1
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Erduran F, Adışen E, Hayran Y, Aksoy GG, Alpsoy E, Selçuk LB, Günaydın SD, Yazıcı AC, Öktem A, Güngör M, Afacan E, Kuşçu DD, Elmas L, Aydoğan K, Bayramgürler D, Demirsoy EO, Akyol M, Güner RY, Erdoğan HK, Acer E, Ergun T, Yaylı S, Bulut F, Saraç E, Aktaş A. Analysis of clinical characteristics and factors affecting treatment responses in patients with pyoderma gangrenosum: a multicenter study of 239 patients ☆. An Bras Dermatol 2024:S0365-0596(24)00079-5. [PMID: 38735817 DOI: 10.1016/j.abd.2024.02.002] [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: 10/30/2023] [Revised: 02/08/2024] [Accepted: 02/17/2024] [Indexed: 05/14/2024] Open
Abstract
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.
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Affiliation(s)
- Funda Erduran
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey.
| | - Esra Adışen
- Department of Dermatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Yıldız Hayran
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Güneş Gür Aksoy
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Erkan Alpsoy
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Leyla Baykal Selçuk
- Department of Dermatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Sibel Doğan Günaydın
- Department of Dermatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ayça Cordan Yazıcı
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Ayşe Öktem
- Ankara University Faculty of Medicine, Department of Dermatology, Ankara, Turkey
| | - Malik Güngör
- Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Elif Afacan
- Department of Dermatology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Deniz Devrim Kuşçu
- Ankara University Faculty of Medicine, Department of Dermatology, Ankara, Turkey
| | - Leyla Elmas
- Department of Dermatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kübra Aydoğan
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Dilek Bayramgürler
- Department of Dermatology, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | | | - Melih Akyol
- Department of Dermatology, Sivas Cumhuriyet University Faculty of Medicine, Sivas, Turkey
| | - Rukiye Yasak Güner
- Department of Dermatology, Sivas Cumhuriyet University Faculty of Medicine, Sivas, Turkey
| | - Hilal Kaya Erdoğan
- Department of Dermatology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Ersoy Acer
- Department of Dermatology, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Tulin Ergun
- Marmara University Faculty of Medicine, Department of Dermatology, İstanbul, Turkey
| | - Savaş Yaylı
- Department of Dermatology, Koç University Faculty of Medicine, İstanbul, Turkey
| | - Ferhan Bulut
- Marmara University Faculty of Medicine, Department of Dermatology, İstanbul, Turkey
| | - Esra Saraç
- Department of Dermatology, Koç University Faculty of Medicine, İstanbul, Turkey
| | - Akın Aktaş
- Department of Dermatology, Ankara Bilkent City Hospital, Ankara, Turkey
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Yadav R, Vague M, Rettig M, Loo CP, Brown K, Samiea A, Moreau JM, Ortega-Loayza AG. IL-12/IL23 blockade reveals patterns of asynchronous inflammation in pyoderma gangrenosum. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.26.591387. [PMID: 38746177 PMCID: PMC11092430 DOI: 10.1101/2024.04.26.591387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis causing chronic and recalcitrant painful ulcerations. Pathogenic mechanisms are yet poorly understood limiting therapeutic options, however, IL-12/IL-23 inhibition via ustekinumab has previously been associated with positive outcomes. We aimed to elucidate the dysregulated immune landscape of PG and lesional skin changes associated with IL-12/IL-23 blockade. We applied spatial transcriptomics and comparative computation analysis on lesional biopsies from two patients obtained before and after IL-12/IL-23 blockade with ustekinumab. Our data indicate lesional PG skin exhibits complex patterns of inflammation, including a not previously described major infiltration of B cells and establishment of tertiary lymphoid structures. In both patients, IL-12/IL-23 blockade led to marked clinical improvement but was associated with amelioration of contrasting inflammatory pathways. Notably, plasma cell markers and tertiary structures were recalcitrant to the treatment regime suggesting that B cells might play a role in the refractory nature of PG.
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3
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Zaino ML, Schadt CR, Callen JP, Owen LG. Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup. Dermatol Clin 2024; 42:157-170. [PMID: 38423678 DOI: 10.1016/j.det.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.
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Affiliation(s)
- Mallory L Zaino
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA.
| | - Courtney R Schadt
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
| | - Jeffrey P Callen
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
| | - Lafayette G Owen
- Department of Dermatology, University of Louisville, 3810 Springhurst Boulevard, Suite 200, Louisville, KY, USA
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4
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Chadli S, Maamar M, Khibri H, Harmouche H, Tazi Mezalek Z. From Skin to Blood: Ulcerative Pyoderma Gangrenosum Unveiling Acute Myeloid Leukemia. Cureus 2024; 16:e58838. [PMID: 38784334 PMCID: PMC11114624 DOI: 10.7759/cureus.58838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/25/2024] Open
Abstract
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.
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Affiliation(s)
- Sarra Chadli
- Internal Medicine, Ibn Sina University Hospital, Mohammed V University, Rabat, MAR
| | - Mouna Maamar
- Internal Medicine, Ibn Sina University Hospital, Mohammed V University, Rabat, MAR
| | - Hajar Khibri
- Internal Medicine, Ibn Sina University Hospital, Mohammed V University, Rabat, MAR
| | - Hicham Harmouche
- Internal Medicine, Ibn Sina University Hospital, Mohammed V University, Rabat, MAR
| | - Zoubida Tazi Mezalek
- Internal Medicine, Ibn Sina University Hospital, Mohammed V University, Rabat, MAR
- Hematology, Ibn Sina University Hospital, Mohammed V University, Rabat, MAR
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5
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Becker SL, Rios-Duarte JA, Morrison GM, Xia E, Mostaghimi A, Himed S, Kaffenberger BH, Zhang D, Shields BE, Cogen AL, Ortega-Loayza AG. Perioperative management and clinical outcomes of peristomal pyoderma gangrenosum. Arch Dermatol Res 2024; 316:98. [PMID: 38446235 DOI: 10.1007/s00403-024-02826-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 12/20/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024]
Abstract
Peristomal pyoderma gangrenosum is an uncommon subtype of pyoderma gangrenosum mainly affecting stoma sites of patients with inflammatory bowel disease. While surgical treatments are often used to assist healing, little is known about the relationship between surgical interventions and the rate of recurrence of peristomal pyoderma gangrenosum. The aim of this study was to identify patient and clinical factors associated with peristomal pyoderma gangrenosum recurrence following surgical intervention. A multi-institutional retrospective case series and literature review was conducted to evaluate patient characteristics and perioperative treatment. Patients of any age with peristomal pyoderma gangrenosum undergoing surgical operations related to their pyoderma gangrenosum or due to another comorbidity were included. Descriptive statistics were used to characterize demographic information. Associations were evaluated using Wilcoxon's rank-sum test for continuous variables and Fisher's exact test for categorical data. Thirty-seven cases were included, 78.3% of which had a history of inflammatory bowel disease. Overall, 13 (35.1%) cases experienced recurrence at 30 days. There was no significant association identified between patient demographics, stoma location, surgical intervention, or perioperative treatment with rate of recurrence at 30 days post-operation. While no clinical risk factors or treatments were associated with recurrence, our work underscores the importance of a multidisciplinary approach to this disease to address gastrointestinal, dermatologic, and surgical components of treatment.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health and Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
| | | | - Georgia Mae Morrison
- Department of Dermatology, Oregon Health and Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Eric Xia
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sonia Himed
- Department of Dermatology, The Ohio State University, Columbus, OH, USA
| | | | | | | | | | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
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6
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Kurimoto T, Mitsui Y. Pathergy in a patient with pyoderma gangrenosum. J Dermatol 2024; 51:e29-e30. [PMID: 38087852 DOI: 10.1111/1346-8138.17076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 02/04/2024]
Affiliation(s)
- Toru Kurimoto
- Department of Dermatology, Nara Prefecture General Medical Center, Nara, Japan
| | - Yasuhiro Mitsui
- Department of Dermatology, Nara Prefecture General Medical Center, Nara, Japan
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7
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Hofmann AG, Deinsberger J, Oszwald A, Weber B. The Histopathology of Leg Ulcers. Dermatopathology (Basel) 2024; 11:62-78. [PMID: 38390849 PMCID: PMC10885126 DOI: 10.3390/dermatopathology11010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Ulcerations of the lower extremities are a frequently encountered problem in clinical practice and are of significant interest in public health due to the high prevalence of underlying pathologies, including chronic venous disease, diabetes and peripheral arterial occlusive disease. However, leg ulcers can also present as signs and symptoms of various rare diseases and even as an adverse reaction to drugs. In such cases, correct diagnosis ultimately relies on histopathological examination. Apart from the macroscopic presentation, patient history and anatomic location, which are sometimes indicative, most ulcers have very distinct histopathological features. These features are found in different layers of the skin or even associated vessels. In this narrative review, we discuss and highlight the histopathological differences of several types of leg ulcers that can contribute to efficient and accurate diagnosis.
