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Morgenstjerne-Schwenck LET, Knudsen JT, Prasad SC. Efficacy and safety of skin grafting in treatment of vasculitic ulcer and pyoderma gangrenosum-A systematic review. Wound Repair Regen 2020; 29:240-253. [PMID: 33377584 DOI: 10.1111/wrr.12882] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/02/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
| | - Jane T Knudsen
- Department of Dermatovenerology and Allergy, Odense University Hospital, Odense, Denmark
| | - Sumangali C Prasad
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Dermatovenerology and Allergy, Odense University Hospital, Odense, Denmark
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2
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McDonald L, Baker G, Kerr O. Scalp ulceration: a rare manifestation of giant cell arteritis. BMJ Case Rep 2019; 12:12/11/e230795. [PMID: 31678922 DOI: 10.1136/bcr-2019-230795] [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] [Indexed: 02/01/2023] Open
Abstract
An 81-year-old woman presented with an enlarging, tender ulcer on her scalp over an 8-week period, attributing it to a prior graze with garden shears. C-reactive protein and erythrocyte sedimentation rate were elevated at 87.7 mg/L and 112 mm/hour, respectively. Incisional biopsies demonstrated ulceration and full thickness necrosis with no evidence of malignancy. Vasculitis was suggested as a likely cause of such extensive necrosis and subsequent temporal artery biopsy findings were consistent with giant cell arteritis. The patient was initially treated with high-dose oral prednisolone and achieved complete healing of the scalp necrosis within 12 months, with a gradual down-titration of steroid therapy thereafter. Scalp necrosis is a rare, potentially life-threatening complication of giant cell arteritis. This case highlights the importance of considering scalp necrosis as a manifestation of giant cell arteritis when assessing scalp ulceration. Prompt diagnosis and treatment can prevent significant morbidity and potential mortality.
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Affiliation(s)
- Louise McDonald
- Department of Dermatology, Belfast Health and Social Care Trust, Belfast, UK
| | - Gavin Baker
- Department of Histopathology, Belfast Health and Social Care Trust, Belfast, UK
| | - Olga Kerr
- Department of Dermatology, Belfast Health and Social Care Trust, Belfast, UK
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3
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Rose C, Holl-Ulrich K. [Granulomatous reaction pattern of the skin : Interstitial granulomatous dermatitis - lymphoma - vasculitis]. Hautarzt 2019; 68:553-559. [PMID: 28608042 DOI: 10.1007/s00105-017-4004-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A particular diagnostic situation in the classification of a granulomatous dermatitis results when no circumscribed granulomas but instead a diffuse interstitial histiocytic inflammatory infiltrate, a granulomatous vasculitis or a neoplastic lymphocytic infiltrate is found. Interstitial granulomatous dermatitis was originally described in patients with arthritis. Later, it was recognized that there are also associations with other usually immunological diseases. Differentiating between interstitial granulomatous dermatitis and the interstitial form of granuloma annulare, early morphea and variants of borreliosis or scleromyxedema as well as interstitial granulomatous drug reaction can be very difficult. In long-standing cutaneous granulomatous infiltrates, T‑cell lymphoma should be excluded. Occasionally only a small number of atypical lymphocytes can be found. The detection of a monoclonal T‑cell expansion is then particularly helpful. Only recently, a CD8-positive granulomatous cutaneous T‑cell lymphoma was described which occurred in patients with immunodeficiencies. A granulomatous vasculitis in the skin is extremely rare. According to the Chapel Hill classification from 2012, systemic granulomatous vasculitis is equated with giant cell arteritis. Extracutaneous large arteries are involved. On rare occasions, involvement of the temporal artery can result in skin necrosis. More commonly granulomatous infiltrates in combination with vasculitis can be observed, whereby various infectious diseases, sarcoidosis and nodular vasculitis should be considered. Granulomatosis with polyangiitis (formerly Wegener's granulomatosis), presents in the skin as leukocytoclastic vasculitis. Here granulomas are extremely rare.
