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Watanabe Y, Nobeyama Y, Asahina A. A case of postoperative pyoderma gangrenosum on penis caused by patient himself. J Dermatol 2024; 51:e154-e155. [PMID: 38009860 DOI: 10.1111/1346-8138.17047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/24/2023] [Accepted: 11/03/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Yoshinori Watanabe
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshimasa Nobeyama
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
| | - Akihiko Asahina
- Department of Dermatology, The Jikei University School of Medicine, Tokyo, Japan
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2
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Zaino ML, Schadt CR, Callen JP, Owen LG. Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup. Dermatol Clin 2024; 42:157-170. [PMID: 38423678 DOI: 10.1016/j.det.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.
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Affiliation(s)
- Mallory L Zaino
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA.
| | - Courtney R Schadt
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
| | - Jeffrey P Callen
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
| | - Lafayette G Owen
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
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3
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Kipers T, Tolkachjov SN. Postoperative and Peristomal Pyoderma Gangrenosum: Subtypes of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:171-181. [PMID: 38423679 DOI: 10.1016/j.det.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Postoperative pyoderma gangrenosum and peristomal pyoderma gangrenosum are 2 subtypes of pyoderma gangrenosum. The diagnosis is made as a clinicopathologic correlation when assessing a rapidly progressing ulcer with irregular and undermined borders following a surgical procedure, trauma, or the creation of a stoma. Familiarity with the associated risk factors and distinguishing features of these disorders can facilitate prompt recognition, proper diagnosis, and the initiation of treatment. Management usually involves the use of corticosteroids and steroid-sparing agents as immunomodulators to shift the inflammatory neutrophilic dermatoses to chronic noninflammatory wounds and eventual healing.
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Affiliation(s)
- Théodora Kipers
- School of Medicine, Texas A&M University School of Medicine, 5536 Tremont Street, Dallas, TX 75214, USA
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology; Department of Dermatology, Baylor University Medical Center; University of Texas at Southwestern; Texas A&M University School of Medicine, 1640 FM 544, Suite 100, TX 75056, USA.
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4
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Köken Avşar A, Demirci Yıldırım T, Sarı İ. Tofacitinib therapy for severe pyoderma gangrenosum in a patient with enteropathic arthritis: a case-based review. Rheumatol Int 2024:10.1007/s00296-024-05560-1. [PMID: 38488863 DOI: 10.1007/s00296-024-05560-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/11/2024] [Indexed: 03/17/2024]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that is associated with systemic inflammatory conditions. Currently, there is no universally accepted standard therapy for PG, but immunosuppressive (IS) treatment seems essential. We report a patient here who was successfully treated with tofacitinib despite being PG-refractory to multiple anti-tumor necrosis factor alpha (anti-TNF) therapies and conventional IS. In addition, we performed a comprehensive review of all cases of PG treated with JAK inhibitors. We identified 27 cases treated with JAK inhibitors. Approximately 80% of the patients achieved complete recovery within a median of 12 weeks, even though 17 patients (63%) had received biologics before JAKinib treatment. Notably, this recovery could appear as early as 2 weeks. JAK inhibitors may prove useful in the future, particularly for treating immunosuppressive and steroid-resistant pyoderma gangrenosum, according to recent case reports.
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Affiliation(s)
- Aydan Köken Avşar
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Tuba Demirci Yıldırım
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - İsmail Sarı
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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5
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Jiang M, Zhang G, Hsieh TY. Recalcitrant Pyoderma Gangrenosum of the Face: A Case Report. Cureus 2024; 16:e57136. [PMID: 38681354 PMCID: PMC11055618 DOI: 10.7759/cureus.57136] [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: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic dermatosis. The ulcerative subtype presents with a tender nodule or pustule that progresses into a painful, necrotic ulcer.New lesions arise after minor trauma in one-third of patients, a phenomenon termed "pathergy." We present a 62-year-old Caucasian female with primary sclerosing cholangitis, hepatic cirrhosis, chronic hepatitis B, and severe PG. At the initial presentation, she had lesions on her face and four extremities. She had severe full-thickness ulcerations on the bilateral cheeks and underwent incision and drainage with washout of bilateral maxillary abscesses, left sinus curettage, and wound debridement. She has required multiple hospitalizations for severe flares. Treatment with steroids was complicated by spinal compression fractures. Steroid-sparring agents were ineffective. Her lesions involved bilateral cheeks, temples, temporal scalp, and eyelids with oroantral fistulae. Her facial ulcerations included a large septal perforation causing saddle nose deformity and eradication of a branch of the left facial nerve causing incomplete eye closure. She underwent bilateral facial wound irrigation with antibiotic irrigation and wound debridement. Due to social factors, she has been lost to follow-up and a definitive etiology of her PG has not yet been elucidated. Although rare, PG should remain a consideration in patients with ulcerative lesions on the head and neck. Wound debridement is typically discouraged given the risk of pathergy, but there may be a role for surgical intervention in adequately immunosuppressed patients.
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Affiliation(s)
- Megan Jiang
- Otolaryngology, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Grace Zhang
- Otolaryngology, University of Cincinnati Medical Center, Cincinnati, USA
| | - Tsung-Yen Hsieh
- Otolaryngology, University of Cincinnati College of Medicine, Cincinnati, USA
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6
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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.
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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
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Satoh TK. Genetic mutations in pyoderma gangrenosum, hidradenitis suppurativa, and associated autoinflammatory syndromes: Insights into pathogenic mechanisms and shared pathways. J Dermatol 2024; 51:160-171. [PMID: 38031879 DOI: 10.1111/1346-8138.17028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
Pyoderma gangrenosum (PG), hidradenitis suppurativa (HS), and the associated autoinflammatory syndromes, including pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome, PSTPIP1-associated myeloid-related proteinemia inflammatory (PAMI) syndrome, pyoderma gangrenosum, acne, and hidradenitis suppurativa (PASH) syndrome, and pyogenic arthritis, pyoderma gangrenosum, acne, and suppurative hidradenitis (PAPASH) syndrome are dermatological conditions characterized by chronic inflammation and tissue damage. Recent advances in genetic research have identified specific mutations associated with these disorders, shedding light on their underlying pathogenic mechanisms. This review aims to summarize the current knowledge of identified mutations and presumed pathophysiology in PG, HS, and the associated autoinflammatory syndromes.
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Affiliation(s)
- Takashi K Satoh
- Department of Dermatology and Allergy, University Hospital, LMU, Munich, Germany
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Keramidas E, Rodopoulou S, Avgerinos N. Early Diagnosis and Treatment of Pyoderma Gangrenosum: Reviewing Mobile Phone Photos Saved a Patient From Unnecessary Surgeries. Cureus 2024; 16:e54797. [PMID: 38405660 PMCID: PMC10893982 DOI: 10.7759/cureus.54797] [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: 02/23/2024] [Indexed: 02/27/2024] Open
Abstract
Pyoderma gangrenosum of the breast following surgery is a rare aseptic inflammatory cutaneous condition that causes very rapid progressing and expanding painful ulceration of the surgical site and the adjacent skin. The greatest issue concerning pyoderma gangrenosum is its diagnosis. Almost invariably, it is misdiagnosed as a wound infection, which results in delayed identification, lengthy antibiotic regimens, and ineffective detrimental surgical debridements, causing significant patient disfigurement. We present a rare case report of pyoderma gangrenosum complicating the surgical site of the breast reduction procedure two months after simultaneous performance of operations including breast reduction, abdominoplasty, and lumbar liposuction. The diagnosis was established within four hours from the initial lesion and symptom presentation due to the accurate evaluation of photographs sent from the patient's mobile phone to the surgeon every half hour. Immediate appropriate treatment with oral corticosteroids within this time interval was initiated, resulting in favorable healing for the patient within four months.