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Affiliation(s)
- Amun Georg Hofmann
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - André Oszwald
- Department of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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8
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Brucato D, Bonomi F, Pompei B, Schmauss D, Meani F, Harder Y. Pyoderma gangrenosum following reduction mammoplasty: Systematic review of the literature and case report. J Plast Reconstr Aesthet Surg 2024; 88:535-546. [PMID: 38118291 DOI: 10.1016/j.bjps.2023.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/15/2023] [Accepted: 11/26/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that can develop at a surgical site. Diagnosis can be challenging at its presentation causing delays in appropriate treatment. The aim of this study is to review the current literature as well as to describe the clinical presentation, diagnostic pathway, and treatment of PG after reduction mammaplasty in order to define a standardized multidisciplinary diagnostic and therapeutic approach. In the future, this may ease early identification and prompt treatment, and eventually minimize severe morbidity and long-term sequelae. METHODS The entire PubMed/Medline database was screened following the PRISMA guidelines to identify studies describing PG that have occurred after reduction mammoplasty. RESULTS Twenty-eight articles including 31 patients reported a PG after breast reduction surgery between January 1988 and March 2022. Twenty-one (68%) patients presented with skin ulcerations, 14 (45%) with erythema, and 5 (16%) with vesicles. Out of the 30 cases that underwent bilateral surgery, 18 (60%) developed PG bilaterally. In 12 out of 31 patients, nipple-areolar complex (NAC) involvement was evaluated, though in 10 patients (83%) the NAC was spared. Of the 20 patients (65%) who underwent skin biopsies for histopathological examination, 18 (90%) showed neutrophilic infiltration of the dermal layers. All 31 patients (100%) showed rapid clinical improvement after the introduction of immunosuppressive therapy. CONCLUSIONS PG can result in devastating skin alterations also after reduction mammoplasty, if misdiagnosed. However, it presents with constant yet unspecific local and general signs and symptoms that can be recognized to early initiate an appropriate pharmacological treatment.
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Affiliation(s)
- Davide Brucato
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Francesca Bonomi
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Barbara Pompei
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Daniel Schmauss
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Francesco Meani
- Breast Cancer Service, Clinica Luganese Moncucco and Clinica Santa Chiara, Locarno, Switzerland
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery EOC, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
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9
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Iliescu C, Popa L, Mihai M, Popescu MN, Beiu C. Pyoderma Gangrenosum: The Impact of Treatment Non-adherence on Disease Progression. Cureus 2024; 16:e51490. [PMID: 38304683 PMCID: PMC10831138 DOI: 10.7759/cureus.51490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 02/03/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, ulcerative, rapidly progressing, destructive, inflammatory cutaneous disease that is both diagnostically and therapeutically challenging. Due to the lack of standardized diagnostic criteria or conclusive guidelines for patient management, clinicians often find themselves without reliable tools for the daily management of PG patients. Additionally, the lack of strict therapeutic compliance in patients with this diagnosis might contribute to a catastrophic evolution of the condition. We report a case of ulcerative PG that is illustrative of the inherent challenges posed by patients frequently changing healthcare providers and treatment regimens, displaying inconsistency and non-adherence. Such behaviors can lead to the loss of disease control, particularly in the context of extensive or rapidly progressing PG, ultimately culminating in the development of mutilating forms of this disease.
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Affiliation(s)
- Carmen Iliescu
- Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Liliana Popa
- Oncological Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Mara Mihai
- Oncological Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Marius N Popescu
- Physical Medicine and Rehabilitation, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
| | - Cristina Beiu
- Oncological Dermatology, Elias Emergency University Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, ROU
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10
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Patel S, Hijaz B, Nambudiri VE. Anaemia as a comorbidity in pyoderma gangrenosum hospitalizations. Exp Dermatol 2024; 33:e14925. [PMID: 37726957 DOI: 10.1111/exd.14925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/24/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Shrey Patel
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Baraa Hijaz
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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11
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Sanchez-Melendez SN, Malik R, Patel PM, Milosavljevic S, Patel S, Nambudiri VE. Pyoderma gangrenosum and impact on quality of life: A narrative review. Exp Dermatol 2024; 33:e14876. [PMID: 37424357 DOI: 10.1111/exd.14876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
Pyoderma gangrenosum (PG) is an autoinflammatory disorder typically characterized by progressive ulcers with dense neutrophilic infiltrates in the absence of infectious causes. The chronic nature of this disease significantly impacts the patients' quality of life (QoL). Yet there is currently a dearth of information in the literature regarding standardised treatment guidelines and the impact of PG on patients' QoL. We conducted a literature search on PubMed using the terms "pyoderma gangrenosum" AND "quality of life." We identified nine relevant articles that provide insight into which domains are affected and what treatment can improve QoL. The most common domains involved are physical, emotional, and psychological. Patients tend to feel depressed/anxious, isolated, and embarrassed secondary to PG manifestations. Comorbidities such as Crohn's disease, monoclonal gammopathy of dermatologic significance, and ulcerative colitis can worsen the impact on these patients' QoL. Pain is also a significant contributor to decreasing patients' QoL. Treatments such as topical steroids, adalimumab, and canakinumab may help improve QoL scores. We believe this information can help clinicians guide the care of patients with PG and highlight the need for more studies and clinical trials focusing on PG treatments' impact on QoL.
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Affiliation(s)
- Stephanie N Sanchez-Melendez
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Ponce Health Sciences University, School of Medicine, Ponce, Puerto Rico, USA
| | - Rhea Malik
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Payal M Patel
- Department of Dermatology, Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | | | - Shrey Patel
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinod E Nambudiri
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Park AN, Raj A, Bajda J, Gorantla VR. Narrative Review: Pyoderma Gangrenosum. Cureus 2024; 16:e51805. [PMID: 38187026 PMCID: PMC10771820 DOI: 10.7759/cureus.51805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 01/09/2024] Open
Abstract
Pyoderma gangrenosum (PG) is a skin lesion, characteristically a neutrophilic dermatosis, that can be complicated by rapid progression, necrosis, and ulceration. This is an important pathology to be discussed given that there are no established criteria for diagnosis or treatment. This review aims to elucidate characteristics and variations of PG that distinguish it from other ulcerative skin lesions. Variability in presentation can lead to missed or incorrect diagnosis, and some of the currently proposed criteria for categorizing and diagnosing PG have been included here. These criteria distinguish PG in terms of the nature of the lesion, the location, etiology, responsiveness to immunosuppressive therapy, and patient history. The etiology and pathogenesis of PG remain unknown, but we summarize prominent theories and explanations. Furthermore, recent research indicates that the incidence of PG has a strong correlation with autoimmune conditions, particularly inflammatory bowel disease. Major treatments for PG coincide with these findings, as the majority involve targeted anti-inflammatories, immunosuppressants, and surgical interventions. These treatments are addressed in this review, with added context for local versus systemic disease.
