Pyoderma Gangrenosum: An Update on Pathophysiology, Diagnosis and Treatment

Vegetative Pyoderma Gangrenosum Mimicking Squamous Cell Carcinoma: A Poorly Recognized Diagnostic Challenge

ABSTRACT

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that is difficult to diagnose due to non-specific clinical, laboratory, and histopathologic features. Distinguishing pseudoepitheliomatous hyperplasia (PEH) from squamous cell carcinoma (SCC) is also histopathologically challenging. The connection between PEH and PG is not well recognized, and instances of PG mimicking SCC are rare. We report a case of vegetative PG accompanied by PEH, originally mistaken for SCC. A 78-year-old woman presented with a 3-month history of an ulcerated, exophytic, and painful mass on her right lower leg. An incisional biopsy revealed PEH and neutrophilic microabscesses, initially raising concerns for SCC keratoacanthoma type with PEH or well-differentiated, infiltrative SCC. However, following additional review of clinical and histopathologic findings at the cutaneous oncology tumor board, the diagnosis of vegetative PG with associated PEH was favored. This case highlights the significance of recognizing PEH as a histopathology feature that can be seen in PG and lead to difficulty distinguishing PG with PEH from SCC. We stress the importance of promptly diagnosing PG through clinical and histopathologic correlation to prevent diagnostic delays and unnecessary surgeries or treatments.

The Importance and Challenges of Early Diagnosis of Paraneoplastic Skin Syndromes in Cancer Detection-A Review

Skin paraneoplastic syndromes (SPNSs) are a group of disorders that arise as a consequence of cancer but are not directly related to the tumor mass itself. This review aims to provide a comprehensive overview of these syndromes, encompassing their pathophysiology, clinical features, diagnostic approaches, differential diagnosis, and management strategies. These syndromes, which include conditions such as Bazex syndrome, acanthosis nigricans, dermatomyositis, and necrolytic migratory erythema often manifest prior to or concurrently with a cancer diagnosis, serving as potential early warning signs of underlying malignancies. This review delves into the spectrum of SPNSs and their associations with specific cancer types. Special emphasis is placed on the critical role of dermatologists and oncologists in identifying these skin manifestations as potential markers of malignancy. By raising awareness of SPNSs, this paper highlights the pivotal importance of prompt recognition and intervention in reducing cancer-related mortality.

Pyoderma gangrenosum refined elements for core item selection and evaluation (PRECISE-PG): a study protocol for reaching consensus on core outcome domain items in clinical trials of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a debilitating inflammatory skin condition characterized by painful, necrotic ulcers, significantly impairing patient quality of life. The variability in clinical outcomes and the lack of standardized treatment protocols challenge effective PG clinical management and research. The Understanding Pyoderma Gangrenosum, Review and Assessment of Disease Effects (UPGRADE) project seeks to address this gap by establishing a core outcome set (COS) for PG clinical trials. UPGRADE has reached consensus on three core outcome domains: Pain, Quality of Life, and Clinical Signs. Here we describe a protocol detailing the next steps of UPGRADE's COS development to employ an international multistakeholder modified Delphi consensus process to reach consensus on the content of each core domain through the identification and definition of core domain-specific domain items. The process outlined in this protocol will involve generating domain items from the existing literature, refining these items through iterative e-Delphi surveys, and finalizing them in a consensus meeting. This work will enhance the granularity of these domains and facilitate more precise outcome measurement in clinical trials. The development of these detailed domain items is crucial for standardizing outcome reporting across PG trials, thereby improving research quality and enabling better treatment strategies, ultimately enhancing patient outcomes.

Resolution of Pyoderma Gangrenosum During Adjuvant Breast Cancer Therapy

Background/Objectives: Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly developing, painful ulcerative lesions. It exhibits pathergy, a phenomenon in which minor trauma or injury to the skin triggers an exaggerated inflammatory response. This leads to the development of new skin lesions or the worsening of existing ones. Treatment typically involves a combination of corticosteroids and immunosuppressive agents. However, even with effective therapy, the overall management of pyoderma gangrenosum remains challenging, and wound healing can be prolonged. The development of pyoderma gangrenosum after breast cancer surgery is rare, and its presence complicates the treatment of patients requiring additional oncologic therapy. In particular, the effect of radiation on these lesions is not well documented. Given the known skin toxicity of radiotherapy and its negative impact on wound healing, the use of adjuvant breast radiation raises significant concerns in this context. Methods: We present the case of a 66-year-old female with Stage IIB invasive ductal carcinoma of the left breast who developed postoperative pyoderma gangrenosum after breast-conserving surgery. The patient was treated with systemic corticosteroids and cyclosporine, and then subsequently underwent standard-of-care adjuvant chemotherapy and radiation. Results: During therapy, she demonstrated rapid resolution of her pyoderma gangrenosum without experiencing excess skin toxicity. Conclusions: While the literature on the direct application of radiation in pyoderma gangrenosum is limited, our case provides evidence supporting the safety of radiation therapy in oncologic cases complicated by this disease. In addition to receiving the benefit of adjuvant therapy for her breast cancer, our patient demonstrated an improvement in her postoperative PG with no adverse skin effects.