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9
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Jiménez-Luévano MA, Jiménez-Partida AE, Jiménez-Partida MA, Hernández-Flores G, Cerda-Cruz CR, Bravo-Cuellar A, Villaseñor-García MM. Ulcerative colitis and pyoderma gangrenosum refractory to treatment successfully managed with pentoxifylline: a case report. Ann Med Surg (Lond) 2024; 86:1144-1146. [PMID: 38333294 PMCID: PMC10849416 DOI: 10.1097/ms9.0000000000001637] [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: 08/17/2023] [Accepted: 12/08/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction and importance Pyoderma gangrenosum is an unusual inflammatory pathology, with neutrophilic dermatosis, of unknown etiology. It is associated with diseases such as bowel disease. Generally, it is treated with anti-inflammatory drugs, corticosteroids, immunosuppressants, and antibodies against tumor necrosis factor, but relapse and adverse effects are persistent. Pentoxifylline is a drug with immunoregulatory and anti-inflammatory properties. Case presentation A 47-year-old male with a diagnosis of ulcerative colitis initially managed favorably for 7 years with mesalazine. At 3 years of treatment, he presented a sudden ulcer that affected skin and subcutaneous tissue (13×10 cm) in the lower right limb. During the last 2 years, he was treated with mesalazine and infliximab with partial results and permanent relapses. Therefore, pentoxifylline was added to his treatment. Clinical discussion The justification for the addition of pentoxifylline is mainly its action as an inhibitor of Nuclear Factor-kappa Beta (NF-κB) transcription, which stimulates the expression of proinflammatory interleukin genes such as IL-1, IL-6, IL- 8, and TNF-α and showing immunoregulatory and antioxidant activities. Conclusion With pentoxifylline, this lesion healed at 6 weeks without relapses after 2 years.
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Affiliation(s)
| | - Ana E. Jiménez-Partida
- Servicio de Gastroenterología, Hospital Regional ‘Dr. Valentín Gómez Farías’, ISSSTE Zapopan
| | | | | | - César R. Cerda-Cruz
- Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social
| | - Alejandro Bravo-Cuellar
- Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social
- Centro Universitario de los Altos, Universidad de Guadalajara, Tepatitlán de Morelos, Jalisco, México
| | - María M. Villaseñor-García
- Centro de Investigación Biomédica de Occidente, Instituto Mexicano del Seguro Social
- Centro Universitario de Ciencias Exactas e Ingenierías, Universidad de Guadalajara, Guadalajara
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10
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Hashim A, Boucher F. A case report and a call for early recognition: post-operative Pyoderma Gangrenosum after breast-conserving surgery in a locally advanced breast tumor. Case Reports Plast Surg Hand Surg 2024; 11:2304620. [PMID: 38250334 PMCID: PMC10798280 DOI: 10.1080/23320885.2024.2304620] [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] [Received: 05/30/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
We present a case of a patient addressed to our plastic surgery department after a breast tumor resection and subsequent necrosis and ulceration of the right breast. A diagnosis of pyoderma gangrenosum was made based on the clinical criteria, early recognition resulted in complete recovery without further reconstructive surgery.
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Affiliation(s)
- Abdulrahman Hashim
- Department of Plastic and Reconstructive Surgery, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France, Department of Surgery, University of Jeddah Medical School, Jeddah, Saudi Arabia
| | - Fabien Boucher
- Department of Plastic and Reconstructive Surgery, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
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11
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Iliescu C, Popa L, Mihai M, Popescu MN, Beiu C. Pyoderma Gangrenosum: The Impact of Treatment Non-adherence on Disease Progression. Cureus 2024; 16:e51490. [PMID: 38304683 PMCID: PMC10831138 DOI: 10.7759/cureus.51490] [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: 01/01/2024] [Indexed: 02/03/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, ulcerative, rapidly progressing, destructive, inflammatory cutaneous disease that is both diagnostically and therapeutically challenging. Due to the lack of standardized diagnostic criteria or conclusive guidelines for patient management, clinicians often find themselves without reliable tools for the daily management of PG patients. Additionally, the lack of strict therapeutic compliance in patients with this diagnosis might contribute to a catastrophic evolution of the condition. We report a case of ulcerative PG that is illustrative of the inherent challenges posed by patients frequently changing healthcare providers and treatment regimens, displaying inconsistency and non-adherence. Such behaviors can lead to the loss of disease control, particularly in the context of extensive or rapidly progressing PG, ultimately culminating in the development of mutilating forms of this disease.
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Affiliation(s)
- Carmen Iliescu
- Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Liliana Popa
- Oncological Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Mara Mihai
- Oncological Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Marius N Popescu
- Physical Medicine and Rehabilitation, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Cristina Beiu
- Oncological Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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12
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Sanchez-Melendez SN, Malik R, Patel PM, Milosavljevic S, Patel S, Nambudiri VE. Pyoderma gangrenosum and impact on quality of life: A narrative review. Exp Dermatol 2024; 33:e14876. [PMID: 37424357 DOI: 10.1111/exd.14876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
Pyoderma gangrenosum (PG) is an autoinflammatory disorder typically characterized by progressive ulcers with dense neutrophilic infiltrates in the absence of infectious causes. The chronic nature of this disease significantly impacts the patients' quality of life (QoL). Yet there is currently a dearth of information in the literature regarding standardised treatment guidelines and the impact of PG on patients' QoL. We conducted a literature search on PubMed using the terms "pyoderma gangrenosum" AND "quality of life." We identified nine relevant articles that provide insight into which domains are affected and what treatment can improve QoL. The most common domains involved are physical, emotional, and psychological. Patients tend to feel depressed/anxious, isolated, and embarrassed secondary to PG manifestations. Comorbidities such as Crohn's disease, monoclonal gammopathy of dermatologic significance, and ulcerative colitis can worsen the impact on these patients' QoL. Pain is also a significant contributor to decreasing patients' QoL. Treatments such as topical steroids, adalimumab, and canakinumab may help improve QoL scores. We believe this information can help clinicians guide the care of patients with PG and highlight the need for more studies and clinical trials focusing on PG treatments' impact on QoL.