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Affiliation(s)
- Ann N Park
- Anatomical Sciences, St. George's University School of Medicine, True Blue, GRD
| | - Aishwarya Raj
- Anatomical Sciences, St. George's University School of Medicine, True Blue, GRD
| | - Joe Bajda
- Anatomical Sciences, St. George's University School of Medicine, True Blue, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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13
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Kwon IJ, Park JW, Park S, Lim H, Yu J, Oh SH. Ulcerative Colitis Diagnosed through Evaluation of Underlying Diseases in a Pyoderma Gangrenosum Adolescent without Gastrointestinal Symptoms. Ann Dermatol 2023; 35:S292-S295. [PMID: 38061724 PMCID: PMC10727860 DOI: 10.5021/ad.22.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/04/2022] [Accepted: 05/26/2022] [Indexed: 12/20/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, non-infectious, neutrophilic dermatosis characterized by painful ulcers with indistinct borders and peripheral erythema. The diagnosis of PG requires the exclusion of other causes of similar appearing skin manifestations, including vasculitis and infections. The pathogenesis of PG is not clear; however, dysregulation of the immune system has been suggested in previous studies. More than half of the PG patients have underlying diseases; the most common being inflammatory bowel disease (IBD). The progression of PG in IBD patients is seen after the onset of IBD, usually during its exacerbation. On the other hand, PG may follow a course independent of the intestinal disease. We present a case of an 18-year-old young male with PG that presented before being diagnosed with ulcerative colitis as an associated condition. He had a painful ulcerative lesion on his right shin with no previous gastrointestinal symptoms. This case suggests that investigating for underlying disorders is essential in PG patients despite the lack of symptoms other than the skin lesions.
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Affiliation(s)
- Il Joo Kwon
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sowon Park
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Severance Pediatric IBD Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeji Lim
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Severance Pediatric IBD Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeeun Yu
- Dr.Yu's Pediatric and Adolescence Medicine, Osan, Korea
| | - Sang Ho Oh
- Department of Dermatology and Cutaneous Biology Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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14
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Becker SL, Velasco R, Ortega-Loayza AG. Recalcitrant Pyoderma Gangrenosum: Clinical Burden and Unmet Needs. Clin Cosmet Investig Dermatol 2023; 16:2143-2152. [PMID: 37581011 PMCID: PMC10423579 DOI: 10.2147/ccid.s381490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare, autoinflammatory disease leading to aseptic ulcers which carries a significant disease burden and is often difficult to treat, with many patients failing first-line treatment and requiring additional therapies. Such cases are typically referred to in the literature as "recalcitrant", "refractory", or "resistant", though little is known about the clinical characteristics of such cases. We performed a narrative literature review to characterize patient demographics and clinical course associated with difficult to treat pyoderma gangrenosum cases in order to identify trends to guide future clinical management and therapeutic innovation. We identified 148 cases with clinical manifestations and associated patient demographics stratified by ulcer and patient features. Consistent with previous work, a greater prevalence of PG was observed among female patients and those with a history of inflammatory bowel disease, however interestingly despite an aggressive course to their PG, few patients had comorbidities complicating their disease course. Additionally, despite the requirement of three or more treatments for most patients' disease to resolve, the majority healed within the typical window observed in previous clinical studies with low rates of recurrence. Biologics were the most common medication patients were on at time of remission. Collectively, our results suggest a potential benefit for a reduced threshold for biologic initiation in PG patients and a need for standardization of language in the field to facilitate treatment outcomes comparisons and interventions.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, Portland, OR, USA
| | - Rose Velasco
- University of Illinois College of Medicine, Chicago, IL, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, Portland, OR, USA
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15
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Baco SJ, Mišić J, Peruničić V. Postoperative Pyoderma Gangrenosum (PPG) After Appendectomy: A Case Report. Cureus 2023; 15:e42016. [PMID: 37469578 PMCID: PMC10353335 DOI: 10.7759/cureus.42016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 07/21/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, poorly understood, non-infectious, autoimmune phenomenon. It is an inflammatory neutrophilic dermatosis characterized by hyperactivity of the skin and the development of papules and pustules that rapidly progress to painful ulcerations with a violaceous and necrotic border. Approximately three to six cases of PG per million of the population occur per year and in the case of postoperative pyoderma gangrenosum (PPG), it is only one to three cases per million operated people. We are presenting a 41-year-old patient with a clinical presentation of PPG, developed in the surgical site on the sixth postoperative day (POD 6) following open appendectomy for acute appendicitis. Initial treatment was for surgical site infection (SSI) with wound opening, regular dressings, and broad-spectrum antibiotics. Due to unresponsiveness to therapy and the unexpected postoperative course with the progression of skin lesions, we suspected PPG. Corticosteroid therapy was introduced in a shock dose, once daily intravenous (IV), with superb results and stopping the spread of the process after only two days. Considering the rarity of PPG, especially when it first occurs postoperatively, we believe that the image of skin changes with superficial spreading and characteristic violaceous ulcerations can be of crucial importance for early diagnosis. A multidisciplinary approach with a mandatory examination by a dermatologist is important in order to make an early diagnosis and prevent wrong treatment, with the potential worsening of the patient's condition. Atraumatic wound care and negative pressure wound therapy are recommended. Patients at risk should perioperatively receive corticosteroids and postoperatively be closely observed for the potential development of PPG. Debridement is not recommended, and surgical treatment and further tissue trauma are undesirable and even prohibited.
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Affiliation(s)
- Stanko J Baco
- Department of General Surgery, Public Health Institution Hospital "Dr Mladen Stojanovic", Prijedor, BIH
| | - Jovica Mišić
- Department of General Surgery, Saint Luke the Apostle Hospital, Doboj, BIH
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16
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Kögel J, Berneburg M, Karrer S, Drexler K, Niebel D. [Multilocular pyoderma gangrenosum : Association with primary manifestation of primary biliary cholangitis]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00105-023-05161-2. [PMID: 37326669 DOI: 10.1007/s00105-023-05161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/17/2023]
Abstract
A 16-year-old female patient with previously diagnosed acne vulgaris was transferred to our clinic in reduced general condition with rapidly progressive and extremely painful ulcerations. In the laboratory exam, inflammatory parameters were highly elevated, but she was normothermic. Based on the findings, we diagnosed multilocular pyoderma gangrenosum. Further investigations established the diagnosis of primary biliary cholangitis as the underlying condition. Treatment with systemic corticosteroids was initiated and we started therapy with ursodeoxycholic acid. This led to improvement within a few days. PAPA-syndrome (pyogenic arthritis, pyoderma gangrenosum and acne vulgaris) could be ruled out by genetic analysis.
