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Li F, Zhao J, Duan H, Zhang H, Zhang L, Zhao L, Wen Y, Gu X. Pyoderma gangrenosum complicated with hematological malignancies: Two case reports. Medicine (Baltimore) 2024; 103:e37159. [PMID: 38457569 PMCID: PMC10919523 DOI: 10.1097/md.0000000000037159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/12/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic skin disease. The diagnosis of PG is mainly based on clinical manifestations. Therefore, the clinical features of PG are important for confirming the diagnosis of this disease. Herein, the clinical data of 2 young males with PG complicated with hematological malignancies were reported, and the literature were reviewed. CASE PRESENTATION The first case was a 22-year-old male who was admitted due to a systemic rash, headache, and fever. Physical examination showed black scabs on the skins of the extremities, trunk, scalp, and face. Biopsy of the skin lesion showed epidermal edema, spongy formation, neutrophil infiltration, acute and chronic inflammatory cell infiltration in the dermis, showing purulent inflammation with epidermal erosion. The bone marrow biopsy showed obviously active proliferation of nucleated cells, granulocytes at various stages, abnormal morphological neutrophils, and occasionally observed young red blood cells. The diagnosis of PG and chronic myelomonocytic leukemia (CMML-0) was made. The second case was a 28-year-old male who presented a swollen, painful right calf following injury and then developed ulcers on skin and soft tissues. Bone marrow biopsy showed obviously active nucleated cell proliferation, suggesting a myeloid tumor. He was also diagnosed with PG and hematological malignancies. They both received hormone and antiinfection therapy. After treatment, their body temperature, infection, and skin lesions were improved. However, both of them were readmitted and had a poor prognosis. CONCLUSIONS PG may be associated with hematological malignancies. For patients with typical skin lesions and obvious abnormal blood routines, it is necessary to investigate the possibility of PG with hematological malignancies.
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Affiliation(s)
- Fen Li
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Jie Zhao
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Huanan Duan
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Haixi Zhang
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Lin Zhang
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Liangyun Zhao
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Yan Wen
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Xuezhong Gu
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
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2
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A S, Fernandes MS, Bhat RM, Dandakeri S, Jayaraman J. Brocq's geometric phagedena over penis with keloidal scars. Int J STD AIDS 2022; 33:1148-1151. [PMID: 36220799 DOI: 10.1177/09564624221127837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pyoderma gangrenosum is a rare neutrophilic inflammatory skin disorder commonly seen over lower limbs. Involvement of penile area is rare. We report this rare case of occurrence of ulcerative type of pyoderma gangrenosum over penis with pustular type elsewhere over the body, healing with keloids in an immunocompetent young man with no systemic associations.
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Affiliation(s)
- Shilpa A
- Department of Dermatology, 29216Fr. Muller Medical College, Mangalore, India
| | | | - Ramesh M Bhat
- Department of Dermatology, 29216Fr. Muller Medical College, Mangalore, India
| | - Sukumar Dandakeri
- Department of Dermatology, 29216Fr. Muller Medical College, Mangalore, India
| | - Jyothi Jayaraman
- Department of Dermatology, 29216Fr. Muller Medical College, Mangalore, India
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3
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Nazir A, Zafar A. Management of Idiopathic Pyoderma Gangrenosum With Azathioprine As the Primary Adjunct in an Asian Man: A Case Report. Cureus 2022; 14:e25177. [PMID: 35746991 PMCID: PMC9209338 DOI: 10.7759/cureus.25177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/19/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a very rare, non-infectious, progressive inflammatory condition falling under the umbrella of neutrophilic dermatoses. It is an ulcerative condition with a wide variety of cutaneous manifestations and multiple clinical variants (classic ulcerative, pustular, bullous, and superficial granulomatous). Additionally, owing to similar patterns of mucocutaneous ulceration, it has certain overlaps with other neutrophilic diseases frequently observed in clinical practice. Pyoderma gangrenosum may occur in association with systemic conditions such as inflammatory bowel disease, hematological malignancies, or as a part of an inherited inflammatory syndrome. However, in rare cases, it may have an idiopathic origin as well. With no specific standardized diagnostic and treatment protocols in place, the management of pyoderma gangrenosum is primarily guided by pre-existing literature or is tailored according