1
|
Prentice DA, Christou E, Pearson WA. Disseminated Cutaneous Mucormycosis Developing in Peristomal Pyoderma Gangrenosum. Cureus 2024; 16:e61137. [PMID: 38919219 PMCID: PMC11199072 DOI: 10.7759/cureus.61137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/27/2024] Open
Abstract
A patient on long-term glucocorticoid therapy for peristomal pyoderma gangrenosum (PPG) who developed mucormycosis (MM) of the wound with dissemination was presented. The importance of skin biopsy, together with clinical evaluation in patients with PPG who are resistant to conventional therapy or who develop new symptoms related to their PPG is stressed. The risk and pathogenesis of invasive fungal infections with long-term corticosteroid therapy were explored. The epidemiology and detection of mucormycosis is discussed in this article.
Collapse
Affiliation(s)
- David A Prentice
- Neurosciences, Perron Institute for Neurological and Translational Science, Perth, AUS
- Department of Internal Medicine, Royal Perth Hospital, Perth, AUS
| | - Erasmia Christou
- Department of General Surgery, Royal Perth Hospital, Perth, AUS
- School of Medicine, University of Western Australia, Nedlands, AUS
| | - Wendy A Pearson
- Stomal Therapy Service, Royal Perth Hospital, Perth, AUS
- School of Nursing, Curtin University, Bentley, AUS
| |
Collapse
|
2
|
Pearson WA, Prentice DA, Lim LY, Gianoncelli O, Hashiguchi A, Parisella TK, Ta JT. Clinical efficacy of crushed prednisolone and hydrocolloid powder in the primary treatment of peristomal pyoderma gangrenosum and correlation to in vitro drug release data. Int Wound J 2024; 21:e14808. [PMID: 38425135 PMCID: PMC10904972 DOI: 10.1111/iwj.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
We evaluated the primary application of crushed prednisolone combined with hydrocolloid powder for clinically diagnosed peristomal pyoderma gangrenosum (PPG). We present our data on this cohort and follow-up of our previous patients. Of the 23 patients who were commenced on this regime, 18 healed (78%). Twenty-two patients commenced on this regime as the primary treatment for their PPG, and for one, it was a rescue remedy after failed conventional therapy. Four patients with significant medical comorbidities failed to heal and one had their stomal reversal surgery before being fully healed. The proposed treatment regime for PPG is demonstrated to be effective, inexpensive and able to be managed in the patient's usual home environment. In vitro drug release analysis was undertaken, and data are presented to provide further insights into the efficacy of this regime.
Collapse
Affiliation(s)
- Wendy Ann Pearson
- Royal Perth HospitalPerthWestern AustraliaAustralia
- Curtin UniversityBentleyWestern AustraliaAustralia
| | - David Andrew Prentice
- Perron Institute for Neurological and Translational ScienceNedlandsWestern AustraliaAustralia
| | - Lee Yong Lim
- University of Western AustraliaCrawleyWestern AustraliaAustralia
| | - Olivia Gianoncelli
- Royal Perth HospitalPerthWestern AustraliaAustralia
- University of Western AustraliaCrawleyWestern AustraliaAustralia
| | - Alice Hashiguchi
- Royal Perth HospitalPerthWestern AustraliaAustralia
- University of Western AustraliaCrawleyWestern AustraliaAustralia
| | - Tahlia Kate Parisella
- University of Western AustraliaCrawleyWestern AustraliaAustralia
- Sir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Jade Thien Ta
- University of Western AustraliaCrawleyWestern AustraliaAustralia
| |
Collapse
|
3
|
Dissemond J, Marzano AV, Hampton PJ, Ortega-Loayza AG. Pyoderma Gangrenosum: Treatment Options. Drugs 2023; 83:1255-1267. [PMID: 37610614 PMCID: PMC10511384 DOI: 10.1007/s40265-023-01931-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.
Collapse
Affiliation(s)
- Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Philip J Hampton
- Department of Dermatology, Newcastle Dermatology, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science, University, Portland, OR, USA
| |
Collapse
|
4
|
Crushed Corticosteroid Tablets in Peristomal Pyoderma Gangrenosum: A Case Report. J Wound Ostomy Continence Nurs 2021; 48:460-462. [PMID: 34495940 DOI: 10.1097/won.0000000000000798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peristomal pyoderma gangrenosum (PPG) is a variant of pyoderma gangrenosum (PG). It results from a pathergy response to trauma from effluent from the ostomy or secondary to trauma caused by removal of the ostomy appliance adhesive in contact with the skin. Currently, no evidence-based guidelines for the management of PPG exist. This case study reports a dramatic response to crushed corticosteroid tablets in a patient who proved refractory to first- and second-line treatments of her PPG and several surgeries. CASE Ms T. was a 39-year-old woman with Crohn's disease who underwent several ileostomies, developed PPG, and failed treatment with adalimumab. Her PPG was successfully treated topically with crushed prednisone tablets. CONCLUSION We found that crushed corticosteroid tablets were an effective treatment of PPG, due to the ability to reduce pain and allow adhesion of the ostomy appliance.