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Affiliation(s)
- Stephanie N Sanchez-Melendez
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Ponce Health Sciences University, School of Medicine, Ponce, Puerto Rico, USA
| | - Rhea Malik
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Payal M Patel
- Department of Dermatology, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | | | - Shrey Patel
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Park AN, Raj A, Bajda J, Gorantla VR. Narrative Review: Pyoderma Gangrenosum. Cureus 2024; 16:e51805. [PMID: 38187026 PMCID: PMC10771820 DOI: 10.7759/cureus.51805] [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: 01/07/2024] [Indexed: 01/09/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a skin lesion, characteristically a neutrophilic dermatosis, that can be complicated by rapid progression, necrosis, and ulceration. This is an important pathology to be discussed given that there are no established criteria for diagnosis or treatment. This review aims to elucidate characteristics and variations of PG that distinguish it from other ulcerative skin lesions. Variability in presentation can lead to missed or incorrect diagnosis, and some of the currently proposed criteria for categorizing and diagnosing PG have been included here. These criteria distinguish PG in terms of the nature of the lesion, the location, etiology, responsiveness to immunosuppressive therapy, and patient history. The etiology and pathogenesis of PG remain unknown, but we summarize prominent theories and explanations. Furthermore, recent research indicates that the incidence of PG has a strong correlation with autoimmune conditions, particularly inflammatory bowel disease. Major treatments for PG coincide with these findings, as the majority involve targeted anti-inflammatories, immunosuppressants, and surgical interventions. These treatments are addressed in this review, with added context for local versus systemic disease.
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Affiliation(s)
- Ann N Park
- Anatomical Sciences, St. George's University School of Medicine, True Blue, GRD
| | - Aishwarya Raj
- Anatomical Sciences, St. George's University School of Medicine, True Blue, GRD
| | - Joe Bajda
- Anatomical Sciences, St. George's University School of Medicine, True Blue, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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14
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Sathyanarayana VA, Roy D, Nagaraju B, Rao VKR. Tofacitinib in pyoderma gangrenosum - A case series. Int J Rheum Dis 2024; 27:e14810. [PMID: 37395471 DOI: 10.1111/1756-185x.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory disorder falling under the spectrum of neutrophilic dermatosis, characterized by distinctive skin ulceration which is non-infective, non-neoplastic and usually with no primary vasculitis. PG lesions are notorious for relapse and hence require multiple trials of medications often with prolonged and concomitant use of steroids. Due to lack of evidence-based studies on effective treatment options for PG, we have presented three isolated biopsy-proven PG cases who were successfully treated with Tofacitinib, a Janus kinase/signal transducers and activators of transcription (JAK/STAT) pathway inhibitor, without relapse in follow up.
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Affiliation(s)
| | - Debaditya Roy
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education and Research (IPGMER), Kolkata, India
| | | | - Vijay K R Rao
- Divisha Arthritis and Medical Center, Bangalore, India
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15
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Mori Y, Izumiyama T, Otsuka K, Kanabuchi R, Yamamoto J, Sekine M, Mori N, Asano Y, Aizawa T. Pyoderma gangrenosum after surgery for forefoot deformity in a patient with rheumatoid arthritis: A case report. Mod Rheumatol Case Rep 2023; 8:11-15. [PMID: 37638693 DOI: 10.1093/mrcr/rxad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/29/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory skin disease characterised by skin ulcers that are associated with autoimmune diseases. Although the effectiveness of immunosuppression with glucocorticoids and tumour necrosis factor inhibitors in treating PG has been reported, the utility of negative-pressure wound therapy (NPWT) for severe ulcerative lesions in patients with PG remains controversial. Herein, we report the case of a 76-year-old woman with rheumatoid arthritis who developed PG after undergoing surgery for a forefoot deformity. The patient showed improvement in deep ulcer lesions through NPWT while receiving treatment with abatacept and systemic glucocorticoids. Subsequent topical glucocorticoid therapy led to the remission of the PG. This case suggests that NPWT, when used under immunosuppressive conditions, does not exacerbate the pathergy and may be beneficial for treating severe ulcerative PG.
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Affiliation(s)
- Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuya Izumiyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Otsuka
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuichi Kanabuchi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Yamamoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mana Sekine
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshihide Asano
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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16
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Lyons D, Sexton F, Martin-Smith J, Raghallaigh SN. Postpartum pyoderma gangrenosum following lactation-induced mastitis and abscess incision. JAAD Case Rep 2023; 42:59-61. [PMID: 38058410 PMCID: PMC10696303 DOI: 10.1016/j.jdcr.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Affiliation(s)
- Daniel Lyons
- Department of Dermatology, Beaumont Hospital, Dublin, Ireland
| | - Fiona Sexton
- Department of Dermatology, Beaumont Hospital, Dublin, Ireland
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17
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Mastronardi M, Cavalcanti E, Labarile N, Armentano R, Gabriele F, Curlo M. Pyoderma gangrenosum in ulcerative colitis patient treated with vedolizumab: adsorptive granulocyte/monocyte apheresis as a new therapeutic option refractory cases - a case report and literature review. Ther Adv Chronic Dis 2023; 14:20406223231194190. [PMID: 37928629 PMCID: PMC10623906 DOI: 10.1177/20406223231194190] [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: 02/05/2023] [Accepted: 07/25/2023] [Indexed: 11/07/2023] Open
Abstract
Extraintestinal manifestations occur rather frequently in ulcerative colitis (UC) and Crohn's disease patients and are usually related to an exacerbation of the underlying intestinal bowel disease but sometimes may run a course independent of the inflammatory bowel diseases (IBD). About one-third of patients with IBD develop extraintestinal manifestations, such as pyoderma gangrenosum (PG). PG is an uncommon inflammatory skin disorder of unknown pathogenesis. There are no specific serological or histological markers, and diagnosis is predominantly clinical. Topical and systemic therapies are both vital aspects of treatment and immune modulators have been used with increasing success in recent years, although immunosuppressive drugs raise some concerns due to an increased risk of serious and opportunistic infections and cancer, particularly in elderly and comorbid patients, underlining the unmet need for safer alternative therapies. Thus, in this case report, we highlighted an adsorptive granulocyte/monocyte apheresis (GMA) as a new therapeutic possibility in IBD patients with extraintestinal manifestations. We report a case of a 60-year woman with a history of UC with a Mayo grade 3 score which was associated with a PG. Given that the patients maintained clinical remission with vedolizumab, we preferred not to perform a combined treatment with other antitumor necrosis factor-alpha or ciclosporin, thus avoiding an increased risk of serious infections in the patient. Therefore, we performed the extracorporeal leukocyte apheresis. The patient progressed favorably, with progressive improvement of skin and bowel disease. Therefore, adsorptive GMA has a very favorable safety profile and has been confirmed in numerous studies. In this study, we underlined that an intensive regimen of GMA paves the way to an ideal option for patients with severe and refractory PG complicated with UC.