to the individual’s disease pattern, type, and associations. Currently, the pathophysiology of pyoderma gangrenosum remains elusive at best. All the aforementioned reasons contribute significantly to PG being labeled as a "diagnostic dilemma" or more commonly as a "diagnosis of exclusion" with frequent incidences of delayed diagnosis or misdiagnosis resulting in catastrophic delays in management. A 35-year-old Asian male presented with bilateral painful, violaceous ulcers with undermined edges involving the shins for the past three months. Routine investigations carried out were indicative of an underlying infection owing to a raised leucocyte count. Discharge from the lesion, however, showed no evidence of microbial growth. The ulcer progressively increased in size, despite optimal wound care and empirical treatment. Skin biopsy demonstrated central necrosis and ulceration of the epidermis and dermis with neutrophilic infiltrates. Phenomenon of pathergy was demonstrated following the formation of a new ulcer at the site of intravenous cannulation during hospital admission. Additionally, aggravation of pre-existing ulcers following their debridement was also indicative of a positive pathergy test. Ultimately, the diagnosis of pyoderma gangrenosum was made upon the successful exclusion of all the other differential diagnoses. Presence of an associated systemic disease could not be appreciated, leading to it being labeled as a case of idiopathic pyoderma gangrenosum. Supportive treatment with non-adhesive, moist dressings was initiated along with topical tacrolimus (0.1%) application. Treatment modalities utilized were steroids and azathioprine in divided doses owing to contraindications to the traditional option of cyclosporine. The patient showed a rapid response to steroids and azathioprine. The ulcers healed with characteristic cribriform scarring within three months of initiation of treatment.
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4
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Adaskevich UP. Pyoderma gangrenosum: current state of the problem. CONSILIUM MEDICUM 2021. [DOI: 10.26442/20751753.2021.8.201054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that presents with rapidly developing, painful skin ulcers hallmarked by undermined borders and peripheral erythema. Epidemiological studies indicate that the average age of PG onset is in the mid-40s, with an incidence of 310 cases per million person-years. PG is often associated with a variety of other immune-mediated diseases, most commonly inflammatory bowel disease and rheumatoid arthritis. The cause of PG is not well understood, but PG is generally considered an autoinflammatory disorder. Studies have focused on the role of T cells, especially at the wound margin; these cells may support the destructive autoinflammatory response by the innate immune system. PG is difficult to diagnose as several differential diagnoses are possible; in addition to clinical examination, laboratory tests of biopsied wound tissue are required for an accurate diagnosis, and new validated diagnostic criteria will facilitate the process. Treatment of PG typically starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) to reduce inflammation followed by the addition of more slowly acting immunosuppressive drugs with superior adverse event profiles, including biologics (in particular, anti-tumour necrosis factor agents).
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Alhumam A. Rare Case of Pyoderma Gangrenosum in the Setting of PAPA Syndrome in a 12-Year-Old Child. INT J LOW EXTR WOUND 2021:15347346211036023. [PMID: 34382449 DOI: 10.1177/15347346211036023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report on a 12-year-old boy who presented with an intermittently painful wound present for months without any tendency to heal after a slackline accident two years ago. A biopsy of the ulcer margin revealed epithelial hyperplasia, marked fibrosis, and vascular proliferation without evidence of vasculitis. Pretibial findings on the right side were a 3.8 × 3.1 cm fibrin-covered, flat ulcer with slight reddening of the surrounding area. Other findings were unremarkable with hypermobility of the wrists and finger joints. Local therapy with a foam dressing, topical steroid in the wound margin, and class II compression stockings showed no effect. The pediatric rheumatologist evaluated the ulcer with a camptodactyly of digit 5, subluxation of the wrists on both sides, and symmetric ulnar deviation. Elevated S100 as an isolated autoimmune phenomenon or concomitant with systemic autoimmune disease or autoinflammation (eg, Pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome) was also observed. The therapy with oral steroids, initially 30 mg/day and gradual reduction in the course, only achieved a tissue bridge's formation with the same size extension of the ulcer. Unfortunately, the patient spontaneously developed a second ulcer on the left lateral malleolus, which is why the therapy was changed to dapsone 50 mg/day and tacrolimus in the wound margin after nine weeks. In the absence of success, further treatment with ciclosporin or tumor necrosis factor-alpha antibody therapy is planned in interdisciplinary cooperation.