Collapse
|
5
|
Morss-Walton PC, Yi JZ, Gunning ME, McGee JS. Ostomy 101 for dermatologists: Managing peristomal skin diseases. Dermatol Ther 2021; 34:e15069. [PMID: 34309140 DOI: 10.1111/dth.15069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/23/2021] [Indexed: 11/30/2022]
Abstract
An estimated 1 million North Americans live with ostomies, with up to 80% of ostomy patients developing stoma-related skin morbidities. While ostomy nurses are often the first line of management, dermatologists may be involved in the care of ostomy patients with complex or persistent peristomal skin complications. Therefore, an understanding of the ostomy apparatus and possible peristomal skin conditions that may arise allows dermatologists to identify skin complications early and work effectively with a multidisciplinary team. In this article, we aim to review the ostomy apparatus, discuss the differential diagnoses, and provide practical guidelines for the management of peristomal skin conditions. Pubmed, Ovid Medline, and Google Scholar were searched for relevant articles assessing peristomal skin complications and their management. Peristomal skin complications may be local (e.g., contact dermatitis, infection, fistula, and mechanical trauma) or secondary to systemic disease (e.g., inflammatory bowel disease, pyoderma gangrenosum, and psoriasis). Ensuring appropriate ostomy fit and proper use of ostomy accessory products helps to reduce effluent leakage and prevent damage to the peristomal skin. For persistent peristomal skin conditions, corticosteroid sprays, systemic therapies, and surgical interventions may be warranted.
Collapse
Affiliation(s)
| | - Julie Z Yi
- Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Mary-Ellen Gunning
- Nursing Wound Ostomy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jean S McGee
- Department of Dermatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Chong C, Palanisamy P, Yeo ESA. Case to highlight a rare differential diagnosis of necrotising fasciitis in the presence of a stoma: peristomal pyoderma gangrenosum. BMJ Case Rep 2021; 14:14/5/e237534. [PMID: 33962915 PMCID: PMC8108668 DOI: 10.1136/bcr-2020-237534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Peristomal pyoderma gangrenosum (PPG) is a rare clinical entity, which can masquerade as the more common and lethal necrotising fasciitis. The authors present a case of PPG in a 65-year-old woman who underwent robotic abdominoperineal resection for low rectal carcinoma and returned 8 days postoperation for peristomal skin ulcerations and pain, accompanied by leucocytosis; thus, she was treated as per necrotising fasciitis and underwent surgical debridement. Thereafter, her wound continued to worsen despite conventional wound care with vacuum-assisted closure and demonstrated signs of pathergy. The case was referred to dermatology where a diagnosis of PPG was made. This case report presents a cautionary tale for fellow clinicians, highlights the diagnostic challenge, and presents an updated literature review on diagnosis and management of this unique condition.
Collapse
Affiliation(s)
- Cheryl Chong
- Department of General Surgery, Sengkang General Hospital, Singapore
| | - Prasad Palanisamy
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
| | | |
Collapse
|
7
|
Pearson WA, Prentice DA, Sinclair DL, Lim LY, Carville KJ. A novel topical therapy for resistant and early peristomal pyoderma gangrenosum. Int Wound J 2019; 16:1136-1143. [PMID: 31298491 DOI: 10.1111/iwj.13164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/30/2019] [Accepted: 06/15/2019] [Indexed: 11/30/2022] Open
Abstract
Peristomal pyoderma gangrenosum (PPG) is an under-recognised and difficult condition to treat. We describe a case series using a novel topical combination therapy that promotes wound healing and allows for adhesion of the stoma appliance. A crushed oral prednisolone tablet mixed with Stomahesive Protective Powder (ConvaTec) was applied topically to seven patients with PPG and resulted in pain relief and wound healing in six of seven patients. Only one patient experienced recurrence. The novel topical therapy we describe is cost-effective, readily available, and easily applied in any inpatient or outpatient setting.
Collapse
Affiliation(s)
- Wendy A Pearson
- Stomal Therapy Service, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia
| | - David A Prentice
- Stomal Therapy Service, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Deborah L Sinclair
- Stomal Therapy, Saint John of God Hospital, Perth, Western Australia, Australia
| | - Lee Y Lim
- School of Allied Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Keryln J Carville
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,Primary Health Care and Community, Silver Chain Group, Perth, Western Australia, Australia
| |
Collapse
|