Paraneoplastic Dermatoses: A Clue for Underlying Malignancies

Paraneoplastic dermatoses (PDs) belong to a group of rare and polymorphous dermatoses, and they can often be the first sign of underlying malignancies. Therefore, dermatologists should be able to identify skin features to identify earlier underlying neoplasms. Indeed, lack of familiarity with cutaneous clues of internal malignancies can lead to a delay in the diagnosis and an impairment of the prognosis of the patients. In this review, we described several PDs, including more common and rarer PD. Indeed, while malignant acanthosis nigricans, characterized by velvety, verrucous, hyperpigmented plaques that usually affect intertriginous areas, is a well-known PD, necrolytic migratory erythema is usually misdiagnosed because its clinical features can be similar to seborrheic dermatitis. Furthermore, we focused on two paradigmatic PDs, namely paraneoplastic autoimmune multiorgan syndrome (PAMS) and paraneoplastic dermatomyositis. Indeed, PAMS represents a paradigmatic form of obligate PD, which is always associated with an underlying neoplasm, while paraneoplastic dermatomyositis belongs to the facultative PD, which can be associated with neoplasia in a variable percentage of cases.

A Case of Pyoderma Gangrenosum in a 40-Year-Old Male Patient: A Challenging Diagnosis

Pyoderma gangrenosum (PG) is a rare, immune-mediated neutrophilic dermatosis, presenting with painful ulcerative skin lesions. These lesions often start as pustules on an erythematous base, progressing to large ulcers with purulent edges. Diagnosing PG can be challenging, as it lacks definitive tests and requires exclusion of other conditions, including infections and vascular diseases. PG is frequently associated with systemic autoimmune diseases such as inflammatory bowel disease, rheumatoid arthritis, and monoclonal gammopathies. This report describes a case of a 40-year-old Hispanic male patient with recurrent, painful lesions on his lower extremities. Initially misdiagnosed as cellulitis, the patient had a complex history of peripheral vascular disease, which added to the diagnostic difficulty. The patient's history of recurrent ulcerations, persistent post-inflammatory hyperpigmentation, and rapid response to corticosteroids led to a clinical diagnosis of PG. This case highlights the need for careful differential diagnosis in chronic, non-healing lesions, emphasizing that PG should be considered, particularly in atypical presentations or in patients without common systemic associations. Early recognition and immunosuppressive therapy are crucial to avoid misdiagnosis and improve patient outcomes.

Secukinumab Treatment in Patients with Hidradenitis Suppurativa in Real-World Clinical Settings: A Multicenter Study

INTRODUCTION

Treatment of hidradenitis suppurativa (HS) remains a challenge in clinical practice for dermatologists. Although the effectiveness and safety of secukinumab (SEC) in the treatment of HS have been demonstrated in phase III studies, real-world data is limited.

OBJECTIVES

We conducted a retrospective multicenter study to evaluate the effectiveness and safety of SEC treatment in HS patients in real-world settings.

METHODS

Adult patients who were diagnosed with HS and used SEC for at least 3 months were included in the study.

RESULTS

A total of 31 patients were included in the study; 14 of them (45.2%) were female. The mean age was 39.32 ± 10.26 years, and the mean disease duration was 11.77 ± 7.99 years. Nine (29%) patients were biologic-naive and 10 (32.3%) were adalimumab-naive. Disease severity was Hurley I in 7 patients (22.6%), Hurley II in 9 patients (29%), and Hurley III in 15 patients (48.4%). The Hidradenitis Suppurativa Clinical Response (HiSCR) was achieved in 20 patients (64.5%) in the third month of treatment. SEC treatment was discontinued due to primary ineffectiveness in 9 (29%) patients, secondary ineffectiveness in 1 (3.2%) patient, adverse effects in 1 (3.2%) patient, and loss of follow-up in 1 (3.2%) patient. Paradoxical pyoderma gangrenosum was observed as an adverse effect in 1 patient that resolved after discontinuing SEC and starting infliximab.

CONCLUSIONS

SEC appears to be an effective and safe treatment option for HS, especially when used in the early and mild stages of the disease and in biologic-naive patients.

Nonmalignant Dermatologic Disorders in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is associated with extraintestinal manifestations that can affect multiple body systems. Extraintestinal manifestations (EIMSs) are seen in up to 50% of patients with IBD. Skin involvement is particularly common occurring in up to 15%-20% of patients. Skin reactivity presents in multiple forms with unique pathology. Therapy for IBD also may affect the skin directly through inflammatory processes or indirectly because of skin infections. This review will concentrate on the most common nonmalignant dermatologic conditions associated with IBD with a focus on prevalence, diagnostic approaches, and management strategies.

Living with Pyoderma Gangrenosum: A Qualitative Study

Pyoderma gangrenosum is a rare, autoinflammatory disorder characterized by rapidly progressive painful ulcers that are challenging to diagnose and treat. This qualitative study aimed to explore the experiences of patients living with pyoderma gangrenosum. Using an inductive qualitative approach, semi-structured interviews were completed with a purposive sample of 21 patients with pyoderma gangrenosum recruited from a public dermatology outpatient clinic in Melbourne, Australia. A reflexive thematic analysis was performed, yielding 5 themes: pain, physical challenges, social functioning and relationships, mental health, and treatment. The impact of pyoderma gangrenosum on quality of life was multifaceted and varied throughout disease progression, remission, and recurrence. Experiences of delayed diagnosis and misdiagnosis were common, causing distress and resulting in unnecessary treatments including surgery. Severe pain disrupted sleep and limited daily activities, eroding patients' sense of self-control and perpetuating depressed mood and anxiety. Management should include early specialist referral, providing information sheets for managing pain and wound care, and communicating disease expectations. In conclusion, this study has deepened understanding and given personal perspectives on what it is like to live with a condition poorly understood by many health professionals. Increased efforts should be made to increase clinician awareness regarding pyoderma gangrenosum to facilitate early diagnosis.