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Affiliation(s)
- Aminah Alhumam
- Institute for Health Services Research in Dermatology and Nursing (IVDP), 37734University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany.,Department of Dermatology, College of Medicine King Faisal University, Al-Ahsa, Saudi Arabia
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6
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Multifocal Pyoderma Gangrenosum with an Underlying Hemophagocytic Lymphohistiocytosis: Case Report and the Review of the Literature. Dermatol Ther (Heidelb) 2021; 11:1217-1237. [PMID: 34176093 PMCID: PMC8322207 DOI: 10.1007/s13555-021-00571-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Indexed: 11/11/2022] Open
Abstract
Pyoderma gangrenosum (PG) is an uncommon, serious, ulcerating skin disease of uncertain etiology. It manifests as a noninfectious, progressive necrosis of the skin characterized by sterile neutrophilic infiltrates. It seems to be a disorder of the immune system. PG is associated with certain underlying conditions in at least 50% of cases. Therefore, it is important to look carefully for comorbidities in every patient with PG and treat them adequately to improve the prognosis. Here, we demonstrate a 35-year-old man diagnosed with multifocal PG and hemophagocytic lymphohistiocytosis (HLH) with fatal outcome, despite combined, long-term, intensive dermatological and hematological treatment with high doses of steroids, cyclosporin, intravenous immunoglobulins (IVIG), HLH-2004 protocol with intravenously administered etoposide, and anakinra. This case is presented owing to the extremely rare coexistence of PG and HLH and the related diagnostic and therapeutic difficulties. It is also worth underlying that the diagnosis of HLH should perhaps be considered in the presence of a high percentage of double-negative T lymphocytes (DNTs) in flow cytometry, after excluding the diagnosis of lymphoma and leukemia. In this article we have also performed and present the critical literature review of local and systemic options in the management of PG lesions based on a detailed search of the PubMed database.
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7
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Inflammatory arthritis-associated pyoderma gangrenosum: a systematic review. Clin Rheumatol 2021; 40:3963-3969. [PMID: 34002351 DOI: 10.1007/s10067-021-05768-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION/OBJECTIVES Pyoderma gangrenosum (PG) is a rare, rapidly progressive neutrophilic dermatosis commonly associated with systemic inflammatory diseases. We aimed to characterize the association of PG and inflammatory arthritis, as little is known outside of case reports and small cohort studies. METHOD We performed a systematic review in PubMed, EMBASE, and Scopus from inception to present using the terms arthritis and pyoderma gangrenosum. Patient demographics, clinical presentation, and treatment outcomes were recorded. Descriptive statistics and stratified analysis were used to compare factors of interest by type of arthritis. RESULTS A total of 1399 articles were screened, and 129 patients with inflammatory arthritis and PG were included in the review. The most common types of arthritis were rheumatoid arthritis (RA) (50.4%), inflammatory bowel disease (IBD)-associated arthritis (10.9%), and psoriatic arthritis (8.5%). In the vast majority of cases, joint symptoms preceded PG, by a median of 10 years (inter-quartile range [IQR] 5-16). Corticosteroid monotherapy and biologic therapies, used alone or in combination, resulted in improvement or complete resolution of ulcers 71.4% and 67.3% of the time, respectively. Within the latter, infliximab, adalimumab, and anakinra were most successful in inducing remission overall. RA and non-RA did not differ significantly in treatment success or healing time. CONCLUSIONS This study shows that PG is frequently preceded by inflammatory arthritis, most commonly RA. Clinicians used a wide variety of treatment regimens with variable outcomes. While larger studies are needed to standardize the treatment of inflammatory arthritis-associated PG, this study suggests that in addition to systemic corticosteroids, biologic medications can be effective treatment options for these patients. KEY POINTS • Inflammatory arthritis, most commonly rheumatoid arthritis, often precedes rather than follows pyoderma gangrenosum. • Other forms of arthritis associated with PG included IBD-associated arthritis and psoriatic arthritis. • Biologic therapies, such as infliximab, adalimumab, and anakinra, were largely successful in treating arthritis-associated pyoderma gangrenosum and may play an important role in corticosteroid-sparing therapy or in a maintenance regimen for this subset of patients. • The type of inflammatory arthritis associated with pyoderma gangrenosum may not be a helpful treatment guide as it was not significantly associated with treatment outcomes or healing time.