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Affiliation(s)
- Julian Kögel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Mark Berneburg
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Sigrid Karrer
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Konstantin Drexler
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Dennis Niebel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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17
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Hampton S. Raising awareness of pyoderma gangrenosum to ensure person-centred safety within clinical and social wound care clinics. Br J Community Nurs 2023; 28:S41-S42. [PMID: 37262090 DOI: 10.12968/bjcn.2023.28.sup6.s41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Sylvie Hampton
- Independent Tissue Viability Consultant, Director of Wound Care Consultants Ltd and Lead Tissue Viability Nurse in Home Wound Care
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18
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Deoghare S, Gupta S, Pol D, Masare A, Kumar A. Recurrent Genital Herpes Triggering Ulcerative Pyoderma Gangrenosum. Cureus 2023; 15:e40953. [PMID: 37503492 PMCID: PMC10368958 DOI: 10.7759/cureus.40953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis that presents as painful, rapidly growing skin ulcers with undermined edges and a violaceous, ragged border at the periphery and is non-responsive to conventional treatments. The average onset age is in the fourth decade, with a female preponderance. Genital PG is uncommon and may present singly or coexist with common sexually transmitted genital ulcerative diseases, which causes delays in the diagnosis and treatment of genital PG, thereby adding to the morbidity. Here, we highlight a case of non-healing genital ulcers that did not respond to conventional antibiotic treatment and aggravated each month with menstruation. In this case, menstruation acted as a trigger factor for the development of a herpes genital infection. The latter acts as a pathergy for the monthly aggravation of genital PG. The patient responded to treatment with anti-viral medications and immunosuppressive medications.
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Affiliation(s)
- Shreya Deoghare
- Department of Dermatology, Venereology, and Leprosy, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Shailya Gupta
- Department of Dermatology, Venereology, and Leprosy, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Devayani Pol
- Department of Dermatology, Venereology, and Leprosy, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Anuja Masare
- Department of Dermatology, Venereology, and Leprosy, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
| | - Ajay Kumar
- Department of Dermatology, Venereology, and Leprosy, Dr. D. Y. Patil Medical College Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, IND
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19
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Babakoohi S, Gu SL, Ehsan H, Markova A. Dermatologic complications in transplantation and cellular therapy for acute leukemia. Best Pract Res Clin Haematol 2023; 36:101464. [PMID: 37353285 PMCID: PMC10291442 DOI: 10.1016/j.beha.2023.101464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/09/2023]
Abstract
Adoptive cellular immunotherapy, mainly hematopoietic stem cell transplant and CAR-T cell therapy have revolutionized treatment of patients with acute leukemia. Indications and inclusion criteria for these treatments have expanded in recent years. While these therapies are associated with significant improvements in disease response and overall survival, patients may experience adverse events from associated chemotherapy conditioning, engraftment, cytokine storm, supportive medications, and post-transplant maintenance targeted therapies. Supportive oncodermatology is a growing specialty to manage cutaneous toxicities resulting from the anti-cancer therapies. In this review, we summarize diagnosis and management of the common cutaneous adverse events including drug eruptions, graft-versus-host disease, neoplastic and paraneoplastic complications in patients undergoing cellular therapies.
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Affiliation(s)
- Shahab Babakoohi
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA.
| | - Stephanie L Gu
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Hamid Ehsan
- Levine Cancer Institute, Atrium Health Wake Forest Baptist, Charlotte, NC, USA
| | - Alina Markova
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
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20
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Vu MLD, Lin FE, Ashcroft CR, Van Der Veer SJ, Hall JR. A Diagnostic Dilemma: Atypical Systemic Pyoderma Gangrenosum. Cureus 2023; 15:e38763. [PMID: 37303437 PMCID: PMC10249513 DOI: 10.7759/cureus.38763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2023] [Indexed: 06/13/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that classically presents with chronic ulcerations with raised, violaceous, and undermined borders commonly found on the lower extremities. Less common presentations include tender nodules, pustules, or bullae that may occur on other sites of the body. In rarer circumstances, PG can lead to a systemic inflammatory response syndrome with extensive pulmonary infiltrates but ultimately cause and etiology of the disease are still uncertain. Unfortunately, there is no laboratory test or histopathologic finding that is specific to PG, which makes the diagnosis even more elusive.
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Affiliation(s)
- My Linh D Vu
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | - Fiona E Lin
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | - Cody R Ashcroft
- Internal Medicine, Brooke Army Medical Center, San Antonio, USA
| | | | - Jacob R Hall
- Dermatology, Brooke Army Medical Center, San Antonio, USA
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21
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Byun JY, Kang YK, Jang YH, Kim YK, Kim DW. Management of Steroid-Induced Glaucoma in a Patient with Pyoderma Gangrenosum. J Clin Med 2023; 12:jcm12082930. [PMID: 37109266 PMCID: PMC10144976 DOI: 10.3390/jcm12082930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/28/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Pyoderma gangrenosum (PG) is an uncommon inflammatory skin disorder typically presenting as painful skin ulcers, which may also exhibit extracutaneous findings. PG can occur at the site of trauma or surgery, which is known as the pathergic phenomenon. A 36-year-old man developed bilateral steroid-induced glaucoma after prolonged systemic immunosuppressive treatment for cutaneous pyoderma gangrenosum. After successful Ahmed glaucoma valve implantation surgery with donor scleral patch graft in the right eye, the same surgery failed repeatedly in the left eye and complicated with the prolonged conjunctival necrosis and the exposure of the donor scleral patch graft. Under the impression of ocular involvement of PG, microinvasive glaucoma surgery (MIGS) with XEN® Gel Stent was performed in the left eye; the conjunctival bleb was successfully formed without conjunctival necrosis, and intraocular pressure was well maintained. Ophthalmic surgery can be complicated in patients with PG, and the surgical option should be selected prudently to minimize surgical trauma. MIGS, as a minimally invasive surgical technique, could offer an advantage for patients with PG.
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Affiliation(s)
- Ji Yeon Byun
- Department of Dermatology, Ewha Womans University College of Medicine, Seoul 07804, Republic of Korea
| | - Yong Koo Kang
- Department of Ophthalmology, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yong Hyun Jang
- Department of Dermatology, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Young Kook Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Dai Woo Kim
- Department of Ophthalmology, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
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22
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Dey S, Sanghavi N, Wasserman A, Kar K. Treatment of Pyoderma Gangrenosum With Mycophenolate and Hyperbaric Oxygen Therapy: A Case Report and Literature Review. Cureus 2023; 15:e38159. [PMID: 37252490 PMCID: PMC10218763 DOI: 10.7759/cureus.38159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Pyoderma gangrenosum is an uncommon inflammatory ulcerative skin disorder with an unclear etiology. In many cases, it is associated with several underlying systemic diseases, with inflammatory bowel disease being the most common one. Since it does not have any specific clinical or laboratory findings, it is a diagnosis of exclusion. A multidisciplinary approach is vital in treating pyoderma gangrenosum. Its recurrence remains common, and it also has an unpredictable prognosis. Here, we report a case report of pyoderma gangrenosum, which was successfully treated with mycophenolate and hyperbaric oxygen therapy.