Systemic auto-inflammatory manifestations in patients with spondyloarthritis

OBJECTIVES

(1) characterizing a group of spondyloarthritis (SpA) patients with systemic auto-inflammatory symptoms (S-SpA); (2) comparing SpA features with and without auto-inflammatory symptoms; (3) comparing the auto-inflammatory features of S-SpA and Still's disease (SD).

METHODS

Retrospective observational study. Clinical data of adult and pediatric patients with S-SpA, SD or SpA were collected retrospectively and analyzed.

RESULTS

Forty-one subjects with S-SpA, 39 with SD and 42 with SpA were enrolled. The median latency between systemic and articular manifestations in S-SpA was 4.4 (IQR: 7.2) years. S-SpA and SpA had similar frequency of peripheral arthritis and enthesitis (N.S.), while tenosynovitis was more frequent (P=0.01) and uveitis less frequent (P<0.01) in S-SpA. MRI showed signs of sacroiliac inflammation and damage in both S-SpA and SpA equally (N.S.). S-SpA patients had less corner inflammatory lesions (P<0.05) and inflammation at the facet joints (P<0.01), more interspinous enthesitis (P=0.01) and inter-apophyseal capsulitis (P<0.01). Compared to SD, S-SpA patients had lower-grade fever (P<0.01), less rash (P<0.01) and weight loss (P<0.05), but more pharyngitis (P<0.01), gastrointestinal symptoms (P<0.01) and chest pain (P<0.05). ESR, CRP, WBC, ANC, LDH tested higher in SD (P<0.01). Resolution of systemic symptoms was less frequent in S-SpA than SD on corticosteroid (P<0.01) and methotrexate (P<0.05) treatment. When considering all SD patients, a complete response to corticosteroids in the systemic phase significantly reduced the likelihood of developing SpA (OR=0.06, coefficient -2.87 [CI: -5.0 to -0.8]).

CONCLUSIONS

SpA should be actively investigated in patients with auto-inflammatory manifestations, including undifferentiated auto-inflammatory disease and SD.

Inflammatory and vaso-occlusive ulcers: Part I - Clinical presentation and diagnosis

In this CME, we review 2 specific categories of ulcers: inflammatory (where inflammation is the primary pathologic process leading to ulceration) and vaso-occlusive (where occlusion is the primary process). Inflammatory ulcers include pyoderma gangrenosum and vasculitides, whereas livedoid vasculopathy, calciphylaxis, and Martorell ulcers are vaso-occlusive ulcers. Determining the causes of ulcers in these conditions may require laboratory evaluation, biopsy, and imaging.

The Clinical and Molecular Response of Pyoderma Gangrenosum to IL-23 Blockade: Result from a Proof-of-Concept Open-Label Clinical Trial

Pyoderma gangrenosum is a severe ulcerative disease with a great need for novel therapies. A major barrier to the development of novel therapies is a lack of understanding of disease pathogenesis. We present the results of a proof-of-concept open-label clinical trial of IL-23p19 antagonism with tildrakizumab in pyoderma gangrenosum. Gene expression analysis identified proinflammatory genes associated with IFN responses and dendritic cell activity, including IFI27, XBP1, SAA1 LGALS3, and signal transducer and activator of transcription 3 significantly downregulated in lesional tissue after 12 weeks of therapy. Immunohistochemistry confirmed reduction in IL-17A- and IL-17F-positive cells as well as reduction in TNF-a-, C5a-, and IL-1B-positive cells in week 12 samples compared with those at baseline. Significant reduction in serum inflammation was observed through serum proteomics, with IL-8, IL-6, and CASP-8 levels reduced comparable with those in healthy controls at week 12. Clinical outcomes demonstrated significant reduction in ulcer size, pain, itch, and QOL outcomes in line with the molecular findings. Differential expression of key inflammatory cytokines such as IL-8, CXCL5, PD-L1, SPP1, and matrix metalloproteinase 1 was observed in tissue and serum when stratified by clinical responders and nonresponders. These data provide insights into the clinical relevance of alterations in molecular markers in pyoderma gangrenosum and the potential for the identification of clinically relevant biomarkers of disease activity.

Analysis of clinical characteristics and factors affecting treatment responses in patients with pyoderma gangrenosum: a multicenter study of 239 patients☆

BACKGROUND

Pyoderma Gangrenosum (PG) is a chronic disease characterized by recalcitrant skin ulcers.

OBJECTIVE

We aimed to evaluate the demographic, clinical characteristics, treatments and factors affecting the treatment responses of patients with PG.

METHODS

We performed a multicenter study of 12 tertiary care centers. We analyzed the data of the patients who were followed up with a diagnosis of PG between the years 2012‒2022 retrospectively.

RESULTS

We included a total of 239 patients of whom 143 were female and 96 were male, with an average age of 54.2 ± 17.4 years. The most common treatment was systemic steroids (n = 181, 75.7%). Among these patients, 50.8% (n = 92) used systemic steroids as the sole systemic agent, while 49.2% (n = 89) used at least one adjuvant immunosuppressive agent. The independent factors determined in regression analysis to influence response to systemic steroids positively were disease onset age ≥ 30-years, negative pathergy, absence of leukocytosis, negative wound culture, presence of a single lesion, and absence of upper extremity involvement. Biological agents were used in 18.4% (n = 44) of the patients in the present study. We also analyzed pathergy positive PG and early onset (onset age < 30) PG separately due to their distinct clinical features which were revealed during statistical analysis.

STUDY LIMITATIONS

Retrospective nature of the present study.