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8
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Hegde S, Saep M, Saldanha P, Shenoy M. Lesions of pyoderma gangrenosum mimicking sweet's syndrome; A diagnostic dilemma. Indian Dermatol Online J 2021; 12:920-922. [PMID: 34934736 PMCID: PMC8653741 DOI: 10.4103/idoj.idoj_815_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 04/11/2021] [Accepted: 04/23/2021] [Indexed: 11/04/2022] Open
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9
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Ghaoui N, Hanna E, Abbas O, Kibbi AG, Kurban M. Update on the use of dapsone in dermatology. Int J Dermatol 2020; 59:787-795. [PMID: 31909480 DOI: 10.1111/ijd.14761] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 10/22/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
Dapsone (4,4'-diaminodiphenylsulfone) is the only remaining sulfone used in anthropoid therapeutics and is commercially available as an oral formulation, an inhaled preparation, and a 5% or 7.5% cream. Dapsone has antimicrobial effects stemming from its sulfonamide-like ability to inhibit the synthesis of dihydrofolic acid. It also has anti-inflammatory properties such as inhibiting the production of reactive oxygen species, reducing the effect of eosinophil peroxidase on mast cells and down-regulating neutrophil-mediated inflammatory responses. This allows for its use in the treatment of a wide variety of inflammatory and infectious skin conditions. Currently in dermatology, the US Food and Drug Administration (FDA)-approved indications for dapsone are leprosy, dermatitis herpetiformis, and acne vulgaris. However, it proved itself as an adjunctive therapeutic agent to many other skin disorders. In this review, we discuss existing evidence on the mechanisms of action of dapsone, its FDA-approved indications, off-label uses, and side effects.
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Affiliation(s)
- Nohra Ghaoui
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Edith Hanna
- Department of Dermatology, University of Toronto, Toronto, ON, Canada
| | - Ossama Abbas
- Department of Dermatology, American University of Beirut, Beirut, Lebanon
| | - Abdul-Ghani Kibbi
- Department of Dermatology, American University of Beirut, Beirut, Lebanon
| | - Mazen Kurban
- Department of Dermatology, American University of Beirut, Beirut, Lebanon.,Department of Biochemistry and Molecular Genetics, American University of Beirut, Beirut, Lebanon
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10
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Abstract
Pyoderma Gangrenosum (PG) is a rare neutrophilic dermatosis with multiple different clinical presentations and associated comorbidities. PG has historically been a challenging disorder to diagnose, leading to the development of new diagnostic criteria rather than the traditional approach of a diagnosis of exclusion. The pathophysiology is thought to involve both innate and adaptive immune system dysregulation, neutrophilic abnormalities, environmental, and genetic factors. As of today, no gold standard therapy exists for the treatment of PG, and the literature is restricted to mainly case reports, case series, and 2 small randomized clinical trials. Topical, systemic, and biologic therapy, as well as adequate analgesia and proper wound care all play a role in the management of PG. Recent studies have identified additional cytokines and signalling cascades thought to be involved in the pathogenesis of PG, ultimately leading to the development of new targeted therapies. This review will focus on recent advances in the pathophysiology, clinical presentation and associated comorbidities, diagnosis, and management of PG.
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Affiliation(s)
- Josh Fletcher
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
| | - Raed Alhusayen
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, M4N 3M5, Canada
| | - Afsaneh Alavi
- Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Dermatology, Department of Medicine, Women's College Hospital, Toronto, Ontario, M5S 1B2, Canada
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11
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Montagnon CM, Fracica EA, Patel AA, Camilleri MJ, Murad MH, Dingli D, Wetter DA, Tolkachjov SN. Pyoderma gangrenosum in hematologic malignancies: A systematic review. J Am Acad Dermatol 2019; 82:1346-1359. [PMID: 31560977 DOI: 10.1016/j.jaad.2019.09.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/15/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a devastating neutrophilic dermatosis that may be associated with trauma or systemic diseases. The associations, characteristics, and temporal relationship of PG with hematologic malignancies are not well understood. OBJECTIVE We performed a systematic review of PG associated with hematologic malignancies using data from case reports, case series, and retrospective studies. METHODS We searched MEDLINE, EMBASE, Scopus, and Web of Science from each database's inception to December 12, 2018. Two reviewers independently selected studies and extracted data. RESULTS Two hundred seventy-nine publications met the inclusion criteria (340 cases). Myelodysplastic syndrome (MDS) was the most commonly reported hematologic malignancy associated with PG, followed by monoclonal gammopathy of undetermined significance and acute myeloid leukemia. The mean age of patients was 56.5 years, with males being more common. There was a predominance of the ulcerative PG subtype and multifocal distributions across all hematologic malignancies. The majority of MDS cases preceded PG, which was reversed for MGUS. LIMITATIONS The data were limited by reporting bias because PG subtypes rely on the rendered diagnosis reported. In addition, the classification for hematologic malignancies has evolved since 1978. CONCLUSION Patients with PG should be evaluated for hematologic malignancies, with MDS being the most common.