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Affiliation(s)
- Subo Dey
- Internal Medicine, Westchester Medical Center, Valhalla, USA
| | - Nirali Sanghavi
- Internal Medicine, Westchester Medical Center, Valhalla, USA
| | - Amy Wasserman
- Rheumatology, Westchester Medical Center, Valhalla, USA
| | - Kausik Kar
- Internal Medicine, Wound and Hyperbaric Medicine, Westchester Medical Center, Valhalla, USA
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23
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Kusraeva DT, Olisova OY, Teplyuk NP, Grabovskaya OV, Kayumova LN, Bobkova AE, Varshavsky VA, Komleva LF, Petrenko EV, Bobrova KY. PYODERMA GANGRENOSUM MIMICKING GRANULOMATOSIS WITH POLYANGIITIS: CACE REPORT AND RIVIEW OF THE LITERATURE. VESTNIK DERMATOLOGII I VENEROLOGII 2023. [DOI: 10.25208/vdv1386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Pyoderma gangrenosum is an autoinflammatory neutrophilic dermatosis. Diagnosis of the disease remains a difficult task to date, due to the lack of a gold standard of examination and differential diagnostic signs. The primary elements in the development of PG may be papules, pustules or bullae the dissection of which subsequently leads to the formation of ulcers with irregular, violaceous, undermined borders. In rare cases, the diagnosis of the disease can also be complicated by the rapid development of internal organs damage symptoms, which must be regarded as extracutaneous manifestations of PG. Extracutaneous lesions can occur before, during or after the appearance of skin rashes, and the detection of sterile neutrophil infiltrates in the defeat of internal organs confirm the concept of PG as a multisystemic disease. The presented case of a rare course of PG with multiple skin lesions and extracutaneous manifestations, simulating systemic vasculitis, emphasizes the importance of a detailed examination of patients in order to make a correct diagnosis and prescribe timely adequate treatment.
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24
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Moura RR, Brandão L, Moltrasio C, Agrelli A, Tricarico PM, Maronese CA, Crovella S, Marzano AV. Different molecular pathways are disrupted in Pyoderma gangrenosum patients and are associated with the severity of the disease. Sci Rep 2023; 13:4919. [PMID: 36966241 PMCID: PMC10039684 DOI: 10.1038/s41598-023-31914-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/20/2023] [Indexed: 03/27/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory skin disease classified within the spectrum of neutrophilic dermatoses. The pathophysiology of PG is yet incompletely understood but a prominent role of genetics facilitating immune dysregulation has been proposed. This study investigated the potential contribution of disrupted molecular pathways in determining the susceptibility and clinical severity of PG. Variant Enrichment Analysis, a bioinformatic pipeline applicable for Whole Exome Sequencing data was performed in unrelated PG patients. Eleven patients were enrolled, including 5 with unilesional and 6 with multilesional PG. Fourteen pathways were exclusively enriched in the "multilesional" group, mainly related to immune system (i.e., type I interferon signaling pathway), cell metabolism and structural functions. In the "unilesional" group, nine pathways were found to be exclusively enriched, mostly related to cell signaling and cell metabolism. Genetically altered pathways involved in immune system biology and wound repair appear to be nodal pathogenic drivers in PG pathogenesis.
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Affiliation(s)
- Ronald Rodrigues Moura
- Department of Advanced Diagnostics, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137, Trieste, Italy
| | - Lucas Brandão
- Department of Pathology, Federal University of Pernambuco, Recife, 50670-901, Brazil
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Almerinda Agrelli
- Laboratory of Nanostructured Materials (LMNANO), Center for Strategic Technologies Northeastern (CETENE), Av. Prof. Luís Freire, 1-Cidade Universitária, Recife, 50740-545, Brazil
| | - Paola Maura Tricarico
- Department of Advanced Diagnostics, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137, Trieste, Italy
| | - Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Università Degli Studi Di Milano, Via Pace 9, 20122, Milan, Italy
| | - Sergio Crovella
- Biological Science Program, Department of Biological and Environmental Sciences, College of Arts and Sciences, Qatar University, Doha, State of Qatar
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Physiopathology and Transplantation, Università Degli Studi Di Milano, Via Pace 9, 20122, Milan, Italy.
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25
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Chen B, Li W, Qu B. Practical aspects of the diagnosis and management of pyoderma gangrenosum. Front Med (Lausanne) 2023; 10:1134939. [PMID: 36865058 PMCID: PMC9971223 DOI: 10.3389/fmed.2023.1134939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.
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Affiliation(s)
| | - Wei Li
- Department of Burns, Sichuan Academy of Medical Sciences and Sichuan People’s Hospital, Chengdu, China
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26
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[Pyoderma gangrenosum in a grade 3 open fracture after a forest accident : When one cannot see the wood for the trees]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:168-172. [PMID: 35420293 DOI: 10.1007/s00113-022-01176-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 02/07/2023]
Abstract
We describe the case of a forest worker with a Gustilo-Anderson III dislocation fracture of the ankle joint. After initial external fixation, round necrotic skin lesions with hyperemic border walls appeared on the entire lower leg. Recurrent débridements worsened the soft tissue instead of improving it. An immunoglobulin and corticosteroid treatment was initiated, which diminished the inflammatory reaction and granulation of soft tissue began. Posttraumatic pyoderma gangrenosum is a rare diagnosis. Nevertheless, it needs to be on the list of differential diagnoses if uncommon soft tissue reactions appear.
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27
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Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases. An Bras Dermatol 2023; 98:141-158. [PMID: 36682966 PMCID: PMC9984718 DOI: 10.1016/j.abd.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 08/09/2022] [Indexed: 01/21/2023] Open
Abstract
Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.
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28
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Kim YJ, Lee KH, Won CH, Chang SE, Lee MW, Choi JH, Lee WJ. Clinicopathological features and prognosis of pyoderma gangrenosum in Korea: A single centre, retrospective, observational study over 20 years. Indian J Dermatol Venereol Leprol 2023; 89:25-34. [PMID: 35389018 DOI: 10.25259/ijdvl_968_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/01/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pyoderma gangrenosum is a rare autoinflammatory neutrophilic dermatosis that rapidly evolves. However, little is known about the clinicopathological features and prognosis of pyoderma gangrenosum. AIMS We aimed to document clinicopathologic and prognostic data of the patients with pyoderma gangrenosum. METHODS In this retrospective observational study, we reviewed case records of patients diagnosed with pyoderma gangrenosum between 1999-2019. RESULTS Fifty-three patients were identified by reviewing medical records for skin biopsy; of these, 37 were men and 16 were women. Mean age at onset was 43.3 ± 18.5 years. The most frequently affected area was the lower extremities (60.4%), followed by the head and neck (17.0%). The most common subtype was ulcerative (47.2%), followed by bullous (22.6%). 30 cases had underlying diseases and the most common were malignancy (24.5%), followed by inflammatory bowel diseases (18.9%). The proportion of cases with history of trauma were significantly higher in post-operative type (100%) as compared to the bullous type (8.3%). Histologic features of granulation tissue were frequently found in post-operative type (66.7%) and bullous type (58.3%). Granulomas were predominantly found in bullous type (58.3%). Age <60 years appeared to be significantly associated with multiple lesions. Partial-to-complete remission was observed in 40 cases (75.5%). Nine (17.0%) cases experienced recurrence with a median progression-free period of six months (interquartile range of 3.0-9.0 months). Cases with underlying hematologic disorders and the bullous subtype were significantly associated with early recurrence. LIMITATIONS This study was a single-centre study with a retrospective design. CONCLUSION Pyoderma gangrenosum appears to have ethnic differences. Underlying haematologic disorders and bullous subtype have a worse prognosis. However, the type of histopathology did not correlate with the clinical outcome of pyoderma gangrenosum.
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Affiliation(s)
- Young Jae Kim
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Keon Hee Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chong Hyun Won
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Eun Chang
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mi Woo Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jee Ho Choi
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Jin Lee
- Department of Dermatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Patel JK, Pillai DS, Bodar P, Nair PA. Penile ulcerative pyoderma gangrenosum: A rare entity. Indian J Sex Transm Dis AIDS 2023; 44:77-79. [PMID: 37457536 PMCID: PMC10343122 DOI: 10.4103/ijstd.ijstd_115_22] [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: 11/28/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 07/18/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a rare, chronic, ulcerative, neutrophilic, and inflammatory skin disease. It most commonly affects the lower limb, may affect peristomal skin, and rarely involves mucosal and internal sites. Genital involvement has been rarely reported. Hereby, we report a case of penile PG in a 70-year-old male treated with oral steroids.