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Affiliation(s)
- C Rose
- Dermatopathologie Lübeck, Maria-Goeppert-Str. 5, 23562, Lübeck, Deutschland.
| | - K Holl-Ulrich
- Konsultations- und Referenzzentrum für Vaskulitis-Diagnostik, MVZ am Marienkrankenhaus gGmbH, Hamburg, Deutschland
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4
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Griffin L, Hackett C, Ryan S, Leonard N, Ramsay B. A case of scalp necrosis. Clin Exp Dermatol 2018; 44:106-109. [PMID: 29952020 DOI: 10.1111/ced.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 11/30/2022]
Affiliation(s)
- L Griffin
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - C Hackett
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - S Ryan
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - N Leonard
- Department of Pathology, St James Hospital, Dublin, Ireland
| | - B Ramsay
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
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5
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Yuksel V, Guclu O, Tastekin E, Halici U, Huseyin S, Inal V, Canbaz S. Clinical correlation of biopsy results in patients with temporal arteritis. Rev Assoc Med Bras (1992) 2017; 63:953-956. [PMID: 29451658 DOI: 10.1590/1806-9282.63.11.953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/07/2017] [Indexed: 02/08/2023] Open
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6
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Oh LJ, Wong E, Gill AJ, McCluskey P, Smith JEH. Value of temporal artery biopsy length in diagnosing giant cell arteritis. ANZ J Surg 2016; 88:191-195. [PMID: 27800647 DOI: 10.1111/ans.13822] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/05/2016] [Accepted: 09/20/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is considered an ophthalmological emergency with severe sight and life-threatening sequelae. Temporal artery biopsy (TAB) is the current gold standard for the diagnosis of GCA; however, the required length of biopsy remains an issue of contention in the literature. METHODS Retrospective case-control study of a consecutive cohort of 545 patients who had undergone TABs across five hospitals between 1 January 1992 and 1 January 2016. In patients with either positive or negative TABs, we collected age, sex, biopsy length and erythrocyte sedimentation rate (ESR). RESULTS A total of 538 patients were included in the final analysis. Of these, 23.4% of TABs were positive, with the average length being 17.6 mm. There was a significant difference in means for positive (19.9 mm) and negative (16.8 mm) biopsies (P = 0.0009). Each millimetre increase in TAB length increased the odds of a positive TAB by 3.4% (P = 0.024). A cut-off point of ≥15 mm increased the odds of a positive TAB by 2.25 compared with a TAB <15 mm (P = 0.003). We also found that ESR ≥50 mm/h was a very strong predictor for a positive TAB result (P < 0.0001). CONCLUSION Biopsy length and ESR were significant predictors of a pathological diagnosis of GCA. We also found that the optimal length threshold predictive for GCA was 15 mm in order to avoid a false-negative GCA diagnosis. Although TAB remains the gold standard for diagnosis, clinicians should refer to both clinical and pathological data to guide their management.
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Affiliation(s)
- Lawrence J Oh
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia
| | - Eugene Wong
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia.,Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Peter McCluskey
- Department of Opthalmology, The University of Sydney, Sydney, New South Wales, Australia.,Department of Opthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - James E H Smith
- Department of Ophthalmology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Opthalmology, Sydney Eye Hospital, Sydney, New South Wales, Australia
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Micieli JA, Micieli R, Margolin EA. A review of specialties performing temporal artery biopsies in Ontario: a retrospective cohort study. CMAJ Open 2015; 3:E281-5. [PMID: 26442226 PMCID: PMC4593411 DOI: 10.9778/cmajo.20140108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Temporal artery biopsy is the gold standard for the diagnosis of giant cell arteritis, but the numbers and types of surgical specialists performing temporal artery biopsies are unknown. The goal of this study was to determine which surgical specialists performed temporal artery biopsies and how geographic location influenced this trend over a period of 10 years. METHODS This retrospective cohort study included all physicians practising in Ontario from 2002 to 2013. Using comprehensive physician services data from the IntelliHEALTH Medical Services database, physicians performing temporal artery biopsies were identified by the Ontario Health Insurance Plan billing code submitted for remuneration. Physicians were categorized by specialty and geographic Local Health Integration Unit. RESULTS A total of 9958 patients underwent a temporal artery biopsy during the study period: the biopsies were performed by 11 different subspecialties. The number of patients undergoing a temporal artery biopsy declined over the 10-year study period. Most procedures were performed by general surgeons (38.1%), followed by ophthalmologists (31.0%) and plastic surgeons (23.6%). Ophthalmologists performed more temporal artery biopsies per person compared with general surgeons, but significantly more general surgeons performed at least 1 biopsy. There was significant variation based on geographic location: plastic surgeons performed the most biopsies in regions with a population of more than 1 million people, and general surgeons performed most of the biopsies in rural areas. INTERPRETATION Geographic location heavily influenced which specialty was most likely to perform temporal artery biopsies. General surgery, ophthalmology and plastic surgery emerged as leaders in this area, and their residency programs should include formal training in this procedure in their curricula.