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Affiliation(s)
- Mauro Mastronardi
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
| | - Elisabetta Cavalcanti
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Via Turi 27, Castellana Grotte, Bari 70013, Italy
| | - Nunzia Labarile
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
| | - Raffaele Armentano
- Histopathology Unit of National Institute of Gastroenterology “S. de Bellis”, Research Hospital, Castellana Grotte, Bari, Italy
| | - Francesco Gabriele
- Intensive Therapy Unit of National Institute of Gastroenterology “S. de Bellis”, Research Hospital, Castellana Grotte, Bari, Italy
| | - Margherita Curlo
- Department of Gastroenterology of National Institute of Gastroenterology “S. de Bellis”, Castellana Grotte, Bari, Italy
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18
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Kwon IJ, Park JW, Park S, Lim H, Yu J, Oh SH. Ulcerative Colitis Diagnosed through Evaluation of Underlying Diseases in a Pyoderma Gangrenosum Adolescent without Gastrointestinal Symptoms. Ann Dermatol 2023; 35:S292-S295. [PMID: 38061724 PMCID: PMC10727860 DOI: 10.5021/ad.22.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/04/2022] [Accepted: 05/26/2022] [Indexed: 12/20/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, non-infectious, neutrophilic dermatosis characterized by painful ulcers with indistinct borders and peripheral erythema. The diagnosis of PG requires the exclusion of other causes of similar appearing skin manifestations, including vasculitis and infections. The pathogenesis of PG is not clear; however, dysregulation of the immune system has been suggested in previous studies. More than half of the PG patients have underlying diseases; the most common being inflammatory bowel disease (IBD). The progression of PG in IBD patients is seen after the onset of IBD, usually during its exacerbation. On the other hand, PG may follow a course independent of the intestinal disease. We present a case of an 18-year-old young male with PG that presented before being diagnosed with ulcerative colitis as an associated condition. He had a painful ulcerative lesion on his right shin with no previous gastrointestinal symptoms. This case suggests that investigating for underlying disorders is essential in PG patients despite the lack of symptoms other than the skin lesions.
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Affiliation(s)
- Il Joo Kwon
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sowon Park
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Severance Pediatric IBD Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeji Lim
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Severance Pediatric IBD Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeeun Yu
- Dr.Yu's Pediatric and Adolescence Medicine, Osan, Korea
| | - Sang Ho Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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19
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Erickson KM, Kody S, Ortega-Loayza AG. Pain as a Patient-Reported Outcome Measure in Pyoderma Gangrenosum. JAMA Dermatol 2023; 159:1274-1275. [PMID: 37728937 PMCID: PMC10512163 DOI: 10.1001/jamadermatol.2023.3115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 07/10/2023] [Indexed: 09/22/2023]
Abstract
This survey study investigates the minimal important difference in pain indicating that a patient with pyoderma gangrenosum may be responding to treatment.
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Affiliation(s)
- Katherine M. Erickson
- Department of Dermatology, Oregon Health & Science University, Portland
- Department of Dermatology, New York Medical College, New York
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, Portland
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20
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Miklusiak K, Miklusiak K, Kaczmarczyk O, Cibor D, Zwolińska-Wcisło M. Ustekinumab in the treatment of acute disseminated pyoderma gangrenosum in a patient with Crohn's disease. Dermatol Reports 2023; 15:9630. [PMID: 37908604 PMCID: PMC10614552 DOI: 10.4081/dr.2023.9630] [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: 09/14/2022] [Accepted: 12/03/2023] [Indexed: 11/02/2023] Open
Abstract
Pyoderma gangrenosum (PG) is an auto-inflammatory dermatosis characterized by lesions that often cause ulcers. We present a case of successful ustekinumab treatment for acute general PG in a 31-year-old woman with coexisting Crohn's disease (CD). For a month, the patient suffered from skin ulcers, two of them deep and necrotic; a histopathological examination revealed PG. Treatment included: methylprednisolone, azathioprine, betamethasone, gentamicin and zincic ointments, antiseptic compresses, and adalimumab therapy. Due to resistance to the implemented treatment, the patient was enrolled in a clinical trial that included the administration of an anti-cytokines drug, ustekinumab. Subsequently, a significant reduction was observed in the severity of symptoms of PG with no relapse. The use of ustekinumab in patients with PG who have an inadequate response to current treatment or cannot receive first-line treatment can be considered. This applies especially to patients with accompanying autoimmune diseases such as CD.
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Affiliation(s)
| | - Karol Miklusiak
- Polish Red Cross Maritime Hospital with Oncology Centre, Gdynia
| | - Olga Kaczmarczyk
- Department of Gastroenterology and Hepatology, Jagiellonian University Medical College, Cracow, Poland
| | - Dorota Cibor
- Department of Gastroenterology and Hepatology, Jagiellonian University Medical College, Cracow, Poland
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21
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Yamamoto T, Yamasaki K, Yamanaka K, Komine M, Kawakami T, Yamamoto O, Kanekura T, Higuchi T, Takahashi T, Matsushima Y, Kikuchi N. Clinical guidance of pyoderma gangrenosum 2022. J Dermatol 2023; 50:e253-e275. [PMID: 37311717 DOI: 10.1111/1346-8138.16845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.
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22
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Babakoohi S, Gu SL, Ehsan H, Markova A. Dermatologic complications in transplantation and cellular therapy for acute leukemia. Best Pract Res Clin Haematol 2023; 36:101464. [PMID: 37353285 PMCID: PMC10291442 DOI: 10.1016/j.beha.2023.101464] [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: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.
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Affiliation(s)
- Shahab Babakoohi
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA.
| | - Stephanie L Gu
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Hamid Ehsan
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
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23
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Jordan AI, Zhang L, Yun S. Nonhealing Cutaneous Ulcers in a Patient With Myelodysplastic Syndrome. JAMA Oncol 2023; 9:860-861. [PMID: 37052896 DOI: 10.1001/jamaoncol.2023.0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
A 75-year-old man with myelodysplastic syndrome that has been well controlled with lenalidomide develops multiple nonhealing cutaneous ulcers. What is your diagnosis?
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Affiliation(s)
- Aryanna I Jordan
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa, Florida
| | - Ling Zhang
- Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Seongseok Yun
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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24
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Matar DY, Ng B, Darwish O, Wu M, Orgill DP, Panayi AC. Skin Inflammation with a Focus on Wound Healing. Adv Wound Care (New Rochelle) 2023; 12:269-287. [PMID: 35287486 PMCID: PMC9969897 DOI: 10.1089/wound.2021.0126] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/09/2022] [Indexed: 11/12/2022] Open
Abstract
Significance: The skin is the crucial first-line barrier against foreign pathogens. Compromise of this barrier presents in the context of inflammatory skin conditions and in chronic wounds. Skin conditions arising from dysfunctional inflammatory pathways severely compromise the quality of life of patients and have a high economic impact on the U.S. health care system. The development of a thorough understanding of the mechanisms that can disrupt skin inflammation is imperative to successfully modulate this inflammation with therapies. Recent Advances: Many advances in the understanding of skin inflammation have occurred during the past decade, including the development of multiple new pharmaceuticals. Mechanical force application has been greatly advanced clinically. Bioscaffolds also promote healing, while reducing scarring. Critical Issues: Various skin inflammatory conditions provide a framework for analysis of our understanding of the phases of successful wound healing. The large burden of chronic wounds on our society continues to focus attention on the chronic inflammatory state induced in many of these skin conditions. Future Directions: Better preclinical models of disease states such as chronic wounds, coupled with enhanced diagnostic abilities of human skin, will allow a better understanding of the mechanism of action. This will lead to improved treatments with biologics and other modalities such as the strategic application of mechanical forces and scaffolds, which ultimately results in better outcomes for our patients.