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Affiliation(s)
- Jalpa Kailashbhai Patel
- Department of Dermatology, Venereology and Leprosy, Pramukhswami Medical College, Shree Krishna Hospital, Bhaikaka University, Karamsad, Gujarat, India
| | - Devna Subramonia Pillai
- Department of Dermatology, Venereology and Leprosy, Pramukhswami Medical College, Shree Krishna Hospital, Bhaikaka University, Karamsad, Gujarat, India
| | - Priyanka Bodar
- Department of Dermatology, Venereology and Leprosy, Pramukhswami Medical College, Shree Krishna Hospital, Bhaikaka University, Karamsad, Gujarat, India
| | - Pragya Ashok Nair
- Department of Dermatology, Venereology and Leprosy, Pramukhswami Medical College, Shree Krishna Hospital, Bhaikaka University, Karamsad, Gujarat, India
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Muacevic A, Adler JR, Almohammed Saleh AA, AlAlwan AQ, Aljughayman MA, Alhamed AS, Alsuwaigh A, Aleasa A, Alali T, AlGhadeer MS, Albeladi SA. Successful Management of a Young Patient Suffering From Pyoderma Gangrenosum Following Gastric Bypass Surgery: A Case Report. Cureus 2023; 15:e34305. [PMID: 36860228 PMCID: PMC9969975 DOI: 10.7759/cureus.34305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
Pyoderma gangrenosum (PG) is a pathogenetically ill-defined neutrophilic dermatosis frequently characterized by severely painful ulcerations with no identifiable infective pathogens. There are no diagnostic criteria for PG, nor specific gold standard management, which may complicate the process of dealing with patients suffering from this disease. Here, we report a case of a 27-year-old male patient, with a history of gastric bypass surgery three years ago, who presented with a left leg non-healing ulcer diagnosed as a PG by the clinical presentation and biopsy of the ulcer. He was managed by the administration of systemic immunomodulators, a surgical debridement procedure, and the application of a vacuum. The patient was discharged with vitamin B complex and vitamin D supplements as well as zinc sulfate and folic acid. Also, multiple doses of Infliximab intravenously and vitamin B 12 intramuscularly result in a satisfactory healing process of the ulcer. Since PG is a diagnosis of exclusion, clinicians must be aware of the need for highly specific history-taking, previous surgical history, laboratory investigations, and histopathological workup in order to reach the diagnosis.
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Petrov A, Kappert U, Schmidt T, Matschke KE, Wilbring M. Pyoderma Gangrenosum after Cardiac Surgery. Thorac Cardiovasc Surg 2023; 71:53-61. [PMID: 34894635 DOI: 10.1055/s-0041-1735960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pyoderma gangrenosum after cardiac surgery is a rare, noninfectious ulcerating skin disease mimicking sternal wound infection. METHODS A systematic search of literature for pyoderma gangrenosum complicating cases of cardiac surgery was conducted between September 1985 and September 2020 on PubMed and Cochrane databases. A systematic review and detailed overview of clinical presentation, diagnostic, treatment, and outcome is provided. RESULTS A total of 15 studies enclosing 15 patients suffering from pyoderma gangrenosum following cardiac surgery were identified. Onset of symptoms was observed after a median of 5 days. Patients were predominantly male (81.3%) with a median age of 64 years. Typical clinical presentation mimicked sternal site infection, mainly by means of mediastinitis. Specific signs were rapid progression, erythematous to violaceous color of the wound border, accompanied by unspecific symptoms including fever, malaise, and severe pain. Additionally, pathergy (development of ulcers at the sites of minor cutaneous trauma) was reported frequently. Biopsy is mandatory with a cutaneous neutrophilic inflammation confirming the diagnosis. Initial treatment mostly (75.0% of reported cases) was misled, addressing suspicion of surgical site infection. After correct diagnosis, the treatment was switched to an immunosuppressive therapy. Full sternal wound closure took between 5 weeks and 5 months. Reported case mortality was 12.5% in actually low-risk surgeries. CONCLUSION Despite pyoderma gangrenosum has typical signs, it remains an exclusion diagnosis. The treatment is completely opposite to the main differential diagnosis-the typical surgical site infection. Knowledge about diagnosis and treatment is essential in the context of avoiding fatal mistreatment.
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Affiliation(s)
- Asen Petrov
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Torsten Schmidt
- Department of Cardiac Anesthesiology, University Heart Center Dresden, Dresden, Germany
| | | | - Manuel Wilbring
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
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Kim YC, Shim HS, Jeong H, Park YJ. Pyoderma Gangrenosum Triggered by COVID-19 Vaccination in a Patient with Ulcerative Colitis: A Case Report. INT J LOW EXTR WOUND 2022:15347346221141173. [PMID: 36426538 PMCID: PMC9713538 DOI: 10.1177/15347346221141173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory skin disease that is difficult to diagnose. PG may be an extra-intestinal manifestation of ulcerative colitis (UC). In recent times, coronavirus disease (COVID-19) vaccines have caused various adverse cutaneous reactions. However, to the best our knowledge, combinations thereof have not been reported. We encountered a case of PG triggered by COVID-19 vaccination in a patient with UC. A 40-year-old woman developed severe pain and an abscess in the dorsum of the left foot after receiving the first dose of the messenger RNA (mRNA)-based Pfizer/BioNTech BNT162b2 COVID-19 vaccine. Severe painful ulcers with purulent necrosis and gaseous gangrene progressed rapidly along the extensor tendons and muscles to the toes and ankle. Although surgical debridement can worsen PG by triggering pathergy, we nonetheless performed wide debridement including partial extensor tenotomy with abscess drainage to prevent progression to pyogenic ankle arthritis and to rescue the toes. Antibiotics, corticosteroids, and anticoagulants were prescribed during surgical wound management via negative pressure therapy. After the lesion improved, the skin and soft tissue defect were covered using a superficial circumflex iliac artery perforator free flap and a split-thickness skin graft. The patient was satisfied with the foot salvage, and could walk unaided (without a brace or cane) from 8 weeks after the final surgery. PG may be rare even in UC patients, but mRNA-based COVID-19 vaccines may find an immunosuppressive niche. A high level of caution and suspicion of skin manifestations after vaccination is essential.
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Affiliation(s)
- Yoon-Chung Kim
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Sup Shim
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Howon Jeong
- Department of Orthopaedic Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yune-Jung Park
- Division of Rheumatology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Nishimura M, Mizutani K, Yokota N, Goto H, Akeda T, Kitagawa H, Habe K, Hayashi A, Yamanaka K. Treatment Strategy for Pyoderma Gangrenosum: Skin Grafting with Immunosuppressive Drugs. J Clin Med 2022; 11:jcm11236924. [PMID: 36498498 PMCID: PMC9739536 DOI: 10.3390/jcm11236924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a relatively rare neutrophilic dermatosis presenting as a rapidly progressive and painful skin ulcer characterized by undermined borders and peripheral erythema. Immunosuppressive therapy is the first-line treatment for PG; however, large ulcers often take months or years to heal. Surgical treatments, such as negative pressure wound therapy (NPWT) and skin grafting, are still controversial due to the risk of inducing the pathergy phenomenon and eliciting PG development by traumatic factors. Herein, we report on four cases of PG treated with skin grafting, with or without NPWT, under the control of immunosuppressive drugs at our institution. All cases adapted well, but one case showed recurrence at the periphery of the grafted area five months postoperatively. The current patients were treated with the following doses of oral prednisolone (PSL): PSL 10 mg daily, PSL 5 mg daily + adalimumab 40 mg/week, PSL 12 mg + 6 mg of tacrolimus daily, and PSL 20 mg daily during skin grafting. No severe complications, including infections, were observed. Surgical treatments, such as skin grafting with or without NPWT, may accelerate wound healing, shorten the administration of analgesics and long-term immunosuppressive therapy, and reduce the risk of infection.