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Affiliation(s)
- Jonathan A Micieli
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, Ont
| | | | - Edward A Margolin
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, Ont
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von Vegesack EC, Fick S, Czarnecka A, Radant K, Christian Marsch W, Stadie V. Erfolgreicher Wundverschluss mittels Dermisersatz und Spalthauttransplantat bei tiefreichender bilateraler Skalpnekrose im Rahmen einer Riesenzellarteriitis. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.12558_suppl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Eva Corina von Vegesack
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale) der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Sylvia Fick
- Abteilung Rheumatologie, Klinik für Innere Medizin II, Universitätsklinikum Halle (Saale) der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Agnieszka Czarnecka
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale) der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Katrin Radant
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale) der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Wolfgang Christian Marsch
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale) der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
| | - Volker Stadie
- Klinik und Poliklinik für Dermatologie und Venerologie, Universitätsklinikum Halle (Saale) der Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
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9
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Vegesack EC, Fick S, Czarnecka A, Radant K, Marsch WC, Stadie V. Successful wound closure using artificial dermis and split-skin grafting in deep bilateral scalp necrosis caused by giant cell arteritis. J Dtsch Dermatol Ges 2015; 13:591-3. [DOI: 10.1111/ddg.12558] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Eva Corina Vegesack
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin Luther University, Halle-Wittenberg, Halle (Saale)
| | - Sylvia Fick
- Division of Rheumatology, Second Department of Internal Medicine, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle (Saale)
| | - Agnieszka Czarnecka
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin Luther University, Halle-Wittenberg, Halle (Saale)
| | - Katrin Radant
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin Luther University, Halle-Wittenberg, Halle (Saale)
| | - Wolfgang Christian Marsch
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin Luther University, Halle-Wittenberg, Halle (Saale)
| | - Volker Stadie
- Department of Dermatology and Venereology, University Hospital Halle (Saale), Martin Luther University, Halle-Wittenberg, Halle (Saale)
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10
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Pagnoux C, Kluger N, Francès C, Guillevin L. Cutaneous granulomatous vasculitis and extravascular granulomas. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.1.2.315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Mahe E, Demellawy DE, Bane A, Alowami S. Giant cell temporal arteritis associated with overlying basal cell carcinoma: co-incidence or connection? Rare Tumors 2012; 4:e46. [PMID: 23087802 PMCID: PMC3475953 DOI: 10.4081/rt.2012.e46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 04/23/2012] [Indexed: 11/22/2022] Open
Abstract
Giant cell arteritis is a granulomatous vasculitis of large and medium sized arteries manifesting as temporal arteritis and/or polymyalgia rheumatica. The histological assessment of temporal artery biopsies is frequently encountered in anatomical pathology and has important diagnostic consequences in patients clinically suspected of having giant cell arteritis. We present an intriguing case of giant cell arteritis associated with a Basal cell carcinoma and discuss the ongoing controversy pertaining to the association of giant cell arteritis/polymyalgia rheumatica with malignancy.
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Affiliation(s)
- Etienne Mahe
- Department of Pathology and Molecular Medicine, Hamilton Health Sciences, McMaster University, Hamilton
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Abstract
Various nonfollicular scalp conditions can cause secondary scarring or permanent alopecia. Possible causes are congenital defects, trauma, inflammatory conditions, infections, and neoplasms (rarely drugs). Associated signs and symptoms and other diagnostic procedures such as histopathology may aid in the diagnosis. Detection of the underlying disorder may be difficult in end-stage lesions. Treatment is specific for active conditions. Surgery and hair transplantation are options for localized scars.