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Affiliation(s)
| | | | - Archna A Patel
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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12
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Abstract
RATIONALE Pyoderma gangrenosum (PG) is a rare skin disease. Pregnancy is a unique physiological condition. Here we report a rare case of PG after cesarean section. PATIENT CONCERNS A 32-year-old female presented with wound breakdown 1 day after cesarean section, with progression to a skin ulcer and no response to antibiotic therapy. DIAGNOSES We experienced a case of PG after cesarean section. This was initially misdiagnosed as a wound infection, with fever and wound redness as clinical manifestations. INTERVENTIONS The patient was initially treated with antibiotics, followed by glucocorticoid and human immunoglobulin therapy. Wound debridement, vacuum sealing negative pressure drainage, skin grafting, and hyperbaric oxygen therapy were also performed. OUTCOMES The wound healed without adverse reactions. LESSONS When a surgical incision infection does not respond to antibiotic treatment and the culture is negative, PG should be considered.
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13
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Partridge ACR, Bai JW, Rosen CF, Walsh SR, Gulliver WP, Fleming P. Effectiveness of systemic treatments for pyoderma gangrenosum: a systematic review of observational studies and clinical trials. Br J Dermatol 2018; 179:290-295. [PMID: 29478243 DOI: 10.1111/bjd.16485] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a neutrophilic dermatosis with substantial morbidity. There is no consensus on gold-standard treatments. OBJECTIVES To review the effectiveness of systemic therapy for PG. METHODS We searched six databases for 24 systemic therapies for PG. Primary outcomes were complete healing and clinical improvement; secondary outcomes were time to healing and adverse effects. RESULTS We found 3326 citations and 375 articles underwent full-text review; 41 studies met the inclusion criteria. There were 704 participants in 26 retrospective cohort studies, three prospective cohort studies, seven case series, one case-control study, two open-label trials and two randomized controlled trials (RCTs). Systemic corticosteroids were the most studied (32 studies), followed by ciclosporin (21 studies), biologics (16 studies) and oral dapsone (11 studies). One RCT (STOP-GAP, n = 121) showed that prednisolone and ciclosporin were similar: 15-20% of patients showed complete healing at 6 weeks and 47% at 6 months. Another RCT (n = 30) found that infliximab was superior to placebo at 2 weeks (46% vs. 6% response), with a 21% complete healing rate at 6 weeks. Two uncontrolled trials showed 60% and 37% healing within 4 months for canakinumab and infliximab, respectively; other data suggest that patients with concurrent inflammatory bowel disease may benefit from biologics. The remaining studies were poor quality and had small sample sizes but supported the use of corticosteroids, ciclosporin and biologics. CONCLUSIONS Systemic corticosteroids, ciclosporin, infliximab and canakinumab had the most evidence in treating PG. However, current literature is limited to small and lower-quality studies with substantial heterogeneity.
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Affiliation(s)
- A C R Partridge
- MD Program, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - J W Bai
- MD Program, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - C F Rosen
- Division of Dermatology, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - S R Walsh
- Division of Dermatology, University of Toronto, Toronto, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - W P Gulliver
- Department of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - P Fleming
- Division of Dermatology, University of Toronto, Toronto, Canada
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14
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Bullous Pyoderma Gangrenosum With Subungual Involvement Associated With Ulcerative Colitis. Am J Dermatopathol 2016; 39:476-478. [PMID: 27893467 DOI: 10.1097/dad.0000000000000801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory and ulcerative skin disease of unknown etiology characterized by neutrophilic infiltration of the dermis, mainly affecting the lower extremities. Bullous PG is a rare variant of this disease, usually associated with hematologic disorders. Here, we report a case of pathergy-positive bullous PG with subungual involvement associated with ulcerative colitis.
