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Gönüllü Ö, Kahraman FC, Yıldırım UM. Leg Ulcers in a Patient With Systemic Lupus Erythematosus and Successful Treatment With Anticoagulant Therapy. INT J LOW EXTR WOUND 2024:15347346241248260. [PMID: 38632946 DOI: 10.1177/15347346241248260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Among specific skin manifestations of systemic lupus erythematosus such as leukocytoclastic vasculitis, and vasculopathy, the development of leg ulcers is rare and frequently seen in patients with antiphospholipid antibody positivity. Here we report the rapid healing of a leg ulcer without antiphospholipid antibody positivity in a patient with lupus in response to anticoagulant therapy. As in our case, when immunosuppressive agents are inadequate in lupus patients who develop leg ulcers, it may be beneficial to support the treatment with anticoagulants.
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Affiliation(s)
- Öykü Gönüllü
- Department of Dermatology and Venerology, Göztepe Süleyman Yalçın Şehir Hastanesi, Istanbul Medeniyet University, Istanbul, Turkey
| | - Filiz C Kahraman
- Deparment of Dermatology and Venerology, Sultan 2, Abdülhamid Han Eğitim ve Araştırma Hastanesi, Sağlık Bilimleri University, Istanbul, Turkey
| | - Umut Mert Yıldırım
- Department of Dermatology and Venerology, Göztepe Süleyman Yalçın Şehir Hastanesi, Istanbul Medeniyet University, Istanbul, Turkey
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Teoh SC, Sim CY, Chuah SL, Kok V, Teh CL. Pyoderma gangrenosum and cobalamin deficiency in systemic lupus erythematosus: a rare but non fortuitous association. BMC Rheumatol 2021; 5:7. [PMID: 33653418 PMCID: PMC7927254 DOI: 10.1186/s41927-021-00177-4] [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: 10/07/2020] [Accepted: 01/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is an uncommon, idiopathic, ulcerative neutrophilic dermatosis. In many cases, PG is associated with a wide variety of different disorders but SLE in association with PG is relatively uncommon. In this article we present the case of a middle aged patient with PG as the initial clinical presentation of SLE. We also provide a brief review of cobalamin deficiency which occurred in our patient and evidence-based management options. CASE PRESENTATION A 35 years old man presented with a 5 month history of debilitating painful lower limb and scrotal ulcers. This was associated with polyarthralgia and morning stiffness involving both hands. He also complained of swallowing difficulties. He had unintentional weight loss of 10 kg and fatigue. Physical examination revealed alopecia, multiple cervical lymphadenopathies, bilateral parotid gland enlargement and atrophic glossitis. There was Raynaud's phenomenon noted over both hands and generalised hyper-pigmented fragile skin. Laboratory results disclosed anaemia, leukopenia, hyponatraemia and hypocortisolism. Detailed anaemic workup revealed low serum ferritin and cobalamin level. The autoimmune screen showed positive ANA, anti SmD1, anti SS-A/Ro 52, anti SSA/Ro 60, anti U1-snRNP with low complement levels. Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis and duodenitis. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were all negative. Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum. Based on the clinical findings and positive immunologic studies, he was diagnosed as systemic lupus erythematosus. His general condition improved substantially with commencement of corticosteroids, immunosuppressants and vitamin supplements. CONCLUSIONS We report a case of PG as the first manifestation of SLE which was treated successfully with immunosuppressants and vitamin supplements. Our report highlighted the need to consider connective tissue diseases such as SLE in a patient presenting with PG in order for appropriate treatment to be instituted thereby achieving a good outcome.