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Abstract
Giant cell arteritis is a systemic disease that continues to be a sight-threatening medical emergency requiring prompt recognition and treatment in order to avoid devastating ophthalmic consequences. Although there have been advances in the genetic and immunologic understanding of the underlying pathogenesis of the disease, the exact etiology of the condition, to date, remains unclear. Visual manifestations of giant cell arteritis are the common mode of presentation, making the ophthalmologist critically responsible for early diagnosis and treatment. Although temporal artery biopsy remains the only confirmatory procedure, newer laboratory investigations and blood flow studies with fundus fluorescein angiography have aided in the diagnosis of temporal giant cell arteritis. Maintenance of a high index of clinical suspicion is essential to institute prompt adequate treatment, especially in atypical cases. Corticosteroids remain the mainstay of treatment of giant cell arteritis. Recently, immunosuppressive agents as secondary steroid-sparing drugs have been used, particularly in some steroid-resistant cases. A wider recognition of the disease will minimize the prevalence of irreversible visual loss among patients with giant cell arteritis.
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14
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Re: Giant Leg Ulcer in Wegenerʼs Granulomatosis Treated with Plasmapheresis and Skin Graft. Dermatol Surg 2004. [DOI: 10.1097/00042728-200408000-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Smitz S, Van Damme H. Extensive scalp necrosis and subepicranial abscess in a patient with giant cell arteritis. J Am Geriatr Soc 2003; 52:165-6. [PMID: 14687340 DOI: 10.1111/j.1532-5415.2004.52030_5.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Giant cell arteritis is a systemic disease of the elderly which affects large and medium-sized arteries and which may occur in association with polymyalgia rheumatica. Scalp necrosis is a rare cutaneous complication of giant cell arteritis, and this dermatological presentation is not commonly reported.1-4 Giant cell arteritis should be considered in all elderly patients with scalp ulceration. We describe two patients who presented in this manner.
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Affiliation(s)
- F A Campbell
- Department of Dermatology, Glasgow Royal Infirmary, Glasgow, UK.
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Matsushima M, Yamanaka K, Mori H, Murakami T, Hakamada A, Isoda KI, Mizutani H. Bilateral scalp necrosis with giant cell arteritis. J Dermatol 2003; 30:210-5. [PMID: 12692357 DOI: 10.1111/j.1346-8138.2003.tb00373.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2002] [Accepted: 01/21/2003] [Indexed: 11/29/2022]
Abstract
We present a patient with bilateral scalp necrosis caused by giant cell arteritis (temporal arteritis). A 67-year-old woman, who had been treated with 5 mg of oral prednisolone every other day for polymyalgia rheumatica, developed painful egg-sized regions of necrosis on both of her temples. Doppler pulsemetory revealed bilateral obstruction of the temporal arteries. Biopsy revealed ischemic necrosis of the skin and necrotic angiitis of the temporal arteries with giant cell infiltration. Bilateral stenosis of the internal carotid arteries and moderate retinal bleeding were revealed by angiography. Daily administration of prednisolone (20 mg/day) with intravenous and topical limaprost alphadex markedly improved her condition. The ulcers reepithelized without surgical treatment. There are few reports of bilateral scalp necrosis. Rapid and complete obstruction of the temporal artery may result in this condition. Simultaneous development of two ulcerative lesions in the ventro-parietal cranial regions is thought to correspond to systemic arterial involvement, including involvement of the internal carotid arteries.
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Affiliation(s)
- Midori Matsushima
- Department of Dermatology, Mie University, Faculty of Medicine, Tsu, Japan
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Paletta CE, Dehghan K, Campbell TC, Roth FS. Scalp necrosis: an unusual presentation of giant cell arteritis. Plast Reconstr Surg 2002; 109:1474-5. [PMID: 11965023 DOI: 10.1097/00006534-200204010-00059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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