CONCLUSIONS

Analyses of the factors influencing treatment responses are addressed in this study. Also, we concluded that investigation for accompanying autoinflammatory diseases of pathergy positive PG and early onset PG is necessary and the patients in these two groups are more resistant to treatment, necessitating more complicated treatments.

A Review of Cutaneous Extraintestinal Manifestations of Inflammatory Bowel Disease in Skin of Color

The incidence of inflammatory bowel disease (IBD) is increasing in racial and ethnic minority groups. Cutaneous extraintestinal manifestations (EIMs) of IBD are well-known comorbid conditions that can occur in both active and quiescent IBD. Historically, cutaneous EIMs of IBD are described in White skin with a lack of literature describing these conditions in darker skin tones. This potentially creates a knowledge gap and awareness among providers in recognizing these conditions and offering therapy in a timely manner to non-White patients. This review aims to describe the cutaneous manifestations of IBD in a wide range of skin tones with several examples to improve awareness. With further awareness, this review will enable to provide equitable care to IBD patients with cutaneous EIMs.

Clinical characteristics of pyoderma gangrenosum: Case series and literature review

BACKGROUND

Pyoderma gangrenosum (PG) is a neutrophilic skin disease characterized by recurrent painful cutaneous ulcers, often accompanied by inflammatory bowel disease, joint pain, and other systemic damage. This disease is relatively rare in clinical practice and its diagnosis and treatment are often delayed, leading to secondary infections in the skin lesions, prolonged disease course, and increased disease burden on patients. This study retrospectively analyzed the clinical characteristics and treatment strategies of patients with PG admitted to our hospital and conducted a literature review, in order to improve the understanding of the disease among clinical doctors, enable patients to receive better diagnosis and treatment, and ultimately improve patient prognosis.

METHODS

Clinical data of patients diagnosed with PG and hospitalized in Beijing Chaoyang Hospital, Capital Medical University from January 2014 to December 2022 were retrospectively collected. The clinical manifestations, treatment strategies, efficacy, and disease outcomes were analyzed.

RESULTS

A total of 14 patients, including 8 males and 6 females, aged 14 to 66 years, were included. Skin lesion types: 13 cases were ulcer-type, 1 case was pustule combined with ulcer-type, and the lower limbs were the most commonly affected areas. All the 14 patients presented with comorbidities. All patients were treated with glucocorticoids, with a daily dose equivalent to 20 to 100 mg prednisone and a median dose of 40 mg. Among them, 3 patients were treated with minocycline in combination, 1 patient was treated with mycophenolate mofetil 0.5 twice daily in combination, 1 patient was treated with cyclophosphamide 0.1 once daily in combination, and 1 patient was treated with thalidomide 0.1 every night in combination.

CONCLUSION

PG is a relatively rare immune-related skin disease. Our small sample data analysis found that male PG is not uncommon in the Chinese population. Systemic glucocorticoids can quickly control the symptoms of PG in most patients with PG. In patients with poor efficacy or limited use of glucocorticoids, immunosuppressive drugs or novel targeted drugs such as biologics or small-molecule drugs should be used in combination as early as possible. Skin lesion care focuses on preventing infection, avoiding surgical debridement, and emphasizing pain management and the symptomatic treatment of comorbidities.

Development of Postsurgical Pyoderma Gangrenosum with New Keloid after Keloid Resection

ABSTRACT

Keloids are a dermal fibroproliferative disorder and can arise from trauma, acne, vaccination, and herpes zoster. Pyoderma gangrenosum (PG) is a painful ulcerative skin disorder that is associated with neutrophilic dysfunction. However, the pathophysiologies of keloids and PG are not fully understood. The authors encountered an unusual case of a 24-year-old woman who presented with an anterior chest keloid that bore an ulcer. The keloid was resected along with the ulcer, and histology revealed the ulcer to be a neutrophilic PG ulcer. A year after surgery, another ulcer developed in the scar. The ulcer met the PARACELSUS criteria of a postsurgical PG ulcer. After treatment with systemic prednisone and adalimumab for 250 days, the ulcer re-epithelialized. However, relapsed keloids were then observed at the PG site. Corticosteroid taping may be the safest therapy for patients with a history of PG. Conversely, if there is suspicion that a patient is prone to keloid development, diagnostic biopsies and surgical management of PG ulcers should be avoided or conducted with care.

Other Wounds Encountered in Clinical Practice

This chapter delves into uncommon wounds including pyoderma gangrenosum, sickle cell disease ulcers, vasculitic wounds, Martorell hypertensive ischemic leg ulcers, and malignant ulcers. Emphasizing a multidisciplinary approach, it covers diagnostics, treatments, and challenges, with case studies illustrating complexities in managing these conditions. The discussion extends to radiation-related wounds, underscoring the need for patient-centered care, interdisciplinary collaboration, and realistic goal setting. Overall, the chapter navigates the intricacies of uncommon wounds, emphasizing the importance of tailored approaches for improved outcomes in patients with diverse underlying conditions.

Treatment of Pyoderma Gangrenosum With Vilobelimab

This case report describes a man in his 20s with psoriasis who was receiving stable treatment with adalimumab for 3 years and was diagnosed with pyoderma gangrenosum and was referred for a 6-month history of multiple inflammatory ulcers on the right dorsal foot and ankle.