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Affiliation(s)
- Sing Chiek Teoh
- Department of Medicine, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Chun Yang Sim
- Faculty of Medicine and Health Sciences, University Malaysia Sarawak, Jalan Datuk Mohammad Musa, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Seow Lin Chuah
- Department of Medicine, Rheumatology Unit, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Victoria Kok
- Department of Medicine, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Cheng Lay Teh
- Department of Medicine, Rheumatology Unit, Sarawak General Hospital, Kuching, Sarawak, Malaysia
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Magdoud O, Souissi A, Chelly I, Haouet S, Mokni M. [Pyoderma gangrenosum and systemic lupus erythematosus: A rare association]. Rev Med Interne 2019; 41:54-57. [PMID: 31495525 DOI: 10.1016/j.revmed.2019.08.001] [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: 06/05/2019] [Revised: 08/03/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a neutrophilic dermatosis that is traditionally associated with systemic disorders such as chronic inflammatory bowel diseases, rheumatoid arthritis and malignant hematologic disorders. Its association with systemic lupus erythematosus (SLE) is rare and not well known. We report a case of this association with a review of the literature. CASE REPORT A 43-year-old female patient, followed for 4 years for SLE, presented a deep ulceration of the anterior face of the left thigh with inflammatory borders, an ulcerated nodule of the right shoulder and four small ulcerations of the back of the right hand. The biopsy of the ulceration of the left thigh concluded to PG. The patient was treated by corticosteroids with complete healing of lesions. CONCLUSION The prognosis of lupus does not seem to be aggravated by PG and the treatments of a SLE flare are usually enough for treating associated PG.
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Affiliation(s)
- O Magdoud
- Dermatology department, La Rabta Hospital, Tunis, Tunisia.
| | - A Souissi
- Dermatology department, La Rabta Hospital, Tunis, Tunisia
| | - I Chelly
- Pathology department, La Rabta Hospital, Tunis, Tunisia
| | - S Haouet
- Pathology department, La Rabta Hospital, Tunis, Tunisia
| | - M Mokni
- Dermatology department, La Rabta Hospital, Tunis, Tunisia
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Lebrun D, Robbins A, Hentzien M, Toquet S, Plee J, Durlach A, Bouaziz JD, Bani-Sadr F, Servettaz A. Two case reports of pyoderma gangrenosum and systemic lupus erythematosus: A rare but nonfortuitous association? Medicine (Baltimore) 2018; 97:e11933. [PMID: 30142811 PMCID: PMC6112963 DOI: 10.1097/md.0000000000011933] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Pyoderma gangrenosum (PG), like other neutrophilic dermatosis, may be associated with a variety of systemic disorders including inflammatory bowel diseases, rheumatoid arthritis, and hematologic disorders. Conversely, the association between PG and systemic lupus erythematosus (SLE) has rarely been reported. PATIENT CONCERNS We report here 2 cases of this association. DIAGNOSES The first case involves a 32-year-old woman who developed, 1 year after SLE diagnosis, 3 painful nodular lesions of PG on her face, and cervical area. The second case was observed in a 37-year-old woman referred for ulcerative nodular papules of PG on her legs, whereas she had been diagnosed with SLE 10 years before. SLE was inactive in the first case, whereas PG occurred during a lupus flare up in the second one. INTERVENTIONS We found 23 previous cases of SLE and PG in the literature with most cases (12/20) occurring during a lupus flare. OUTCOMES Although rare, this association may be supported by common innate immunity dysregulation and abnormal neutrophil activation. LESSONS PG and other neutrophilic diseases reported in patients with SLE may be added to the large clinical spectrum of cutaneous lesions observed in SLE.