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Affiliation(s)
- Dany Y. Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Brian Ng
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Oliver Darwish
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, California Northstate University College of Medicine, Elk Grove, California, USA
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, China
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana C. Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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25
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Vu MLD, Lin FE, Ashcroft CR, Van Der Veer SJ, Hall JR. A Diagnostic Dilemma: Atypical Systemic Pyoderma Gangrenosum. Cureus 2023; 15:e38763. [PMID: 37303437 PMCID: PMC10249513 DOI: 10.7759/cureus.38763] [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: 05/06/2023] [Indexed: 06/13/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that classically presents with chronic ulcerations with raised, violaceous, and undermined borders commonly found on the lower extremities. Less common presentations include tender nodules, pustules, or bullae that may occur on other sites of the body. In rarer circumstances, PG can lead to a systemic inflammatory response syndrome with extensive pulmonary infiltrates but ultimately cause and etiology of the disease are still uncertain. Unfortunately, there is no laboratory test or histopathologic finding that is specific to PG, which makes the diagnosis even more elusive.
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Affiliation(s)
- My Linh D Vu
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | - Fiona E Lin
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | - Cody R Ashcroft
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | | | - Jacob R Hall
- Dermatology, Brooke Army Medical Center, San Antonio, USA
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26
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Byun JY, Kang YK, Jang YH, Kim YK, Kim DW. Management of Steroid-Induced Glaucoma in a Patient with Pyoderma Gangrenosum. J Clin Med 2023; 12:jcm12082930. [PMID: 37109266 PMCID: PMC10144976 DOI: 10.3390/jcm12082930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/28/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder typically presenting as painful skin ulcers, which may also exhibit extracutaneous findings. PG can occur at the site of trauma or surgery, which is known as the pathergic phenomenon. A 36-year-old man developed bilateral steroid-induced glaucoma after prolonged systemic immunosuppressive treatment for cutaneous pyoderma gangrenosum. After successful Ahmed glaucoma valve implantation surgery with donor scleral patch graft in the right eye, the same surgery failed repeatedly in the left eye and complicated with the prolonged conjunctival necrosis and the exposure of the donor scleral patch graft. Under the impression of ocular involvement of PG, microinvasive glaucoma surgery (MIGS) with XEN® Gel Stent was performed in the left eye; the conjunctival bleb was successfully formed without conjunctival necrosis, and intraocular pressure was well maintained. Ophthalmic surgery can be complicated in patients with PG, and the surgical option should be selected prudently to minimize surgical trauma. MIGS, as a minimally invasive surgical technique, could offer an advantage for patients with PG.
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Affiliation(s)
- Ji Yeon Byun
- Department of Dermatology, Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea
| | - Yong Koo Kang
- Department of Ophthalmology, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yong Hyun Jang
- Department of Dermatology, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Young Kook Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Dai Woo Kim
- Department of Ophthalmology, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
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27
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Dey S, Sanghavi N, Wasserman A, Kar K. Treatment of Pyoderma Gangrenosum With Mycophenolate and Hyperbaric Oxygen Therapy: A Case Report and Literature Review. Cureus 2023; 15:e38159. [PMID: 37252490 PMCID: PMC10218763 DOI: 10.7759/cureus.38159] [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: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Pyoderma gangrenosum is an uncommon inflammatory ulcerative skin disorder with an unclear etiology. In many cases, it is associated with several underlying systemic diseases, with inflammatory bowel disease being the most common one. Since it does not have any specific clinical or laboratory findings, it is a diagnosis of exclusion. A multidisciplinary approach is vital in treating pyoderma gangrenosum. Its recurrence remains common, and it also has an unpredictable prognosis. Here, we report a case report of pyoderma gangrenosum, which was successfully treated with mycophenolate and hyperbaric oxygen therapy.
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Affiliation(s)
- Subo Dey
- Internal Medicine, Westchester Medical Center, Valhalla, USA
| | - Nirali Sanghavi
- Internal Medicine, Westchester Medical Center, Valhalla, USA
| | - Amy Wasserman
- Rheumatology, Westchester Medical Center, Valhalla, USA
| | - Kausik Kar
- Internal Medicine, Wound and Hyperbaric Medicine, Westchester Medical Center, Valhalla, USA
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28
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Kusraeva DT, Olisova OY, Teplyuk NP, Grabovskaya OV, Kayumova LN, Bobkova AE, Varshavsky VA, Komleva LF, Petrenko EV, Bobrova KY. PYODERMA GANGRENOSUM MIMICKING GRANULOMATOSIS WITH POLYANGIITIS: CACE REPORT AND RIVIEW OF THE LITERATURE. VESTNIK DERMATOLOGII I VENEROLOGII 2023. [DOI: 10.25208/vdv1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Pyoderma gangrenosum is an autoinflammatory neutrophilic dermatosis. Diagnosis of the disease remains a difficult task to date, due to the lack of a gold standard of examination and differential diagnostic signs. The primary elements in the development of PG may be papules, pustules or bullae the dissection of which subsequently leads to the formation of ulcers with irregular, violaceous, undermined borders. In rare cases, the diagnosis of the disease can also be complicated by the rapid development of internal organs damage symptoms, which must be regarded as extracutaneous manifestations of PG. Extracutaneous lesions can occur before, during or after the appearance of skin rashes, and the detection of sterile neutrophil infiltrates in the defeat of internal organs confirm the concept of PG as a multisystemic disease. The presented case of a rare course of PG with multiple skin lesions and extracutaneous manifestations, simulating systemic vasculitis, emphasizes the importance of a detailed examination of patients in order to make a correct diagnosis and prescribe timely adequate treatment.
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29
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Kaur J, Valisekka SS, Hameed M, Bandi PS, Varma S, Onwughalu CJ, Ibrahim H, Mongia H. Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e195-e212. [PMID: 36966041 DOI: 10.1016/j.clml.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.
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Affiliation(s)
- Jasneet Kaur
- Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA..
| | | | - Maha Hameed
- Internal Medicine, Florida State University/Sarasota Memorial Hospital, Sarasota, Florida, USA.
| | | | | | | | - Hany Ibrahim
- Ain Shams University, Faculty of Medicine, Cairo, Egypt.
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30
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Chen B, Li W, Qu B. Practical aspects of the diagnosis and management of pyoderma gangrenosum. Front Med (Lausanne) 2023; 10:1134939. [PMID: 36865058 PMCID: PMC9971223 DOI: 10.3389/fmed.2023.1134939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.
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Affiliation(s)
| | - Wei Li
- Department of Burns, Sichuan Academy of Medical Sciences and Sichuan People’s Hospital, Chengdu, China
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31
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Đorđević Betetto L, Bajuk V. Trigeminal trophic syndrome, a rare and often overlooked cause of facial ulceration: a case report and literature review. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2023. [DOI: 10.15570/actaapa.2023.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
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32
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Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases. An Bras Dermatol 2023; 98:141-158. [PMID: 36682966 PMCID: PMC9984718 DOI: 10.1016/j.abd.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 08/09/2022] [Indexed: 01/21/2023] Open
Abstract
Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.