Topical Tranexamic Acid (TXA) Decreases Time to Drain Removal, Wound Healing Complications, and Postoperative Blood Loss in Autologous Breast Reconstruction: A Retrospective Study

Introduction: Drain placement is commonplace after many plastic surgery procedures to evacuate excess blood and fluid. Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease bleeding and fluid production at surgical sites and can be administered orally, intravenously, and topically. The purpose of this study is to evaluate the effect of topical TXA on drain removal in abdominally based autologous breast reconstruction (ABABR). Methods: A retrospective chart review was performed on patients who underwent ABABR from August 2018 to November 2019. In 1 cohort, a 2.5% TXA solution was topically applied to the abdominal wall prior to closure. Drains were removed when output was less than 30 mL/day for 2 consecutive days. The primary outcome was days to drain removal. Secondary outcomes include daily inpatient drain output, postoperative hemoglobin levels, blood transfusions, and complications within 30 days postoperatively. Results: Eighty-three patients were included, with 47 in the control group and 36 in the TXA group. Drains were removed significantly earlier in patients who received TXA (16 days vs 23 days, P = .02). Additionally, significantly fewer patients required postoperative blood transfusions in the TXA group (2 vs 14, P = .005). Abdominal complications were fewer in the TXA group with significantly less wound healing complications (22% vs 49%, P = .01). There was no difference in flap loss or systemic thromboembolic events. Conclusion: Topical TXA use in ABABR results in earlier abdominal drain removal, less blood transfusions, and lower abdominal wound complications without an increased risk of flap loss or adverse patient outcomes.

Pyoderma Gangrenosum Post-Breast Surgery: A Case Report and Comprehensive Review of Management Strategies

Background/Objectives: Pyoderma gangrenosum (PG) is a rare, autoimmune skin condition characterized by painful, rapidly progressing ulcers, often associated with autoimmune dysregulation. Managing PG following breast surgery presents unique challenges due to its pathergy phenomenon, which complicates surgical interventions. This article outlines the case of PG in a 48-year-old female post-breast surgery and reviews management strategies through a systematic analysis of the literature. Methods: A systematic literature review from 2018 to 2023 identified 24 relevant articles on PG management post-breast surgery. The studies were analyzed to compare the efficacy and complications of conservative versus combined (conservative and surgical) treatment strategies. Results: Results indicate that while conservative management, primarily with corticosteroids, remains preferred, combined strategies, including systemic therapies, vacuum-assisted closure, and surgery, offer significant benefits in select cases. Conclusions: Our findings suggest that a personalized, multifaceted treatment plan is crucial for managing PG effectively, emphasizing the need for early detection, meticulous planning, and comprehensive care to optimize patient outcomes.

The role of split-thickness skin grafting in the treatment of vasculitic and pyoderma gangrenosum ulcers in a multidisciplinary wound centre

Vasculitic and pyoderma gangrenosum ulcers are traditionally treated with immunosuppressants, and the role of surgery in the treatment of these atypical ulcers remains unclear. This study aimed to investigate the need for surgical intervention as well as the outcome and safety of skin grafting in the treatment of 46 patients with vasculitic ulcers and 34 with pyoderma gangrenosum ulcers using data recorded in the validated Wound Registry. Of the 80 patients with atypical ulcers, 14% (n = 11) were treated surgically; these patients were older (p = 0.039), had lower mobility status (p = 0.002), and more often pulmonary diseases, rheumatoid arthritis, and previous arterial procedures (p = 0.007; p = 0.031; p = 0.031, respectively) than those treated conservatively. Of 181 ulcers, 15% (n = 27) were surgically treated, 78% once and 22% multiple times. During follow-up, 92.3% of both surgically and conservatively treated ulcers with available data healed. Of the surgically treated ulcers, median healing time after first surgical procedure was 96 days, and post-surgical complications were considered mild or unrelated to surgery. Our results suggest that if surgery is indicated, skin grafting is a safe and efficient treatment method provided that multidisciplinary approach is applied.

A rare case study of pyoderma gangrenosum with dilated cardiomyopathy and multiple cerebral infarct in malnourished children

Pyoderma gangrenosum (PG) is an extremely rare case of sterile necrotic ulcerative disease associated with malnutrition as a predisposition factor. It is unclear, though, whether dilated cardiomyopathy, which affects blood flow and results in stenosis in the arteries, could play a role as an etiology. In this study, a case of pyoderma gangrenosum in a 10-year-old boy complicated by dilated cardiomyopathy, a previous history of cerebrovascular disease, and a malnourished condition were reported. The patient was reported to have exudative necrotic lesions in both legs. Lesions began as small, multiple, itchy lesions on both legs, which later became blisters and scuffed, and progressed into painful, peeled-off lesions with pus, bleeding, redness around lesions, and maggots within a month. A high fever was an accompanying symptom. The multidisciplinary team was involved to provide a comprehensive treatment for this patient. Antibiotics and necrotomy debridement were performed several times. Anticoagulant treatment was indicated as the coagulation markers were increased and echocardiography suggested thrombus in the left ventricle. The underlying condition that increases the risk of pyoderma gangrenosum should be corrected. The patient was discharged after a clinical improvement, although the continuation of outpatient monitoring was required. Our report suggests that a chronic condition of dilated cardiomyopathy that affects normal blood flow leads to malnutrition, the formation of thrombus, and stenosis of a peripheral artery, all of which contributed to pyoderma gangrenosum. Therefore, early surgical treatment, antibiotic administration, and anticoagulant treatment were recommended.

