Pyoderma gangrenosum: a retrospective review of patient characteristics, comorbidities and therapy in 103 patients

BACKGROUND

Pyoderma gangrenosum (PG) is an uncommon and challenging disease, highly associated with comorbidities, but poorly characterized from a diagnostic and therapeutic perspective.

OBJECTIVES

To describe the epidemiology of PG in a hospital-based retrospective review, focusing on demographics, comorbidities and treatments.

METHODS

We conducted a retrospective chart review. Patient data were taken from the Research Patient Data Repository of Brigham and Women's Hospital and Massachusetts General Hospital from 1 January 2000 to 31 December 2007. We identified and confirmed 103 cases of PG, and collected data on anatomical location, number and size of the PG lesions, patient demographics, comorbidities, mortality rate and treatments.

RESULTS

Of the 103 patients, 78 (76%) were female, and only 7% had a biopsy suggestive of PG. The lower leg was the most common location with 78% of PG ulcers occurring there, and 67 (65% of patients) had two or more ulcers at some point. Thirty-five individuals (34%) had inflammatory bowel disease (IBD), 21 (20%) had haematological disorders, 14 (14%) had major depression, 20 (19%) had seronegative arthritis, 11 (11%) had psoriasis, and nine (9%) had hepatitis. Therapy was generally multimodal. The mortality rate during the 8-year study period was 16%.

CONCLUSIONS

We present one of the largest PG case series to date. In our study, we found that biopsy of a PG lesion rarely yielded characteristic features of the disease and tissue pathology should not be used to exclude a PG diagnosis. We also found a female predominance and associations with IBD and haematological disorders. Patients with PG in this series had high rates of depression and hepatitis. Further work is needed to establish the mechanism(s) underlying these findings.

iMTD (individualized maximal tolerated dose) protocol: A clinical strategy to address interindividual heterogeneity to antiangiogenic therapy

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Background: The determination of optimal biological dose is critical to the successful development of antiangiogenic agents. Recent studies suggest that genetic heterogeneity of angiogenesis and interindividual variations in efficacy response to angiogenic inhibitors and their side effects exist. Imiquimod, approved to treat skin cancer, is a topical immune response modifier with antiangiogenic effects mediated by interferons and interleukins. Although efficacy is associated with increased dosing frequency, adverse events are dose limiting. In clinical studies, imiquimod had a 75% efficacy rate in treating basal cell carcinoma (BCC) when dosed 5×/week × 12 weeks, but moderate to severe local inflammation was seen in up to 50%. Methods: The dose frequency that results in gross clinical skin inflammation is one marker of individual heterogeneity. To optimize efficacy while minimizing side effects, we devised a treatment algorithm termed Individualized Maximal Tolerated Dose (iMTD) to determine the optimal treatment frequency per patient. Imiquimod was applied in an incremental titrating fashion to BCC neoplasms (N=52): 2×/wk × 2 wks escalating to 3×/wk × 2 wks, then M-F × 2 wks, then daily × 2 wks. Dose frequency was increased until the threshold of inflammation, then lowered to the last best-tolerated dose. Tumor response and the maximal required/tolerated dose frequency (MTD) for each patient was recorded. Results: The iMTD protocol resulted in 52/52 complete responses with 0/52 cases of undesired inflammation. In order to achieve these results, a significant interindividual variation in dose tolerance was observed: 62% (32/52) required/tolerated 3×/week dosing for complete clearance, 29% (15/52) daily treatment, and 8% (4/52) 5×/week treatment. Conclusions: Because interindividual heterogeneity to response is not addressed in most clinical trial protocols, a single dose frequency among study cohorts generates outcomes that includes both responders and non-responders. When therapy is titratable by dose scheduling, the iMTD strategy may optimize clinical results while minimizing toxicities, a goal of antiangiogenic therapy.

No significant financial relationships to disclose.

Syringolymphoid hyperplasia and follicular mucinosis in a patient with cutaneous T-cell lymphoma

Syringolymphoid hyperplasia with alopecia is an uncommon chronic dermatosis of which 9 cases have been reported, with or without follicular mucinosis or cutaneous T-cell lymphoma. We report a patient with cutaneous T-cell lymphoma and syringolymphoid hyperplasia and follicular mucinosis and review the previously reported cases. All reported cases with syringolymphoid hyperplasia were men (10 of 10), with the clinical findings of alopecia (9 of 10) and anhidrosis (3 of 10). Only 3 of 10 cases had associated follicular mucinosis. Of the 7 cases investigated, 6 were found to hve cutaneous T-cell lymphoma. Three patients were not investigated for cutaneous T-cell lymphoma. Although syringolymphoid hyperplasia can be idiopathic, it can also reflect a syringotropic cutaneous T-cell lymphoma. Careful follow-up with a biopsy of persistent lesions is recommended to evaluate for the presence of lymphoma.