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33
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Kim YJ, Lee KH, Won CH, Chang SE, Lee MW, Choi JH, Lee WJ. Clinicopathological features and prognosis of pyoderma gangrenosum in Korea: A single centre, retrospective, observational study over 20 years. Indian J Dermatol Venereol Leprol 2023; 89:25-34. [PMID: 35389018 DOI: 10.25259/ijdvl_968_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/01/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pyoderma gangrenosum is a rare autoinflammatory neutrophilic dermatosis that rapidly evolves. However, little is known about the clinicopathological features and prognosis of pyoderma gangrenosum. AIMS We aimed to document clinicopathologic and prognostic data of the patients with pyoderma gangrenosum. METHODS In this retrospective observational study, we reviewed case records of patients diagnosed with pyoderma gangrenosum between 1999-2019. RESULTS Fifty-three patients were identified by reviewing medical records for skin biopsy; of these, 37 were men and 16 were women. Mean age at onset was 43.3 ± 18.5 years. The most frequently affected area was the lower extremities (60.4%), followed by the head and neck (17.0%). The most common subtype was ulcerative (47.2%), followed by bullous (22.6%). 30 cases had underlying diseases and the most common were malignancy (24.5%), followed by inflammatory bowel diseases (18.9%). The proportion of cases with history of trauma were significantly higher in post-operative type (100%) as compared to the bullous type (8.3%). Histologic features of granulation tissue were frequently found in post-operative type (66.7%) and bullous type (58.3%). Granulomas were predominantly found in bullous type (58.3%). Age <60 years appeared to be significantly associated with multiple lesions. Partial-to-complete remission was observed in 40 cases (75.5%). Nine (17.0%) cases experienced recurrence with a median progression-free period of six months (interquartile range of 3.0-9.0 months). Cases with underlying hematologic disorders and the bullous subtype were significantly associated with early recurrence. LIMITATIONS This study was a single-centre study with a retrospective design. CONCLUSION Pyoderma gangrenosum appears to have ethnic differences. Underlying haematologic disorders and bullous subtype have a worse prognosis. However, the type of histopathology did not correlate with the clinical outcome of pyoderma gangrenosum.
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Affiliation(s)
- Young Jae Kim
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Keon Hee Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chong Hyun Won
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Eun Chang
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mi Woo Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jee Ho Choi
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Jin Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Muacevic A, Adler JR, Almohammed Saleh AA, AlAlwan AQ, Aljughayman MA, Alhamed AS, Alsuwaigh A, Aleasa A, Alali T, AlGhadeer MS, Albeladi SA. Successful Management of a Young Patient Suffering From Pyoderma Gangrenosum Following Gastric Bypass Surgery: A Case Report. Cureus 2023; 15:e34305. [PMID: 36860228 PMCID: PMC9969975 DOI: 10.7759/cureus.34305] [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: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a pathogenetically ill-defined neutrophilic dermatosis frequently characterized by severely painful ulcerations with no identifiable infective pathogens. There are no diagnostic criteria for PG, nor specific gold standard management, which may complicate the process of dealing with patients suffering from this disease. Here, we report a case of a 27-year-old male patient, with a history of gastric bypass surgery three years ago, who presented with a left leg non-healing ulcer diagnosed as a PG by the clinical presentation and biopsy of the ulcer. He was managed by the administration of systemic immunomodulators, a surgical debridement procedure, and the application of a vacuum. The patient was discharged with vitamin B complex and vitamin D supplements as well as zinc sulfate and folic acid. Also, multiple doses of Infliximab intravenously and vitamin B 12 intramuscularly result in a satisfactory healing process of the ulcer. Since PG is a diagnosis of exclusion, clinicians must be aware of the need for highly specific history-taking, previous surgical history, laboratory investigations, and histopathological workup in order to reach the diagnosis.
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35
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Filikci Z, Jensen RM, Thorup Sellebjerg F. Inflammatory vaginitis associated with long-term rituximab treatment in a patient with multiple sclerosis. BMJ Case Rep 2022; 15:15/11/e250425. [DOI: 10.1136/bcr-2022-250425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We describe inflammatory vaginitis as a potential side effect of long-term rituximab treatment for multiple sclerosis in the absence of any other systemic disease or underlying malignancy.More studies are needed to characterise the incidence of inflammatory vaginitis among women on long-term rituximab therapy.
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36
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Klumpp A, Luessi F, Engel S, Weidenthaler-Barth B, Becker D, Grabbe S, Schepler H. Ocrelizumab-induced vulvovaginal pyoderma gangrenosum in a patient with relapsing-remitting multiple sclerosis. JAAD Case Rep 2022; 28:24-27. [PMID: 36097621 PMCID: PMC9463556 DOI: 10.1016/j.jdcr.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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37
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Muacevic A, Adler JR. Refractory Pyoderma Gangrenosum: Stabilized on Colchicine and Tumor Necrosis Factor (TNF) Inhibitor. Cureus 2022; 14:e30419. [PMID: 36276600 PMCID: PMC9578333 DOI: 10.7759/cureus.30419] [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] [Accepted: 10/17/2022] [Indexed: 11/05/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare ulcerative, painful inflammatory skin condition that is categorized among neutrophilic dermatoses. We report an otherwise healthy female who initially presented to a dermatology clinic with erythematous nodules and pustules scattered over her legs and thigh, which progressed later to multiple painful ulcers. Upon further investigation, it was diagnosed as idiopathic PG. Prednisone was an initial mainstay of treatment. While tapering, mycophenolate mofetil was started as adjunctive therapy but failed to maintain remission. A tumor necrosis factor inhibitor was initiated alongside colchicine with a significant clinical response.
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Alosaimi MM, Sebzali F, Iqbal A, Rabbat CG, Clase CM. Pyoderma Gangrenosum After Insertion of a Hemodialysis Catheter: Koebner Phenomenon, Systemic Inflammatory Response Syndrome, and a Delay in Diagnosis. Can J Kidney Health Dis 2022; 9:20543581221120618. [PMID: 36160315 PMCID: PMC9493685 DOI: 10.1177/20543581221120618] [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: 03/16/2021] [Indexed: 12/03/2022] Open
Abstract
Rationale: Pyoderma gangrenosum is a rare neutrophilic dermatosis. Misdiagnosis of
pyoderma gangrenosum as an infection is not uncommon. Pyoderma gangrenosum
can be associated with Koebner phenomenon and rarely results in systemic
inflammatory response syndrome and shock. Presenting concerns of the patient: A 61-year-old woman had recently started maintenance hemodialysis, using a
tunneled catheter. She was admitted with fever and signs of inflammation at
the catheter exit site and along the tunnel. Diagnoses: The initial diagnosis was catheter-related tunnel infection. The exit site
broke down into a 5 cm × 5 cm lesion typical of pyoderma, and a new similar
lesion developed at a subcutaneous injection site in her abdomen. Clinical
diagnosis of pyoderma gangrenosum was made. She remained febrile despite
broad antibiotic coverage and catheter removal and developed systemic
inflammatory response syndrome (SIRS) that necessitated transfer to
intensive care unit. Interventions: She responded well to fluids and intravenous steroids. Viral and bacterial
cultures were negative throughout; echocardiography and computed tomography
were unrevealing. Insertion of a new hemodialysis catheter was deferred as
long as clinically possible, was undertaken while the patient was taking
steroids, and was uncomplicated. Outcomes: She remained hemodynamically stable and was discharged after rehabilitation.