Monoclonal gammopathy in the setting of Pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by ulcerative painful lesions with violaceous undermined borders. Up to 75% of PG cases develop in association with an underlying systemic disease. Monoclonal gammopathy is reportedly a concomitant condition with PG, with studies indicating immunoglobulin (Ig) A gammopathy as the most common. Whether gammopathy is associated with PG or is an incidental finding has been debated. We sought to investigate the association and characteristics of gammopathy in patients with PG. We retrospectively identified PG patients at our institution from 2010 to 2022 who were screened for plasma cell dyscrasia. Of 106 patients identified, 29 (27%) had a gammopathy; subtypes included IgA (41%), IgG (28%), and biclonal (IgA and IgG) (14%). Mean age was similar between those with and without gammopathy (60.7 vs. 55.9 years; P = .26). In addition, hematologic or solid organ cancer developed in significantly more patients with vs. without gammopathy (8/29 [28%] vs. 5/77 [6%]; P = .003). Among the subtypes of gammopathy, IgG monoclonal gammopathy had the highest proportion of patients with subsequent cancer development (4 of 8 patients, 50%). Study limitations include a retrospective, single-institution design with a limited number of patients. Overall, our data show a high prevalence of gammopathy in patients with PG; those patients additionally had an increased incidence of cancer, especially hematologic cancer.

Exploring Microemulsion Systems for the Incorporation of Glucocorticoids into Bacterial Cellulose: A Novel Approach for Anti-Inflammatory Wound Dressings

The effective pharmacological treatment of inflamed wounds such as pyoderma gangraenosum remains challenging, as the systemic application of suitable drugs such as glucocorticoids is compromised by severe side effects and the inherent difficulties of wounds as drug targets. Furthermore, conventional semi-solid formulations are not suitable for direct application to open wounds. Thus, the treatment of inflamed wounds could considerably benefit from the development of active wound dressings for the topical administration of anti-inflammatory drugs. Although bacterial cellulose appears to be an ideal candidate for this purpose due to its known suitability for advanced wound care and as a drug delivery system, the incorporation of poorly water-soluble compounds into the hydrophilic material still poses a problem. The use of microemulsions could solve that open issue. The present study therefore explores their use as a novel approach to incorporate poorly water-soluble glucocorticoids into bacterial cellulose. Five microemulsion formulations were loaded with hydrocortisone or dexamethasone and characterized in detail, demonstrating their regular microstructure, biocompatibility and shelf-life stability. Bacterial cellulose was successfully loaded with the formulations as confirmed by transmission electron microscopy and surprisingly showed homogenous incorporation, even of w/o type microemulsions. High and controllable drug permeation through Strat-M® membranes was observed, and the anti-inflammatory activity for permeated glucocorticoids was confirmed in vitro. This study presents a novel approach for the development of anti-inflammatory wound dressings using bacterial cellulose in combination with microemulsions.

Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup

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.

Pediatric Neutrophilic Dermatoses

The term neutrophilic dermatosis encompasses a heterogeneous group of diseases, often associated with an underlying internal noninfectious disease, with an overlapping histopathologic background characterized by perivascular and diffuse neutrophilic infiltrates in one or more layers of the skin; extracutaneous neutrophilic infiltrates may be associated. Neutrophilic dermatoses are not frequent in children and, when they appear in this age group, represent a diagnostic and therapeutic challenge. Apart from the classic neutrophilic dermatoses such as pyoderma gangrenosum, Sweet syndrome, and Behçet disease, a neutrophilic dermatosis can be the presentation of rare genetic diseases of the innate immune system, such as autoinflammatory diseases.

From Skin to Blood: Ulcerative Pyoderma Gangrenosum Unveiling Acute Myeloid Leukemia

While Pyoderma gangrenosum (PG) is commonly associated with hematological disorders such as acute myeloid leukemia (AML), it typically presents concurrently with the hemopathy, mostly in its bullous form, among middle-aged individuals. Here, we report the unusual case of a young female patient who presented with PG in its ulcerative form, three weeks before the onset of AML. A 31-year-old female presented with a one-week history of painful perianal papulopustule that evolved into an irregular ulceration with violaceous borders, mucopurulent serosity, and erythematous surrounding skin. Laboratory work-up demonstrated elevated inflammatory markers and hyperleukocytosis, with no cytopenia, and normal peripheral blood smear. Two weeks later, the ulcer growth was noted with a similar ulceration at a venipuncture site. A complete blood count revealed pancytopenia, with 45% blasts on the peripheral blood smear. Skin biopsies showed an aseptic neutrophilic infiltrate in favor of PG. Intravenous methylprednisolone was administered with rapid resolution of the lesions. However, the patient died shortly after. The post-mortem results of bone marrow aspirate revealed AML, with immunohistochemistry of the skin lesions confirming the clonality of neutrophils derived from the leukemic clone.  This case highlights a distinctive clinical presentation, illustrating the manifestation of PG three weeks before the onset of AML in its ulcerative rather than bullous form, in a young female patient.

Penile Pyoderma Gangrenosum, a Rare Encounter in STI Healthcare: A Case Report and a Review of the Literature

Abstract is missing (Short communication)

Use of Baricitinib in a patient with treatment-resistant pyoderma gangrenosum

Pyoderma gangrenosum is a rare inflammatory neutrophilic disorder with no uniformly effective therapy and limited high-level evidence. Common therapies include immunosuppressive and immunomodulating agents. There exist several case series using small molecules as treatment modalities. Here, we report a case of a 78-year-old female with a diagnosis of pyoderma gangrenosum and metastatic high-grade serous carcinoma of the ovary who was treated with Baricitinib 4 mg daily in combination with a tapering course of prednisone after failing other conventional therapies including systemic corticosteroids, colchicine, and intravenous immunoglobulin.

Recalcitrant Pyoderma Gangrenosum of the Face: A Case Report

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.