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15
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Pourmorteza M, Tawadros F, Bader G, Al-Tarawneh M, Cook E, Shams W, Young M. Successful Treatment of Pyoderma Gangrenosum with Cryoglobulinemia and Hepatitis C. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:434-8. [PMID: 27345376 PMCID: PMC4924887 DOI: 10.12659/ajcr.898611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patient: Male, 68 Final Diagnosis: Pyoderma gangrenosum Symptoms: Worsening lower extremity wound Medication: — Clinical Procedure: — Specialty: Infectious Diseases
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Affiliation(s)
- Mohsen Pourmorteza
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Fady Tawadros
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Gilbert Bader
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Mohamed Al-Tarawneh
- Department of Infectious Disease, East Tennessee State University, Johnson City, TN, USA
| | - Emilie Cook
- Department of Pathology, East Tennessee State University, Johnson City, TN, USA
| | - Wael Shams
- Department of Infectious Disease, East Tennessee State University, Johnson City, TN, USA
| | - Mark Young
- Department of Gastroenterology, East Tennessee State University, Johnson City, TN, USA
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16
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AlDossary SJ, AlFawaz TS, AlMutairi AK. Pyoderma gangrenosum with splenic involvement. Int J Pediatr Adolesc Med 2016; 3:78-80. [PMID: 30805472 PMCID: PMC6372426 DOI: 10.1016/j.ijpam.2016.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/29/2016] [Accepted: 03/24/2016] [Indexed: 11/25/2022]
Abstract
Pyoderma gangrenosum (PG) is a non-infectious disease characterized by necrotizing, ulcerative, and painful skin. The incidence of PG is approximately 3-10 cases per million people per year. Pyoderma gangrenosum is rarely observed in children, which accounts for less than 4%, but it primarily affects adults between the ages of 25 and 54 years old without gender preference. Here, we present a case report of a 16-month-old toddler diagnosed with pyoderma gangrenous with splenic involvement. The young age of the patient and extracutaneous manifestation are of high interest.
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Affiliation(s)
- Shaikha Jameel AlDossary
- Dammam University, Department of Pediatrics, King Fahd University Hospital, Khobar, Saudi Arabia.,King Fahad Medical City, Riyadh, Saudi Arabia
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Freg GNI, Shah V, Nagral A, Jhaveri A. Pyoderma Gangrenosum-A New Manifestation of Wilson Disease? J Clin Exp Hepatol 2016; 6:62-4. [PMID: 27194899 PMCID: PMC4862012 DOI: 10.1016/j.jceh.2015.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/27/2015] [Indexed: 12/12/2022] Open
Abstract
Seventeen year old girl, a known case of Wilson disease presented to us with a non-healing skin ulcer followed by appearance of jaundice, ascites and progressive fatigue of 1 month duration. She was diagnosed to have Wilson disease 5 years back and had been well controlled on d-penicillamine. On enquiry, she was found to be noncompliant with her medication in the preceding 6 months. On examination, she had severe pallor, icterus with moderate ascites and oedema feet. Investigations revealed severe haemolytic anemia and deranged liver function. The lesion was diagnosed to be pyoderma gangrenosum on skin biopsy. The appearance of a cutaneous lesion followed by deterioration in the liver disease and hemolysis suggested uncontrolled Wilson disease as the triggering factor. Chelation therapy improved her haemoglobin and liver function as well as led to healing of the ulcer. We describe pyoderma gangrenosum as a new manifestation of Wilson disease.
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Affiliation(s)
| | - Venisha Shah
- Department of Dermatology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India,Address for correspondence: Dr. Aabha Nagral, 7, Sneha Sagar, Prabhanagar, Prabhadevi, Mumbai 400 025, India. Tel.: +91 9820156834.7, Sneha Sagar, Prabhanagar, PrabhadeviMumbai400 025India
| | - Ajay Jhaveri
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
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Shahmoradi Z, Mokhtari F, Pourazizi M, Abtahi-Naeini B, Saffaei A. Extensive abdominal wall and genital pyoderma gangrenosum: combination therapy in unusual presentations. J Cutan Aesthet Surg 2015; 7:238-40. [PMID: 25722609 PMCID: PMC4338474 DOI: 10.4103/0974-2077.150791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Zabihollah Shahmoradi
- Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan. E-mail:
| | - Fatemeh Mokhtari
- Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan. E-mail:
| | - Mohsen Pourazizi
- Department of Dermatology, Semnan University of Medical Sciences, Semnan
| | - Bahareh Abtahi-Naeini
- Department of Dermatology, Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan. E-mail:
| | - Ali Saffaei