Her wounds slowly granulated and healed. Steroids were tapered. Teaching points: To our knowledge, this is the first case report of a patient with pyoderma
gangrenosum developing at the site of tunneled hemodialysis catheter. Our
patient developed SIRS with no evidence of infection. We summarize 11
previous case reports of pyoderma leading to SIRS and responsive to
steroids.
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Affiliation(s)
- Majed M Alosaimi
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Fatemah Sebzali
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Ali Iqbal
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Christian G Rabbat
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Medicine, St. Joseph's Healthcare Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Treatment of Pediatric Pyoderma Gangrenosum With Modified Negative Pressure Wound Therapy and Intralesional Corticosteroids: A Case Report. J Wound Ostomy Continence Nurs 2022; 49:488-491. [PMID: 36108234 DOI: 10.1097/won.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a rare ulcerative skin disease; its etiology is unknown, though it is often associated with autoimmune diseases. Pyoderma gangrenosum results in significant morbidity and exquisite pain that affects health-related quality of life. Wound healing is delayed, and patients often experience relapse. Pyoderma gangrenosum is susceptible to pathergy and deterioration with surgical intervention or other trauma; therefore, treatment includes atraumatic wound care, infection management, and local or systemic immunosuppression. CASE We describe the use of modified negative pressure wound therapy (NPWT) with intralesional and topical steroids for the treatment of PG in a 15-year-old female patient with ulcerative colitis and a staged J-pouch ileoanal reconstruction. The patient and her family refused all systemic therapy due to prior steroid-associated weight gain. She was unable to tolerate conscious dressing changes, further complicating the treatment plan. Procedural interventions such as NPWT have been used previously for PG; however, they can cause wound pathergy and subsequent wound deterioration. Modified NPWT in conjunction with topical and intralesional steroids induced wound healing without producing pathergy. CONCLUSION Timely recognition of PG is crucial to appropriate delivery of care. Modified NPWT and localized corticosteroid treatment were key to promoting wound healing in this case of pediatric PG.
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Leow LJ, Zubrzycki N. Recalcitrant Ulcerative Pyoderma Gangrenosum of the Leg Responsive to Tildrakizumab: A Case Report. Clin Cosmet Investig Dermatol 2022; 15:1729-1736. [PMID: 36039180 PMCID: PMC9419888 DOI: 10.2147/ccid.s374534] [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: 05/26/2022] [Accepted: 08/12/2022] [Indexed: 12/03/2022]
Abstract
Elevated levels of inflammatory mediators—including the interleukin IL-23—are implicated in the pathogenesis of pyoderma gangrenosum (PG), an autoinflammatory neutrophilic dermatosis characterized by rapidly enlarging, suppurative ulcers and cribriform scarring. Here, we present the first case report of significant response of isolated ulcerative PG with tildrakizumab, a biologic agent directed against the p19 subunit of IL-23, in an elderly woman with extensive treatment-refractory PG on her left leg. Tildrakizumab (100 mg subcutaneously at weeks 0 and 4, then every 8 weeks, and eventually increased in frequency to every 6 weeks), combined with acetic acid soaks each morning and chemical debridement every evening with 3% hydrogen peroxide, resulted in progressive decrease in ulcer size and depth, re-epithelialization, and recovery of sensory perception. This report describes the dramatic clinical response of ulcerative PG on the leg with tildrakizumab.
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Affiliation(s)
- Liang Joo Leow
- Aesthetic Dermatology, Sydney, NSW, Australia.,Department of Dermatology, St Vincent's Private Hospital, Sydney, NSW, Australia.,St Vincent's & Mater Clinical School, University of Notre Dame Australia, Sydney, NSW, Australia
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41
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Zhang H, Sun Y, Li K, Zhang J, Chen X. Multiple Lesions at Different Stages of Pyoderma Gangrenosum in a Crohn's Disease Patient. Clin Cosmet Investig Dermatol 2022; 15:1593-1596. [PMID: 35971452 PMCID: PMC9375554 DOI: 10.2147/ccid.s374973] [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: 05/21/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022]
Abstract
Pyoderma gangrenosum (PG) is an inflammatory dermatosis characterized by the rapid progression of a painful, necrolytic ulcer with an irregular and undermined border. The prevalence of PG in patients with Crohn’s disease (CD) has been estimated to be 0.7%. Here, we report a case that presented various painful skin lesions, including erythema, vesicles, plaques, and ulcers, one week before the fourth infliximab infusion for CD. PG was diagnosed and the lesions subsided after a 390-mg ustekinumab infusion for one month. It suggests that different lesions of PG may occur concomitantly in CD patients, and the therapy should be re-evaluated on time.
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Affiliation(s)
- Heng Zhang
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Yifang Sun
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Kun Li
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Jianzhong Zhang
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Xue Chen
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
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42
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Burlage E, Mulder JWCM, Nellensteijn JM, Zeegers AVCM. Infection mimicking skin condition: pyoderma gangrenosum. BMJ Case Rep 2022; 15:15/8/e247770. [PMID: 37198754 PMCID: PMC9362768 DOI: 10.1136/bcr-2021-247770] [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] [Indexed: 11/04/2022] Open
Abstract
The a priori risk of infection is high when a patient presents with an ulcerative skin condition and elevated inflammatory parameters. If the ulceration is progressive despite adequate antibiotic therapy and tissue cultures are negative, pyoderma gangrenosum should be considered as the diagnosis. This rare infection mimicking skin condition can develop and worsen due to surgery. In this paper, we report two cases that illustrate the importance of making this clinical diagnosis in a timely manner in order to avoid unnecessary surgical interventions and worsening of the clinical picture.
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43
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Neutrophilic Dermatosis and Management Strategies for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2022; 11:146-157. [PMID: 35873076 PMCID: PMC9287689 DOI: 10.1007/s13671-022-00364-7] [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: 07/07/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Neutrophilic dermatoses are a heterogeneous group of disorders with significant overlap in associated conditions, clinical presentation, and histopathologic features. This review provides a structural overview of neutrophilic dermatoses that may present in the inpatient setting along with diagnostic work-up and management strategies. Recent Findings Sweet’s syndrome has been found in patients with coronavirus disease 2019 (COVID-19). Pyoderma gangrenosum (PG) has been shown to be equally associated with ulcerative colitis and Crohn’s disease. A clinical trial shows that cyclosporine is equally effective as prednisone in treating PG. Neutrophilic eccrine hidradenitis has been found in the setting of newer antineoplastic medications, such as BRAF inhibitors, as well as in the setting of malignancy without chemotherapy exposure. Summary Neutrophilic dermatoses are a rare and complex group of dermatoses with varying and overlapping clinical presentations. Physicians should be aware of the growing list of associated diseases in order to build a better differential diagnosis or to potentially investigate for co-existing disease.