The Pathophysiology and Treatment of Pyoderma Gangrenosum-Current Options and New Perspectives

Pyoderma gangrenosum (PG) is an uncommon inflammatory dermatological disorder characterized by painful ulcers that quickly spread peripherally. The pathophysiology of PG is not fully understood; however, it is most commonly considered a disease in the spectrum of neutrophilic dermatoses. The treatment of PG remains challenging due to the lack of generally accepted therapeutic guidelines. Existing therapeutic methods focus on limiting inflammation through the use of immunosuppressive and immunomodulatory therapies. Recently, several reports have indicated the successful use of biologic drugs and small molecules administered for coexisting diseases, resulting in ulcer healing. In this review, we summarize the discoveries regarding the pathophysiology of PG and present treatment options to raise awareness and improve the management of this rare entity.

Progressive Facial Ulcer: A Case Report of Pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly developing and painful skin ulcers with distinctive features. As far as we are concerned, there is no previous case report on facial PG in East-Asia. In this case, we describe a case of a 79-year-old man with a 3-month history of progressive painful ulcers on his cheek and upper lip. Initial suspicion of atypical mycobacterium infection led to an ineffective treatment regimen. Comprehensive infectious testing yielded negative results, and a positive pathergy test indicated a potential diagnosis of PG. A skin biopsy confirmed the diagnosis, and the patient showed significant improvement with intravenous methylprednisolone and oral cyclosporine treatment. After three months, complete resolution of the lesions was achieved without recurrence. The case highlights the diagnostic challenges associated with PG, which is often misdiagnosed due to its resemblance to other conditions. Thorough evaluation is crucial to exclude alternative diagnoses, particularly cutaneous infections. Clinical morphology, tissue biopsy, and culture are essential for accurate diagnosis. The presence of pathergy, the development of new lesions following minor trauma, can also be a diagnostic clue.

Wound Debridement in Pyoderma Gangrenosum

BACKGROUND

Wound debridement improves healing in a variety of acute and chronic ulcers. However, there is concern that debridement may trigger pathergy and worsen pyoderma gangrenosum (PG).

OBJECTIVE

To determine whether published evidence supports conservative wound debridement for PG.

DATA SOURCES

The authors reviewed the literature published in MEDLINE through January 2023 using the search germs "pyoderma gangrenosum" and "debridement."

STUDY SELECTION

Articles reporting sharp surgical debridement or maggot debridement for PG were included in the review. The authors also searched the reference sections of the reviewed articles for additional reports on debridement for PG.

DATA EXTRACTION

Clinical data regarding patient status, procedures performed, and patient outcomes were extracted from the selected articles.

DATA SYNTHESIS

There are multiple reports of uncontrolled, active-phase PG wounds worsening after aggressive excisional debridement of viable inflamed tissues. In contrast, there is no evidence indicating that conservative debridement of nonviable necrotic tissue worsens PG wounds, regardless of the disease activity. There are multiple reports of successful debridement and surgical grafting for PG in remission.

CONCLUSIONS

There is no evidence in favor of or against using conservative debridement of nonviable necrotic tissue for a PG wound. Therefore, it should not be considered contraindicated, even in the active phase of the disease.

Treatment of systemic sclerosis complicated with pyoderma gangrenosum with adalimumab: A case report of a rare disease

Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis characterized by recurrent, painful ulcers that commonly affect the lower extremities but can also involve other parts of the body. Over half of patients with PG have concomitant systemic immune diseases, with the association of PG with systemic sclerosis (SSc) being extremely rare. Treatment of PG primarily involves local therapy, steroids, and immunosuppressants, with an increasing emphasis on biologic agents. Among these, tumor necrosis factor-alpha (TNF-α) antagonists are considered effective. The patient in this report was an elderly female with a history of systemic sclerosis for many years and initially presented with gangrenous ulcers on the fingertips. After inconclusive conventional treatment, adalimumab was added for 5 weeks, resulting in disease suppression, a reduction in ulcer size, and re-epithelialization of the skin lesions after 6 months.

Quantifying the clinical and economic burden of desquamating dermatological conditions: Implications for a supraregional burns centre

INTRODUCTION

This study aimed to identify the spectrum of desquamating skin diseases referred for tertiary burns care and quantify the care requirements and expenses associated with caring for these patients within the burns service.

METHODS

Patient records were identified with nonburn-induced skin loss between 2016 and 2022. Data was extracted from inpatient records, operative notes, and dressing clinic records. A cost analysis was conducted using figures from the National Schedule of National Health Service Costs and our own unit-specific costs.

RESULTS

Twenty patients were identified, with a median age of 46.5 and a median total body surface area of 30%. The mean length of stay was 21.2 days, with 8/20 patients requiring intensive care. Overall mortality was 30%, rising to 50% if patients required intensive treatment unit (ITU) admission. Patients had a mean of 1.5 procedures under general anaesthesia and a mean operative time of 169 min per patient. Postoperatively, a mean of 8.3 dressing changes was required per patient (range 1-21). Of 75% of patients referred as suspected toxic epidermal necrolysis syndrome (TENS), only 32% of patients histologically had TENS (32%), with linear IgA disease, pemphigus vulgaris and bullous lupus comprising the other diagnoses. Cost analysis predicted a total cost to the unit of £1,422,106.

CONCLUSION

Desquamating dermatological diseases are life-threatening conditions with exhaustive care requirements. Our experiences highlight the importance of awareness of the range of desquamating skin conditions beyond TENS to enable optimum management and the need to ensure adequate financial provisions to accommodate the care requirements mandated by these patients.

Pyoderma gangrenosum after surgery for forefoot deformity in a patient with rheumatoid arthritis: A case report

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.