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Affiliation(s)
- Mai Nishimura
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Kento Mizutani
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Naho Yokota
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Hiroyuki Goto
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Tomoko Akeda
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Hiroshi Kitagawa
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Koji Habe
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Akinobu Hayashi
- Department of Oncologic Pathology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan
- Correspondence: ; Tel.: +81-59-232-1111
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Sadeghi S, Goodarzi A. Various Application of Tofacitinib and Ruxolitinib (Janus Kinase Inhibitors) in Dermatology and Rheumatology: A Review of Current Evidence and Future Perspective. Dermatol Pract Concept 2022; 12:e2022178. [PMID: 36534552 PMCID: PMC9681403 DOI: 10.5826/dpc.1204a178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Janus kinase inhibitors (JAKi) are anti-inflammatory medications suppressing Janus kinase-signal transducer and activator of transcription (JAK-STAT) pathway by inhibiting various cytokines receptors on the membrane of cells. Mutations and polymorphisms on JAK and STAT proteins can cause dysregulation in the balance of immune system, and ultimately result in autoimmune disorders. OBJECTIVES To record and summarize the overall efficacy and safety of JAKi in various autoimmune conditions such as alopecia areata (AA), psoriasis vulgaris (PV), psoriatic arthritis (PsA), atopic dermatitis (AD), vitiligo, hidradenitis suppurative (HS), lichen planus (LP), and pyoderma gangrenosum (PG). METHODS A thorough review of articles was performed across PubMed and Google Scholar on meta-analyses, systematic reviews, clinical trials and case studies evaluating the treatment of autoimmune disorders such as AA, PV, PsA, AD, vitiligo, LP, HS, and PG with JAKi. Duplicated data and animal experiments or in vitro/ex vivo studies were excluded. RESULTS All the reviewed articles reported beneficial effects of tofacitinib and ruxolitinib application in the treatment of disorders mentioned above with the autoimmune predisposition. CONCLUSIONS Tofacitinib and ruxolitinib showed potential efficacy in treating several autoimmune disorders. Based on records in the reviewed studies, both medications had acceptable safety profiles; however, physicians are recommended to outweigh the risks and benefits of such treatments for each specific condition.
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Affiliation(s)
- Sara Sadeghi
- Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Azadeh Goodarzi
- Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Faculty of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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An aggressive course of pyoderma gangrenosum mimicking bacterial osteomyelitis after open reduction and internal fixation of a distal radius fracture with a titanium plate. Reumatologia 2022; 60:292-302. [PMID: 36186837 PMCID: PMC9494791 DOI: 10.5114/reum.2022.119046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare condition characterized by the development of aseptic, non-healing skin ulcers. Any skin trauma, such as a surgical incision, can trigger an outbreak of lesions. Our case and literature review show that a physician should consider PG in every event of a non-healing, aseptic wound after surgery. The treatment of PG requires collaboration within a multidisciplinary team and immunosuppressive therapy is the first line of treatment, while surgical interventions should be avoided in the active stage of PG.
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Virkkala J, Polet S, Jokelainen J, Huilaja L, Sinikumpu S. Clinical characteristics and comorbidities of the most common atypical wounds in Northern Finland in 1996-2019: A retrospective registry study. Health Sci Rep 2022; 5:e864. [PMID: 36189416 PMCID: PMC9511497 DOI: 10.1002/hsr2.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aims Atypical wounds comprise about 20% of all chronic wounds. Their diagnosis and treatment are challenging and require multidisciplinary cooperation. More knowledge is needed about the clinical characteristics and comorbidities of atypical wounds to enhance the treatment of these wounds. Methods We studied clinical characteristics and comorbidities of the atypical wounds by using the patient data retrieved from the Oulu University Hospital patient database from the year 1996 to the end of 2019 with the following International Classification of Diseases codes: L88, L95.0, L95.8, L95.9, and L98.1. Results In our data, there were 135 patients with atypical wound, more commonly seen in females (N = 84, 62.2%) than in males (N = 51, 37.8%) (p < 0.05). The mean age of patients at the time of diagnosis was 57.3 years; those with pyoderma gangrenosum (PG) and factitious wounds were the youngest (53.1 and 53.0 years, respectively). The majority of subjects (N = 126, 93.3%) were diagnosed with comorbidity at the time of the diagnosis. The most common type of wound was PG (N = 49/135, 36.3%), followed by vasculitis and factitious wounds. The prevalence of inflammatory bowel diseases and rheumatoid arthritis in PG patients was high (18.4% for both). All patients with Martorell hypertensive ischemic leg ulceration/calciphylaxis had a diagnosis of hypertension and diabetes mellitus. Psychiatric diseases were more common in patients with factitious wounds than in other types of wounds, whereas patients with vasculitis wounds had more commonly hypertension, obesity, and diabetes mellitus; however, these did not reach statistical significance. Conclusion Specific comorbidities associated with atypical wounds, such as high psychiatric comorbidity in factitious wounds. There is a female predominance in atypical wounds and patients are typically younger than patients with other types of wounds. Recognition of the typical clinical picture and comorbidities of atypical wounds may help in identifying these patients and thus also improving their treatment.
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Affiliation(s)
| | - Sara Polet
- Faculty of MedicineUniversity of OuluOuluFinland
| | - Jari Jokelainen
- Northern Finland Birth Cohorts, Arctic Biobank, Infrastructure for Population Studies, Faculty of MedicineUniversity of OuluOuluFinland
| | - Laura Huilaja
- PEDEGO Research Unit, Department of Dermatology and Medical Research Center Oulu, Oulu University HospitalUniversity of OuluOuluFinland
| | - Suvi‐Päivikki Sinikumpu
- PEDEGO Research Unit, Department of Dermatology and Medical Research Center Oulu, Oulu University HospitalUniversity of OuluOuluFinland
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Zhang H, Sun Y, Li K, Zhang J, Chen X. Multiple Lesions at Different Stages of Pyoderma Gangrenosum in a Crohn's Disease Patient. Clin Cosmet Investig Dermatol 2022; 15:1593-1596. [PMID: 35971452 PMCID: PMC9375554 DOI: 10.2147/ccid.s374973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022]
Abstract
Pyoderma gangrenosum (PG) is an inflammatory dermatosis characterized by the rapid progression of a painful, necrolytic ulcer with an irregular and undermined border. The prevalence of PG in patients with Crohn’s disease (CD) has been estimated to be 0.7%. Here, we report a case that presented various painful skin lesions, including erythema, vesicles, plaques, and ulcers, one week before the fourth infliximab infusion for CD. PG was diagnosed and the lesions subsided after a 390-mg ustekinumab infusion for one month. It suggests that different lesions of PG may occur concomitantly in CD patients, and the therapy should be re-evaluated on time.