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Gnesotto L, Mioso G, Alaibac M. Use of granulocyte and monocyte adsorption apheresis in dermatology (Review). Exp Ther Med 2022; 24:536. [PMID: 35837066 PMCID: PMC9257973 DOI: 10.3892/etm.2022.11463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/24/2022] [Indexed: 12/04/2022] Open
Abstract
Adsorptive granulocyte and monocyte apheresis (GMA) is an extracorporeal treatment that selectively removes activated myeloid lineage leukocytes from peripheral blood. This technique consists of a column with cellulose acetate beads as absorptive leukocytapheresis carriers, and was initially used to treat ulcerative colitis. A literature search was conducted to extract recently published studies about the clinical efficacy of GMA in patients with different skin disorders, reporting information on demographics, clinical symptoms, treatment and clinical course. Dermatological diseases, in which GMA has been performed, include generalized pustular psoriasis, pyoderma gangrenosum, palmoplantar pustular psoriasis, Behcet's disease, Sweet's syndrome, adult-onset Still's disease, impetigo herpetiformis, reactive arthritis, acne and hidradenitis suppurativa syndrome, cutaneous allergic vasculitis and systemic lupus erythematosus. In most patients, GMA was started after the failure of conventional therapeutic options and it was helpful in the majority of cases. Based on the information summarized, GMA could be considered a valid non-pharmacological treatment option for patients with several dermatological conditions, which are difficult to treat with other pharmacological preparations.
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Affiliation(s)
- Laura Gnesotto
- Dermatology Unit, Department of Medicine, University of Padova, I‑35128 Padova, Italy
| | - Guido Mioso
- Dermatology Unit, Department of Medicine, University of Padova, I‑35128 Padova, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine, University of Padova, I‑35128 Padova, Italy
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45
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Eltsov I, Sorgente A, de Asmundis C, La Meir M. First in human surgical implantation of a leadless pacemaker on the epicardial portion of the right atrial appendage in a patient with a cardiac electronic devices mediated dermatitis. Interact Cardiovasc Thorac Surg 2022; 35:6538742. [PMID: 35224625 PMCID: PMC9252116 DOI: 10.1093/icvts/ivac050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/31/2022] [Accepted: 02/17/2022] [Indexed: 11/30/2022] Open
Abstract
A 33-year-old woman with Sick Sinus Node syndrome and persistent atrial fibrillation underwent a Maze IV procedure in order treat atrial fibrillation and concomitant atrial epicardial implantation of a leadless pacemaker to manage her sinus node insufficiency. Last option has been chosen due to rare pocket complication after previous classic dual-chamber pacemaker implantation.
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Affiliation(s)
- Ivan Eltsov
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel , Brussels, Belgium
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart , Brussels, Belgium
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart , Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart , Brussels, Belgium
| | - Mark La Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel , Brussels, Belgium
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Kwon CI, Lee GW, Kim CY. Bullous Variant of Pyoderma Gangrenosum in a Patient with Acute Myeloid Leukemia. Ann Dermatol 2022; 34:212-215. [PMID: 35721340 PMCID: PMC9171183 DOI: 10.5021/ad.2022.34.3.212] [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: 05/07/2020] [Revised: 07/27/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022] Open
Abstract
Unlike classic pyoderma gangrenosum (PG), the bullous variant of PG is typically represented by a painful erythematous papule, plaque, and superficial bulla that progress into the ulceration with bullous margin. Generally, bullous PG is most commonly associated with myeloproliferative disorders, such as acute myeloid leukemia (AML). Bullous PG in AML patients rarely occurs, but once it does, it suggests a poor clinical prognosis. Although many cases of classic PG in AML patients have been reported, bullous PG is relatively rare. Therefore, we present a case of bullous PG that developed in a patient with AML and was successfully treated with high-dose systemic steroids.
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Affiliation(s)
- Chang-Il Kwon
- Department of Dermatology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Gyeong-Won Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Gyeongsang Institute of Health Science, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chi-Yeon Kim
- Department of Dermatology, Gyeongsang National University School of Medicine, Jinju, Korea
- Department of Dermatology and Gyeongsang Institute of Health Sciences, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
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Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments. Am J Clin Dermatol 2022; 23:615-634. [PMID: 35606650 PMCID: PMC9464730 DOI: 10.1007/s40257-022-00699-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 12/12/2022]
Abstract
Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving cutaneous ulcers with undermined, irregular, erythematous-violaceous edges. Pyoderma gangrenosum pathogenesis is complex and involves a profound dysregulation of components of both innate and adaptive immunity in genetically predisposed individuals, with the follicular unit increasingly recognized as the putative initial target. T helper 17/T helper 1-skewed inflammation and exaggerated inflammasome activation lead to a dysregulated neutrophil-dominant milieu with high levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-1α, IL-8, IL-12, IL-15, IL-17, IL-23, and IL-36. Low-evidence studies and a lack of validated diagnostic and response criteria have hindered the discovery and validation of new effective treatments for pyoderma gangrenosum. We review established and emerging treatments for pyoderma gangrenosum. A therapeutic algorithm based on available evidence is also provided. For emerging treatments, we review target molecules and their role in the pathogenesis of pyoderma gangrenosum.
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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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49
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Ten Dam L, Ten Broeke M, Poot AM, Gilbers MD, Halfwerk FR. Noninfectious sternal wound inflammation after coronary artery bypass grafting in a patient with myelodysplastic syndrome: A no-touch approach. J Card Surg 2022; 37:2419-2422. [PMID: 35524433 PMCID: PMC9321867 DOI: 10.1111/jocs.16570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/06/2022] [Accepted: 04/17/2022] [Indexed: 11/28/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare, chronic inflammatory noninfectious dermatosis. It is associated with underlying systemic or hematological diseases such as myelodysplastic syndrome (MDS) and can be triggered after surgery. Recognition and diagnosis of PG can be difficult as it can mimic a wound infection. Misdiagnosis could lead to invasive procedures which worsen the disease and have possible disastrous aftermath. A 74‐year‐old male with a history of MDS presents with an atypical sternal wound inflammation. Diagnosis confirmed PG after skin biopsy. No surgical or invasive procedures were performed and the patient was treated on an outpatient basis with prednisolone, clobetasol cream, and cyclosporine. This case shows the importance of a rapid diagnosis of the disease. Awareness is required for the diagnosis of PG in a wound with pronounced livid borders, without improvement after antibiotic treatment or worsening after debridement. Rapid diagnosis and treatment reduce high healthcare costs, morbidity, and mortality.
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Affiliation(s)
- Lotte Ten Dam
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Miarca Ten Broeke
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Angelique M Poot
- Department of Dermatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Martijn D Gilbers
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Frank R Halfwerk
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands.,Department of Biomechanical Engineering, Faculty of Engineering Technology, University of Twente, Enschede, The Netherlands
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Cutaneous manifestations of monoclonal gammopathy. Blood Cancer J 2022; 12:58. [PMID: 35411042 PMCID: PMC9001632 DOI: 10.1038/s41408-022-00661-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 12/29/2022] Open
Abstract
Monoclonal gammopathy associated with dermatological manifestations are a well-recognized complication. These skin disorders can be associated with infiltration and proliferation of a malignant plasma cells or by a deposition of the monoclonal immunoglobulin in a nonmalignant monoclonal gammopathy. These disorders include POEMS syndrome, light chain amyloidosis, Schnitzler syndrome, scleromyxedema and TEMPI syndrome. This article provides a review of clinical manifestations, diagnostics criteria, natural evolution, pathogenesis, and treatment of these cutaneous manifestations.
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