Current insights on the roles of gut microbiota in inflammatory bowel disease-associated extra-intestinal manifestations: pathophysiology and therapeutic targets

Inflammatory bowel disease (IBD) is a chronic, recurrent inflammatory disease of the gastrointestinal tract. In addition to digestive symptoms, patients with IBD may also develop extra-intestinal manifestations (EIMs), the etiology of which remains undefined. The gut microbiota has been reported to exert a critical role in the pathogenesis of IBD, with a similar pattern of gut dysbiosis observed between patients with IBD and those with EIMs. Therefore, it is hypothesized that the gut microbiota is also involved in the pathogenesis of EIMs. The potential mechanisms are presented in this review, including: 1) impaired gut barrier: dysbiosis induces pore formation in the intestinal epithelium, and activates pattern recognition receptors to promote local inflammation; 2) microbial translocation: intestinal pathogens, antigens, and toxins translocate via the impaired gut barrier into extra-intestinal sites; 3) molecular mimicry: certain microbial antigens share similar epitopes with self-antigens, inducing inflammatory responses targeting extra-intestinal tissues; 4) microbiota-related metabolites: dysbiosis results in the dysregulation of microbiota-related metabolites, which could modulate the differentiation of lymphocytes and cytokine production; 5) immunocytes and cytokines: immunocytes are over-activated and pro-inflammatory cytokines are excessively released. Additionally, we summarize microbiota-related therapies, including probiotics, prebiotics, postbiotics, antibiotics, and fecal microbiota transplantation, to promote better clinical management of IBD-associated EIMs.

Certolizumab treatment of localized pyoderma gangrenosum in a pregnant patient

THE PURPOSE OF THE ARTICLE

Pyoderma gangrenosum (PG) is an ulcerating neutrophilic dermatosis with an incidence of 3-10 patients per million. PG equally affects patients of both sexes and of any age. Of these patients, 50-75% are associated with auto-immune disease. The lower extremities are the most commonly affected body parts. Minor trauma to the skin may result in the development of new lesions. Patients complain of chronic, nonhealing ulcers with associated pain. Treatment starts with systemic or intralesional corticosteroids, however, no official treatment protocol currently exists. Recent success has been found with biologic agents such as TNF-a inhibitor, although the treatment efficacy in these reports is limited. As for the pregnant patient, the drug selection is difficult. In this report, we want to assess the efficiency of certolizumab in the pregnant patient.

RESULTS

We report a case of a patient with PG, who responded well to certolizumab, 400 mg as a booster dose, followed by 200 mg biweekly for 8 weeks. The lesions gradually resolved and followed up for 5months without side effect. In addition, we reviewed the literature and compared the current treatment efficiency in the treatment of PG.

CONCLUSION

Certolizumab may be a promising therapeutic option for patients with severe PG.

Predilection sites of pyoderma gangrenosum: Retrospective study of 170 clearly diagnosed patients

Pyoderma gangrenosum (PG) is a non-infectious, neutrophilic dermatosis that was difficult to diagnose in clinical practice. Today, the PARACELSUS score is a validated tool for diagnostics. Based on this score, patients with clearly diagnosed PG were examined with regard to predilection sites. In this retrospective study, the data of patients from the University Hospitals of Essen and Erlangen were analysed in whom the diagnosis of PG could be clearly confirmed using the PARACELSUS score. A total of 170 patients, 49 men (29%) and 121 women (71%) with an average age at first manifestation of 55.5 years, could be included in the analysis. The predilection sites were identified as the lower legs in 80.6% of the patients and the extensor sides in 75.2%. Other localisations of PG were the thighs in 14.1%, mammae and abdomen in 10.0% each, back and gluteal in 7.1% each, feet in 5.9%, arms in 4.7%, genital in 3.5% and head in 2.9%. This retrospective study is the first to identify a collective of PG patients with the highest data quality using the PARACELSUS score. It could be shown that PG can basically occur on the entire integument. However, the predilection sites of PG, which have now been reliably identified for the first time, are the lower legs and in particular the extensor sides.

Facial pyoderma gangrenosum associated with fallopian tube carcinosarcoma

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis associated with underlying disorders. The association between PG and solid organ tumors (SM), including gynecologic cancers, has been previously reported. Here, we report a case of a 61-year-old woman with pyoderma gangrenosum on the posterior auricular region associated with an underlying fallopian tube carcinosarcoma: a rare and aggressive gynecologic malignancy. The patient's ulcer responded favorably to treatment, and surgical resection of the tumor was performed. The patient was then referred for further cancer management. No new lesions or recurrences were found over the 18 months of routine follow-up.

Ustekinumab in the treatment of acute disseminated pyoderma gangrenosum in a patient with Crohn's disease

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.

Invasive Pyoderma Gangrenosum and Concomitant Methicillin-Sensitive Staphylococcus aureus Septic Arthritis of the Glenohumeral Joint

A 78-year-old man with a history of multiple cancers presented with severe shoulder pain, elevated inflammatory markers, an ulcerating skin lesion along the anterior shoulder, symptoms concerning for septic arthritis, and a lytic lesion of the humeral head. A negative work-up for malignancy prompted infectious work-up and biopsies, revealing positive methicillin-sensitive Staphylococcus aureus cultures, yet a curious finding of perivascular lymphocytic infiltrates and fibrinoid necrosis from both the dermal vessel wall from a skin biopsy and humeral head bone biopsy, suggestive of pyoderma gangrenosum. This was a previously undocumented presentation of pyoderma gangrenosum invasion into a large joint with concomitant bacterial septic arthritis. [Orthopedics. 2023;46(5):e321-e325.].