Pyoderma gangrenosum in ulcerative colitis: considerations for an early diagnosis

Misdiagnosis of Pyoderma Gangrenosum Increases Medical Costs and Prolongs Hospital Stay: A Case Report

Pyoderma gangrenosum (PG) is a rare, immunological ulcerative, and necrotic inflammatory skin disease that can be easily misdiagnosed as cellulitis, abscess, diabetic foot ulcer, and other infectious diseases. Misdiagnosing PG leads to unnecessary surgical incision and debridement, which further exacerbates the lesion, ultimately leading to longer treatment periods and higher medical costs. Therefore, early and accurate diagnosis of PG is extremely important for its treatment. In particular, PG should be suspected in patients with inflammatory bowel disease.

All that is red is not cellulitis. Pyoderma gangrenosum

A 60-year-old patient presented with progressive worsening, non-healing ulcer on her shin with surrounding erythema following a minor trauma and was treated with several antibiotics for presumed cellulitis with no improvement. A skin biopsy eventually suggested pyoderma gangrenosum and a colonic biopsy showed an underlying ulcerative colitis.

Systematic review: IBD-associated pyoderma gangrenosum in the biologic era, the response to therapy

BACKGROUND

Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is uncommon and therapeutically challenging. Its treatment remains poorly characterised due to limited individual centre or practitioner experience. No large series are reported since 2003, yet IBD treatment has changed substantially.

AIM

To provide an up-to-date review of the published treatment efficacy of currently available therapies for IBD-related PG in the biologic era.

METHODS

Systematic review of cases published post-2003 since the broad availability of anti-tumour necrosis factor-alpha (TNFα) therapy. Cases which did not have coexistent IBD, were non-English language, of paediatric age or without data on response to therapy were excluded.

RESULTS

Sixty cases were identified; 55% female, 50% UC, 45% CD, 5% IBD-U. At PG diagnosis, 58% had active and only 15% inactive IBD, with 27% with IBD activity unspecified. Predominant sites were lower limb (48%) and peristomally (25%); 42% had multiple lesions. In 12%, trauma preceded PG. In 42%, new PG appeared whilst on IBD-specific therapy, whilst 28% were on no therapy and in 30%, IBD therapy was unspecified. Of patients on no therapy at PG onset (n = 17), 16 healed; seven with first- and eight with second-line therapy. In total, 34/60 patients received infliximab, four received adalimumab, two had both; with 33 (92%) responding to one or the other. There was no correlation of PG duration or size with healing times.

CONCLUSIONS

Pyoderma gangrenosum appears predominantly during active IBD and is seen equally in CD and UC. New PG may be a manifestation of recrudescent IBD or it follow trauma. Anti-TNFα therapy as a first-line agent for PG should be considered, as it appears to be highly effective.

Skin manifestations of inflammatory bowel disease

Ulcerative colitis (UC) is an inflammatory disorder of the colon that is associated with several extraintestinal manifestations in multiple organs. Several mucous membrane and skin disorders occur in patients with UC. These disorders are not unique to UC and often occur secondary to other causes or in the absence of an apparent cause. One or more such disorders may occur together in association with UC. Mucous membrane and skin disorders may antedate, occur with, or postdate the onset of UC. The dermatologist plays an important role in suspecting the diagnosis of UC that presents with associated mucous membrane or skin disorders. This review covers the clinical presentation, differential diagnosis, workup, and management of selected mucocutaneous manifestations in UC.