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy, Isfahan University of Medical Sciences, Isfahan
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DeFilippis E, Feldman S, Huang W. The genetics of pyoderma gangrenosum and implications for treatment: a systematic review. Br J Dermatol 2015; 172:1487-1497. [DOI: 10.1111/bjd.13493] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2014] [Indexed: 12/22/2022]
Affiliation(s)
- E.M. DeFilippis
- Center for Dermatology Research; Department of Dermatology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
| | - S.R. Feldman
- Center for Dermatology Research; Department of Dermatology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
- Department of Pathology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
- Department of Public Health Sciences; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
| | - W.W. Huang
- Center for Dermatology Research; Department of Dermatology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
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Abstract
Background: Pyoderma ga ngrenosum (PG) is a rare, inflammatory, destructive neutrophilic dermatosis, which mimics other ulcerative conditions. Materials and Methods: In a retrospective study based on patients diagnosed with PG over a 3-year period (2010–2013), we evaluated demographics, anatomical sites, number of lesions, subtypes, histopathology, associated conditions, treatment regimens, healing time, and recurrence. Results: Of our five patients, there were three males and two females, age ranging between 19 and 58 years (mean age 38 years). Four had single lesions localized to the lower limbs while one had multiple lesions (more than five) over bilateral hands and legs. Ulcerative subtype was observed in all the patients. One exhibited pathergy. Skin biopsies were done in four patients, revealing dense neutrophilic infiltrates in three cases and leukocytoclastic vasculitis in one. Associated systemic diseases were observed in all patients, four having inflammatory bowel disease and one having both systemic lupus erythematosus and anti-phospholipid syndrome. The patients were all treated with systemic corticosteroids either alone or in combination with immunosuppressants (e.g., azathioprine, mycophenolate mofetil, tacrolimus), and wound dressing. Split-thickness skin graft was done in one patient. Complete healing was achieved in all patients, ranging from one to 3 months after diagnosis. No recurrence was reported. Conclusions: Systemic corticosteroids, either alone or in combination with steroid-sparing agents are the mainstay of treatment. Should family physicians encounter a rapidly progressing ulcer that has poor response to usual wound management, timely referral to dermatology should be made.
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Affiliation(s)
- Daniel Zunsheng Tay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228
| | - Ki-Wei Tan
- Department of Dermatology, Changi General Hospital Singapore, Singapore 529889
| | - Yong-Kwang Tay
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228 ; Department of Dermatology, Changi General Hospital Singapore, Singapore 529889
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Hau E, Vignon Pennamen MD, Battistella M, Saussine A, Bergis M, Cavelier-Balloy B, Janier M, Cordoliani F, Bagot M, Rybojad M, Bouaziz JD. Neutrophilic skin lesions in autoimmune connective tissue diseases: nine cases and a literature review. Medicine (Baltimore) 2014; 93:e346. [PMID: 25546688 PMCID: PMC4602621 DOI: 10.1097/md.0000000000000346] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The pathophysiology of neutrophilic dermatoses (NDs) and autoimmune connective tissue diseases (AICTDs) is incompletely understood. The association between NDs and AICTDs is rare; recently, however, a distinctive subset of cutaneous lupus erythematosus (LE, the prototypical AICTD) with neutrophilic histological features has been proposed to be included in the spectrum of lupus. The aim of our study was to test the validity of such a classification. We conducted a monocentric retrospective study of 7028 AICTDs patients. Among these 7028 patients, a skin biopsy was performed in 932 cases with mainly neutrophilic infiltrate on histology in 9 cases. Combining our 9 cases and an exhaustive literature review, pyoderma gangrenosum, Sweet syndrome (n = 49), Sweet-like ND (n = 13), neutrophilic urticarial dermatosis (n = 6), palisaded neutrophilic granulomatous dermatitis (n = 12), and histiocytoid neutrophilic dermatitis (n = 2) were likely to occur both in AICTDs and autoinflammatory diseases. Other NDs were specifically encountered in AICTDs: bullous LE (n = 71), amicrobial pustulosis of the folds (n = 28), autoimmunity-related ND (n = 24), ND resembling erythema gyratum repens (n = 1), and neutrophilic annular erythema (n = 1). The improvement of AICTDS neutrophilic lesions under neutrophil targeting therapy suggests possible common physiopathological pathways between NDs and AICTDs.
