Risk factors and treatment outcomes of peristomal pyoderma gangrenosum in patients with inflammatory bowel disease

Practical aspects of the diagnosis and management of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.

Diagnosis and Treatment Difficulty in Early-Onset Peristomal Pyoderma Gangrenosum Associated With Ulcerative Colitis: A Case Report

Peristomal pyoderma gangrenosum (PPG) is a rare dermatological condition associated with gastroenterological disease. Most gastrointestinal surgeons find it difficult to suspect and treat PPG, especially at early onset. The patient was an 18-year-old female. The patient underwent three-stage restorative proctocolectomy for refractory ulcerative colitis. On postoperative day (POD) 9, the trocar wound near the ileostomy site dehisced. Because the wound culture was positive, the wound was treated with an antibacterial agent as an infection. However, the wound worsened. The patient was referred to a dermatologist for diagnosis. PPG was diagnosed on POD 37. Wound management was initiated using topical steroids. The wound caused difficulties in pain and dressing management. Although infliximab was administered as a systemic therapy, it was discontinued because of allergic symptoms. Sealing therapy with hydrofiber dressing and adequate stoma pouching with stoma paste provided good exudate absorption and a clean environment by protecting the wound from stoma excretion. Oral prednisone was initiated on POD 82. Improvement in the wound condition was observed with a prednisone dose of 30 mg/day. Complete remission was achieved seven months after onset. Twelve months after the surgery, stoma closure was performed. The local cutaneous condition remained in remission without exacerbation. Suspicion of PPG can be difficult when it develops early after stoma creation. We never forget that PPG should be suspected when a progressive ulcerative lesion is found around the stoma, even early after operation. If PPG is suspected, a multidisciplinary team plays an essential role in its diagnosis and management.

Vedolizumab and Extraintestinal Manifestations in Inflammatory Bowel Disease

In Crohn's disease and ulcerative colitis, inflammation is not limited to the digestive tract. Extraintestinal manifestations (EIMs), which affect up to 50% of patients, can substantially impair quality of life. EIMs may parallel luminal disease activity or have an independent course. They most commonly involve the musculoskeletal system (e.g., peripheral or axial arthritis) and skin (e.g., erythema nodosum and pyoderma gangrenosum). Less commonly, the hepatobiliary tract (e.g., primary sclerosing cholangitis [PSC]) and the eye (e.g., episcleritis, scleritis, and uveitis) are involved. Although the pathophysiology of EIMs is poorly understood, they are likely either manifestations of a primary systemic immune disease with variable expression amongst organs, or secondary phenomena to bowel inflammation. Additional pathophysiologic mechanisms may include aberrant lymphocyte homing mediated by ectopic expression of gut-specific chemokines and adhesion molecules, cross-reactivity between microbial and self-antigens, autoantibodies against epitopes shared by the intestine and extraintestinal tissues, elevated serum concentrations of cytokines, and alterations in innate immunity. Many EIMs independent of intestinal disease activity can be successfully treated with tumor necrosis factor (TNF) antagonists. The efficacy of vedolizumab-a monoclonal antibody targeting the α4β7 integrin-for the treatment of EIMs is uncertain, but data are emerging from post hoc analyses of randomized controlled trials, prospective and retrospective cohort studies, and case series. Vedolizumab may be effective in treating EIMs related to luminal disease activity (e.g., type 1 peripheral arthritis and erythema nodosum) but has not shown biochemical improvement in PSC. Its postulated role in the development of de novo EIMs is heavily confounded by the high proportion of patients previously exposed to TNF antagonists; new EIMs could result from TNF antagonist treatment cessation rather than being caused by vedolizumab. A common limitation of clinical studies is the lack of multidisciplinary involvement in the diagnosis and monitoring of EIMs, which may lead to misdiagnosis and overreporting. Future studies should rigorously measure EIMs in parallel with objective measures of luminal disease activity to provide more robust data on the relative efficacy of new drugs, especially as increasing numbers of gut-selective compounds enter clinical development.

Infliximab treatment for large, multifocal, abdominal pyoderma gangrenosum associated with ulcerative colitis: A case report

Pyoderma gangrenosum is an uncommon neutrophilic dermatosis that is highly associated with pathergy in the setting of trauma or surgery, systemic disease, or may be idiopathic. Herein, we present the case of a 68-year-old female with ulcerative colitis who underwent a subtotal colectomy with an end-ileostomy and presented post-operatively with large, multifocal pyoderma gangrenosum at two abdominal sites. She was managed with intralesional triamcinolone injections and high-dose systemic steroids and was transitioned to IV infliximab. Our case report illustrates the role of infliximab in the treatment of complicated multifocal pyoderma gangrenosum and contemplates the impact of systemic infliximab exposure.