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Affiliation(s)
- Delphine Lebrun
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
- Department of Internal Medicine and Infectious Diseases, Manchester Hospital, Charleville-Mézières
| | - Ailsa Robbins
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Maxime Hentzien
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Ségolène Toquet
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Julie Plee
- Department of Dermatology, Robert Debré Hospital
| | - Anne Durlach
- Laboratory of Pathology, Maison Blanche Hospital, University Hospital, Reims
| | | | - Firouzé Bani-Sadr
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
| | - Amélie Servettaz
- Department of Internal Medicine, Clinical Immunology and Infectious Diseases, Robert Debré Hospital, University Hospital, Reims
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Caimi G, Carlisi M, Urso C, Lo Presti R, Hopps E. Clinical disorders responsible for plasma hyperviscosity and skin complications. Eur J Intern Med 2017; 42:24-28. [PMID: 28390781 DOI: 10.1016/j.ejim.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 12/17/2022]
Abstract
In this brief review, we have examined some clinical disorders which are associated to an altered hemorheological profile and at times accompanied by skin ulcers. This skin condition may be, in fact, observed in patients with primary plasma hyperviscosity such as multiple myeloma, Waldenstrom macroglobulinemia, cryoglobulinemia, cryofibrinogenemia, dysfibrinogenemia and connective tissue diseases. It must be underlined that the altered hemorheological pattern is not the only responsible for this skin complication but, as it worsens the microcirculatory flow, it contributes to determine the occurrence of the skin ulcers.
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Affiliation(s)
- Gregorio Caimi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy.
| | - Melania Carlisi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Caterina Urso
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Rosalia Lo Presti
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
| | - Eugenia Hopps
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Italy
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Sharkawy M, Samadoni AE. Color-coded etiological keys: A simple survey tool towards amputation-free limb survival in diabetic foot lesions. J Diabetes Investig 2016; 7:413-9. [PMID: 27330729 PMCID: PMC4847897 DOI: 10.1111/jdi.12425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/25/2015] [Accepted: 08/28/2015] [Indexed: 12/30/2022] Open
Abstract
Aims/Introduction We devised a simple implementable color‐coded etiological key survey based on six significant categories to screen and manage all diabetic foot patients. The study results were analyzed to verify the impact of this survey. Materials and Methods First we carried out a retrospective internal survey of all diabetic patients that presented to us during the period from January 2004 to January 2007. We used this analysis to develop the color‐coded etiological survey, and applied it to analyze patients prospectively for 5 years from May 2007 to May 2012. Out of 4,102 diabetic foot patients, 739 patients were referred by other medical facilities for major amputation as a result of the severity of their foot lesions. This group was then subjected to further analysis to study the value and impact of the survey on amputation‐free limb survival. Results Blood quality abnormalities were most prevalent followed by peripheral occlusive diseases, whereas tissue loss was the least. After the completion of the assessment process, management was implemented according to the defined protocol based on the lesions’ characteristics. The primary end‐point of major amputation‐free limb survival was achieved in 72.5% of patients, with an average hospital stay of 13.3 days. Statistical analysis of the etiological keys showed a significant impact of tissue loss, and previous foot surgery as a poor predictor of limb loss. Conclusion We conclude that the implementation of the color‐coded etiological key survey can provide efficient and effective service to diabetic foot victims with comparable outcomes to dedicated diabetic foot clinics.
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Akita S. Lower Extremity Wounds in Patients With Idiopathic Thrombocytopenic Purpura and Systemic Lupus Erythematosus. INT J LOW EXTR WOUND 2015; 14:224-30. [PMID: 26353824 DOI: 10.1177/1534734615604776] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Infections in lower extremities are sometimes concerned with systemic immunological disorders such as idiopathic thrombocytopenic purpura and systemic lupus erythematosus, which are treated with systemic steroids. Steroid therapy impairs the epithelial wound healing and with systemic condition, especially with systemic lupus erythematosus, the wound is susceptible for infection. Even a pyoderma gangrenosum sometimes occurs in a patient with idiopathic thrombocytopenic purpura with an incisional wound of hernia. The severe signs and symptoms are the deep skin and soft tissue infections, mainly caused by group A streptococcus, composed of necrotizing fasciitis and muscle necrosis. Medically suspected necrotizing fasciitis patients should be empirically and immediately administered with broad-spectrum antibiotics, which may cover the common suspected pathogens. In type I (polymicrobial) infection, the selection of antimicrobial should be based on medical history and Gram staining and culture. The coverage against anaerobes is important in type I infection. Metronidazole, clindamycin, or beta-lactams with beta-lactamase inhibitor or carbapenems are the treatment of choice against anaerobes, while early surgical debridement-wide enough and deep enough-is the core treatment of necrotizing fasciitis and results in significantly better mortality compared with those who underwent surgery after a few hours of delay. When necrotizing fasciitis is considered and the patient is brought to the operation room, aggressive and extensive surgical debridement is explored. Tissue involved should be completely removed until no further evidence of infection is seen. When further debridement is required, the patient must return to the operating room immediately. In this context, the temporal coverage using the artificial dermis after debridement is useful because there is no loss of the patient's own tissue and yet it is easier for "second-look" surgery or secondary reconstruction, and extensive enough debridement is always the mainstay of the therapy.