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Affiliation(s)
- Estelle Hau
- From the Dermatology Department (EH, AS, MJ, FC, MarB, MR, JDB) and Pathology Department (MDVP, MaxB, BCB), Paris Diderot University, Sorbonne Paris Cité, AP-HP, Saint Louis Hospital, Paris, France
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Kapila S, Reid I, Dixit S, Fulcher G, March L, Jackson C, Cooper A. Use of dermal injection of activated protein C for treatment of large chronic wounds secondary to pyoderma gangrenosum. Clin Exp Dermatol 2014; 39:785-90. [PMID: 25155809 DOI: 10.1111/ced.12361] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a systemic disease that presents with cutaneous necrotizing ulceration, producing deep necrotic ulcers, usually with a raised, undermined, violaceous border. Treatment typically involves high dose immunosuppressive drugs, but more recently anti-tumour necrosis factor and monoclonal antibodies have been used. Activated protein C (APC) stimulates wound healing in patients with treatment-refractory skin ulcers, possibly by stimulating angiogenesis and re-epithelialization, and preventing inflammation. AIM To investigate whether APC may be beneficial as a treatment for ulcers related to cutaneous PG. METHODS Two patients were recruited with a clinical history and physical and histopathological evidence of acute PG. A total of 400 μg (1.0 mL) of APC was injected subcutaneously into the dermal edge of necrotic PG ulcers weekly for a total treatment period of 6 weeks. Photographs were taken, and clinical progress, ulcer size and pain score were monitored during this period and after the cessation of treatment, at weeks 8 and 12. RESULTS Over the 12 weeks of the trial, APC led to a reduction in wound size from 3.8 cm(2) to 0.8 cm(2) in patient 1 (78.9% decrease) and from 41 cm(2) to 16 cm(2) in patient 2 (70.0% decrease, respectively), and a reduction in pain scores from 10 to 0 (100% decrease) in both patients. CONCLUSION Although this study has limited because of its small sample size and lack of a true placebo group, it does indicate that APC has potential as a therapeutic option for patients with chronic skin ulcers from PG.
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Affiliation(s)
- S Kapila
- Department of Dermatology, Kolling Institute of Medical Research, University of Sydney Royal North Shore Hospital, St Leonards, NSW, Australia
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Bhat RM, Saldanha CS, Dandakeri S, Kambil SM. Genital pyoderma gangrenosum. Indian J Sex Transm Dis AIDS 2014; 35:171-2. [PMID: 26396461 DOI: 10.4103/0253-7184.142426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ramesh M Bhat
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
| | - Celia Soni Saldanha
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
| | - Sukumar Dandakeri
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
| | - Srinath M Kambil
- Department of Dermatology, Venereology and Leprosy, Father Muller Medical College, Kankanady, Mangalore, Karnataka, India
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Carneiro FRO, Santos MALD, Sousa BAD, Nascimento CDSSD, Amin GA, Moutinho ATM. Pyoderma gangrenosum in a newborn--case report. An Bras Dermatol 2014; 88:173-5. [PMID: 24346911 PMCID: PMC3876005 DOI: 10.1590/abd1806-4841.20132601] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 03/20/2013] [Indexed: 11/22/2022] Open
Abstract
Pyoderma gangrenosum is a rare, inflammatory, chronic and recurrent disease of
unknown etiology, characterized by noninfectious, necrotizing and painful cutaneous
ulcers. Usually it affects adults aged between 25 and 54 years old and rarely
children (less than 4%), in which it mainly affects the head, face, buttocks, genital
and perianal region. The disease presents a quick response to systemic
corticosteroids. We report a case of a newborn with hemorrhagic and necrotic ulcers,
distributed in the abdomen, buttocks and genital region with rapid and effective
response to oral prednisone.
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Affiliation(s)
- S. Ratnagobal
- School of Medicine, Faculty of Health Science, University of Tasmania, Australia
| | - S. Sinha
- School of Medicine, Faculty of Health Science, University of Tasmania, Australia
- Wound Clinic, Royal Hobart Hospital, Tasmania, Australia
- University of Notre Dame Australia, School of Medicine Sydney, Australia
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Ahronowitz I, Harp J, Shinkai K. Etiology and management of pyoderma gangrenosum: a comprehensive review. Am J Clin Dermatol 2012; 13:191-211. [PMID: 22356259 DOI: 10.2165/11595240-000000000-00000] [Citation(s) in RCA: 265] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Iris Ahronowitz
- Department of Dermatology, University of California, San Francisco, 94115, USA
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Abstract
Pyoderma gangrenosum (PG) is an uncommon, distinctive cutaneous ulceration which is usually idiopathic, but may be associated with many systemic disorders. The etipathogenesis of of PG is still not well understood. Clinically it is classified into ulcerative, pustular, bullous and vegetative types. A few atypical and rare variants have also been described. The diagnosis mainly depends on the recognition of evolving clinical features as investigations only assist in the diagnosis. In view of this a few criteria have been proposed for the diagnosis of PG. the treatment mainly consists of corticosteroids and immunosuppressive agents. A few new agents have also been tried in the management.
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Affiliation(s)
- Ramesh M. Bhat
- Department of Dermatology, Venereology and Leprosy, Fr Muller Medical College, Kankanady, Mangalore, India
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