the associated medical diseases, and, due to the inflammatory nature of PG, topical or systemic immunosuppressant agents are effective, but wound healing is usually slow. Negative wound pressure therapy (NPWT) has become an important tool for the management of complex skin ulcers, and usage in PG has been recently described in the literature: we present four cases of classic PG in which NPWT in association with systemic therapy achieved wound healing and a drastic pain reduction.

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.

Oxigenoterapia hiperbárica como tratamento adjuvante do pioderma gangrenoso

O pioderma gangrenoso é uma dermatose neutrofílica, rara da pele e do tecido subcutâneo, caracterizada por um processo necrosante progressivo e doloroso. A conduta no Pioderma gangrenoso requer, com frequência, o uso de drogas sistêmicas, tais como: corticoides, sulfonas e imunossupressoras, seja de maneira isolada, seja em combinação. Muitos relatos, na literatura, documentam o tratamento com êxito do Pioderma gangrenoso, com a oxigenoterapia hiperbárica. No nosso caso, uma jovem com lesões extensas e muito dolorosas, o tratamento com oxigenoterapia hiperbárica associado ao corticoide e imunossupressor promoveu cicatrização, com excelente resultado, com fechamento rápido da lesão e diminuição do desconforto.

Pyoderma gangrenosum: a report of a rare complication after knee arthroplasty requiring muscle flap cover supplemented by negative pressure therapy and hyperbaric oxygen

Pyoderma gangrenosum (PG) is rare ulcerating skin condition easily confused with wound infection following surgery. We report a complicated case of PG following knee arthroplasty where delayed diagnosis and repeated debridements lead to significant tissue loss. Successful reconstruction was achieved with a muscle flap, but subsequent reactivation of PG and superadded infection placed both the reconstruction and patient's life at risk. Prolonged combined use of negative pressure therapy (NPT), immunosuppression and hyperbaric oxygen (HBO) was successfully used to reduce the wound size, enhance wound granulation, promote re-epithelialisation, and provide pain relief. There is little or no published literature on these treatment modalities for the management of PG, with only one reported case using both NPT and HBO for PG (not following knee arthroplasty). More studies are necessary to determine the role of both modalities in the management of pathergy in large and complex wounds and the rare nature of this complication following knee arthroplasty explains the lack of evidence-based guidance. In conclusion, we suggest a surgical algorithm. This is the first report of PG following knee arthroplasty with the use of both NPT and HBO in order to achieve soft tissue coverage.

Pyoderma gangrenosum after inguinal hernia repair

Pyoderma gangrenosum (PG) is an uncommon, ulcerative skin disease that is often associated with systemic illness. In rare cases, PG occurs after surgery, which can lead to delayed diagnosis as other causes such as wound breakdown or bacterial/fungal infection are considered. We report a rare case of PG following the repair of an inguinal hernia, and review the presentation of this disease after surgery.

Pyoderma gangrenosum of the eyelids: recurrence in a skin graft

A 41-year-old woman presented with pyoderma gangrenosum involving the right eyelids. Over the course of 3 years, she developed progressive scarring of the eyelids with lagophthalmos and corneal exposure. Multiple reconstructive procedures were performed with varying degrees of success. Despite aggressive medical control of her disease, it recurred in grafted skin on her upper and lower eyelids as confirmed by tissue biopsy. Periocular pyoderma gangrenosum is a rare disease where the management may be complicated by disease recurrence in reconstructed tissues, including skin grafts as this case demonstrates.