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Hau E, Vignon Pennamen MD, Battistella M, Saussine A, Bergis M, Cavelier-Balloy B, Janier M, Cordoliani F, Bagot M, Rybojad M, Bouaziz JD. Neutrophilic skin lesions in autoimmune connective tissue diseases: nine cases and a literature review. Medicine (Baltimore) 2014; 93:e346. [PMID: 25546688 PMCID: PMC4602621 DOI: 10.1097/md.0000000000000346] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The pathophysiology of neutrophilic dermatoses (NDs) and autoimmune connective tissue diseases (AICTDs) is incompletely understood. The association between NDs and AICTDs is rare; recently, however, a distinctive subset of cutaneous lupus erythematosus (LE, the prototypical AICTD) with neutrophilic histological features has been proposed to be included in the spectrum of lupus. The aim of our study was to test the validity of such a classification. We conducted a monocentric retrospective study of 7028 AICTDs patients. Among these 7028 patients, a skin biopsy was performed in 932 cases with mainly neutrophilic infiltrate on histology in 9 cases. Combining our 9 cases and an exhaustive literature review, pyoderma gangrenosum, Sweet syndrome (n = 49), Sweet-like ND (n = 13), neutrophilic urticarial dermatosis (n = 6), palisaded neutrophilic granulomatous dermatitis (n = 12), and histiocytoid neutrophilic dermatitis (n = 2) were likely to occur both in AICTDs and autoinflammatory diseases. Other NDs were specifically encountered in AICTDs: bullous LE (n = 71), amicrobial pustulosis of the folds (n = 28), autoimmunity-related ND (n = 24), ND resembling erythema gyratum repens (n = 1), and neutrophilic annular erythema (n = 1). The improvement of AICTDS neutrophilic lesions under neutrophil targeting therapy suggests possible common physiopathological pathways between NDs and AICTDs.
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Affiliation(s)
- Estelle Hau
- From the Dermatology Department (EH, AS, MJ, FC, MarB, MR, JDB) and Pathology Department (MDVP, MaxB, BCB), Paris Diderot University, Sorbonne Paris Cité, AP-HP, Saint Louis Hospital, Paris, France
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González-Moreno J, Ruíz-Ruigomez M, Callejas Rubio JL, Ríos Fernández R, Ortego Centeno N. Pyoderma gangrenosum and systemic lupus erythematosus: a report of five cases and review of the literature. Lupus 2014; 24:130-7. [PMID: 25199808 DOI: 10.1177/0961203314550227] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Pyoderma gangrenosum (PG) is an uncommon, distinctive cutaneous ulceration which is usually idiopathic, but may be associated with many systemic disorders. The etiopathogenesis of PG is still not well understood. PG is part of the spectrum of the neutrophilic dermatoses and it has been proposed as a prototype of cutaneous autoinflammatory disease. PG usually has a good outcome under immunosuppressive treatment. Although PG has been associated with several systemic diseases, it has rarely been reported in association with systemic lupus erythematosus (SLE). In this article we report five cases of SLE-related PG and review the literature. Our findings support the possible relationship between active SLE and PG, although the mechanism remains unclear. Clinical manifestations, used treatments and outcomes of SLE-related PG do not differ from the described for the general population.