Diagnostic clues to dermatitis artefacta

We report a case of dermatitis artefacta in a 36-year-old man who had progressive, nonhealing ulcers and swelling of his right arm. The lesions spared two tattoos. In addition, our patient had several of the classic features of dermatitis artefacta. We outline more than a dozen diagnostic clues that may help the clinician faced with this difficult problem.

Off-label dermatologic therapies. Usage, risks, and mechanisms

Off-label refers to the prescribing of Food and Drug Administration-approved drugs for a use not indicated on the package insert. The prescribing of off-label drugs may benefit patients with many dermatologic diseases including angiogenesis-related conditions. We surveyed 55 dermatologists from a single large academic program to assess their use of particular drugs for specific skin conditions, their perception of such use as being for Food and Drug Administration-approved or for off-label indications, and their attitudes towards off-label therapies. The practice of prescribing off-label drugs was common among the respondents, many of whom had misperceptions about which conditions are Food and Drug Administration-approved indications and about the legal ramifications of off-label therapies. We suggest that understanding the principles of off-label prescribing in conjunction with the mechanisms of drug action in diseases may help clinicians exercise their judgment in finding innovative therapies for their patients.

Lichen planus localized to the nails

BACKGROUND

Lichen planus may rarely be localized to the nails.

OBJECTIVE

A case of ungual lichen planus is reported that was misdiagnosed as onychomycosis.

METHODS

A 52-year-old woman had progressive nail dystrophy for 13 months that was unresponsive to oral terbinafine. A nail biopsy was performed.

RESULTS

Histopathologic findings were consistent with lichen planus.

CONCLUSION

Onychomycosis may be confused clinically with other causes of nail dystrophy. It is important to confirm the diagnosis of onychomycosis with appropriate laboratory or histologic analysis.

Loose anagen syndrome and loose anagen hair

Loose anagen syndrome, or loose anagen hair, is a recently described condition of unknown etiology that may be under-recognized. The typical patient is a child with sparse fine hair that can easily be pulled out. The diagnosis is confirmed by microscopic examination of firmly pulled hairs, many of which are in the anagen phase but lacking an inner and outer root sheath and demonstrating a ruffled cuticle. Some presentations of alopecia areata may be confused with this condition, but the pull test analysis serves to differentiate them. A variety of theories have been postulated to explain the pathophysiology of loose anagen syndrome. In some cases, there is an autosomal dominant pattern of inheritance. In most cases, this condition spontaneously improves with age.

Microvessel count and cerebrospinal fluid basic fibroblast growth factor in children with brain tumours

Tumour growth is angiogenesis-dependent; brain tumours have more intense neovascularisation than other tumours and produce basic fibroblast growth factor, a potent angiogenic mediator. Because little is known about the release of basic fibroblast growth factor from brain tumours into extracellular fluids, we tested cerebrospinal fluid (CSF) from 26 children and young adults with brain tumours and 18 controls for basic fibroblast growth factor and for proliferative activity on cultured capillary endothelial cells. We also measured the density of microvessels in tumours by immunohistochemical staining. Basic fibroblast growth factor was detected in the CSF of 62% (16 of 26) patients with brain tumours but in none of the controls. Specimens with basic fibroblast growth factor stimulated DNA synthesis of capillary endothelial cells in vitro. Endothelial proliferative activity was blocked by neutralising antibodies to basic fibroblast growth factor. Basic fibroblast growth factor correlated with mitogenic activity in CSF in vitro (p < or = 0.0001), and with density of microvessels in histological sections (p < or = 0.005). A microvessel count of > or = 68 per 200 x field was associated with tumour recurrence (p = 0.005) and with mortality (p = 0.02). Basic fibroblast growth factor in brain tumours may mediate angiogenesis as measured by microvessel density in histological sections, so has potential as both a marker for neoplasia and a target for tumour treatments. Furthermore, evaluation of cerebrospinal fluid basic fibroblast growth factor, along with microvessel quantitation in biopsied tumours, may provide improved prognostic information for the management of patients with brain tumours.