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Affiliation(s)
- J González-Moreno
- Internal Medicine Department, Hospital Son Llàtzer, Spain Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - M Ruíz-Ruigomez
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - J L Callejas Rubio
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - R Ríos Fernández
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
| | - N Ortego Centeno
- Autoimmune Diseases Unit, Internal Medicine Department, Hospital Clínico San Cecilio, Spain
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Wollina U, Tchernev G. Pyoderma gangrenosum: pathogenetic oriented treatment approaches. Wien Med Wochenschr 2014; 164:263-73. [DOI: 10.1007/s10354-014-0285-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 05/01/2014] [Indexed: 01/10/2023]
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Dabiri G, Falanga V. Connective tissue ulcers. J Tissue Viability 2013; 22:92-102. [PMID: 23756459 DOI: 10.1016/j.jtv.2013.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 04/30/2013] [Indexed: 01/10/2023]
Abstract
Connective tissue disorders (CTD), which are often also termed collagen vascular diseases, include a number of related inflammatory conditions. Some of these diseases include rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis (scleroderma), localized scleroderma (morphea variants localized to the skin), Sjogren's syndrome, dermatomyositis, polymyositis, and mixed connective tissue disease. In addition to the systemic manifestations of these diseases, there are a number of cutaneous features that make these conditions recognizable on physical exam. Lower extremity ulcers and digital ulcers are an infrequent but disabling complication of long-standing connective tissue disease. The exact frequency with which these ulcers occur is not known, and the cause of the ulcerations is often multifactorial. Moreover, a challenging component of CTD ulcerations is that there are still no established guidelines for their diagnosis and treatment. The morbidity associated with these ulcerations and their underlying conditions is very substantial. Indeed, these less common but intractable ulcers represent a major medical and economic problem for patients, physicians and nurses, and even well organized multidisciplinary wound healing centers.
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Affiliation(s)
- Ganary Dabiri
- Department of Dermatology and Skin Cancer, Roger Williams Medical Center, 50 Maude Street, Providence, RI 02908, USA
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12
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Abstract
Neutrophilic dermatoses, including Sweet's syndrome, pyoderma gangrenosum, and rheumatoid neutrophilic dermatitis, are inflammatory conditions of the skin often associated with underlying systemic disease. These are characterized by the accumulation of neutrophils in the skin. The associated conditions, potential for systemic neutrophilic infiltration, and therapeutic management of these disorders can be similar. Sweet's syndrome can often be effectively treated with a brief course of systemic corticosteroids. Pyoderma gangrenosum, however, can be recurrent, and early initiation of a steroid-sparing agent is prudent. Second-line treatment for both of these conditions includes medications affecting neutrophil function, in addition to immunosuppressant medications.
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Affiliation(s)
- Courtney R Schadt
- Division of Dermatology, University of Louisville, 310 East Broadway, Louisville, KY 40202, USA.
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13
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Leg ulcers in the antiphospholipid syndrome may be considered as a form of pyoderma gangrenosum and they respond favorably to treatment with immunosuppression and anticoagulation. Rheumatol Int 2010; 30:1253-7. [DOI: 10.1007/s00296-010-1418-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Accepted: 03/10/2010] [Indexed: 10/19/2022]
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Dass TA. What is your diagnosis? Leg ulcers in SLE. INDIAN JOURNAL OF RHEUMATOLOGY 2010. [DOI: 10.1016/s0973-3698(10)60535-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Masatlıoğlu SP, Göktay F, Mansur AT, Akkaya AD, Güneş P. Systemic lupus erythematosus presenting as pyoderma gangrenosum in two cases. Rheumatol Int 2008; 29:837-40. [DOI: 10.1007/s00296-008-0791-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2008] [Accepted: 09/07/2008] [Indexed: 11/29/2022]
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Abstract
There are many reasons for tissue breakdown in the leg, and each cause requires a different treatment to either correct the abnormality or to manage the symptoms that cause the patient distress. The pathway to appropriate treatment relies on a working knowledge of anatomy and physiology and good assessment. This article aims to provide a basic knowledge in how to recognize different leg ulcer types.
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