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Affiliation(s)
- Heng Zhang
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Yifang Sun
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Kun Li
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Jianzhong Zhang
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
| | - Xue Chen
- Department of Dermatology, Peking University People's Hospital, Beijing, 100044, People's Republic of China
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Hillen JB, Stanford T, Ward M, Roughead EE, Kalisch Ellett L, Pratt N. Rituximab and Pyoderma Gangrenosum: An Investigation of Disproportionality Using a Systems Biology-Informed Approach in the FAERS Database. Drugs Real World Outcomes 2022; 9:639-647. [PMID: 35933497 DOI: 10.1007/s40801-022-00322-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Studies have found an increased risk of pyoderma gangrenosum associated with rituximab. The structural properties and pharmacological action of rituximab may affect the risk of pyoderma gangrenosum. Additionally, pyoderma gangrenosum is associated with autoimmune disorders for which rituximab is indicated. OBJECTIVE We aimed to determine whether rituximab is disproportionally associated with pyoderma gangrenosum using a systems biology-informed approach. METHODS Adverse event reports were extracted from the US Food and Drug Administration Adverse Event Reporting System (FAERS, 2013-20). The Bayesian Confidence Propagation Neural Network Information Component was used to test for disproportionality. Comparators used to determine potential causal pathways included all other medicines, all medicines with a similar structure (monoclonal antibodies), all medicines with the same pharmacological target (CD20 antagonists) and all medicines used for the same indication(s) as rituximab. RESULTS Thirty-two pyoderma gangrenosum cases were identified, 62.5% were female, with a median age of 48 years. There was an increased association of pyoderma gangrenosum with rituximab compared with all other medicines (exponentiated Information Component 6.75, 95% confidence interval (CI) 4.66-9.23). No association was observed when the comparator was either monoclonal antibodies or CD20 antagonists. Conditions for which an association of pyoderma gangrenosum with rituximab was observed were multiple sclerosis (6.68, 95% CI 1.63-15.15), rheumatoid arthritis (2.67, 95% CI 1.14-4.80) and non-Hodgkin's lymphoma (2.94, 95% CI 1.80-3.73). CONCLUSIONS Pyoderma gangrenosum was reported more frequently with rituximab compared with all other medicines. The varying results when restricting medicines for the same condition suggest the potential for confounding by indication. Post-market surveillance of biologic medicines in FAERS should consider a multi-faceted approach, particularly when the outcome of interest is associated with the underlying immune condition being treated by the medicine of interest.
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Affiliation(s)
- Jodie Belinda Hillen
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Playford Building Level 6, Frome Rd, Adelaide, SA, 5000, Australia
| | - Ty Stanford
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Playford Building Level 6, Frome Rd, Adelaide, SA, 5000, Australia
| | - Michael Ward
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Playford Building Level 6, Frome Rd, Adelaide, SA, 5000, Australia.,Pharmacy Education, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - E E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Playford Building Level 6, Frome Rd, Adelaide, SA, 5000, Australia
| | - Lisa Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Playford Building Level 6, Frome Rd, Adelaide, SA, 5000, Australia
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Playford Building Level 6, Frome Rd, Adelaide, SA, 5000, Australia.
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Burlage E, Mulder JWCM, Nellensteijn JM, Zeegers AVCM. Infection mimicking skin condition: pyoderma gangrenosum. BMJ Case Rep 2022; 15:15/8/e247770. [PMID: 37198754 PMCID: PMC9362768 DOI: 10.1136/bcr-2021-247770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The a priori risk of infection is high when a patient presents with an ulcerative skin condition and elevated inflammatory parameters. If the ulceration is progressive despite adequate antibiotic therapy and tissue cultures are negative, pyoderma gangrenosum should be considered as the diagnosis. This rare infection mimicking skin condition can develop and worsen due to surgery. In this paper, we report two cases that illustrate the importance of making this clinical diagnosis in a timely manner in order to avoid unnecessary surgical interventions and worsening of the clinical picture.
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Martinelli VF, Martinelli Barbosa P, Dantas de Oliveira LS, de Melo LDALV, Casa Nova JM, de Brito CAA. Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review. Int Med Case Rep J 2022; 15:449-456. [PMID: 36051090 PMCID: PMC9427006 DOI: 10.2147/imcrj.s376915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition. Case Presentation Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab. Conclusion PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.
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Affiliation(s)
- Valéria Ferreira Martinelli
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
| | - Pedro Martinelli Barbosa
- Department of Internal Medicine, Medical Sciences Center, Pernambucana of Health College, Recife, Pernambuco, Brazil
| | | | | | - João Manoel Casa Nova
- Department of Gastroenterology, Hospital das Clínicas, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Carlos Alexandre Antunes de Brito
- Department of Gastroenterology, Member of Organização Brasileira de Doença de Crohn e Retocolite – GEDIIB, São Paulo, Brazil
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Pernambuco, Brazil
- Department of Immunology, Autoimune Research Institute, Recife, Pernambuco, Brazil
- Correspondence: Carlos Alexandre Antunes de Brito, Department of Immunology, Autoimune Research Institute, Avenue Rui Barbosa 715, Recife, Pernambuco, 52011-040, Brazil, Tel +55 81 31480101, Email
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Neutrophilic Dermatosis and Management Strategies for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2022; 11:146-157. [PMID: 35873076 PMCID: PMC9287689 DOI: 10.1007/s13671-022-00364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Neutrophilic dermatoses are a heterogeneous group of disorders with significant overlap in associated conditions, clinical presentation, and histopathologic features. This review provides a structural overview of neutrophilic dermatoses that may present in the inpatient setting along with diagnostic work-up and management strategies. Recent Findings Sweet’s syndrome has been found in patients with coronavirus disease 2019 (COVID-19). Pyoderma gangrenosum (PG) has been shown to be equally associated with ulcerative colitis and Crohn’s disease. A clinical trial shows that cyclosporine is equally effective as prednisone in treating PG. Neutrophilic eccrine hidradenitis has been found in the setting of newer antineoplastic medications, such as BRAF inhibitors, as well as in the setting of malignancy without chemotherapy exposure. Summary Neutrophilic dermatoses are a rare and complex group of dermatoses with varying and overlapping clinical presentations. Physicians should be aware of the growing list of associated diseases in order to build a better differential diagnosis or to potentially investigate for co-existing disease.
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Jena A, Sachan A, Singh AK, Sharma V. Multifocal Pyoderma Gangrenosum at Presentation in a Patient With Acute Severe Ulcerative Colitis. Inflamm Bowel Dis 2022; 28:e84-e85. [PMID: 34893838 DOI: 10.1093/ibd/izab309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anurag Sachan
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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43
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Coste V, Klopfenstein T, Andreoletti JB, Clerc J, Noel AC, Gendrin V, Ducournau A, Zayet S. Pyoderma Gangrenosum as Differential Diagnosis to Post-Operative Infection after Breast Plastic Surgery. Surg Infect (Larchmt) 2022; 23:604-606. [PMID: 35649209 DOI: 10.1089/sur.2021.307] [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: 11/13/2022] Open
Abstract
Background: Pyoderma gangrenosum is a scarce ulcerating inflammatory skin disease, which requires excluding other causes of ulceration such as infections, malignancies or connective tissue diseases. Case Report: We report the case of a 38-year-old woman who developed a progressive bilateral breast skin ulcer after breast plastic surgery, suspected initially with an early postoperative infection. The lack of improvement despite adequate antimicrobial drugs conducted to perform a skin biopsy, concluding to an ulcerated neutrophil dermatosis which led to the diagnosis of postoperative pyoderma gangrenosum. The clinical course was favorable with a systemic treatment based on steroids. Conclusions: In order to prevent debridement and extension of local complications, this case report illustrates the importance to suspect pyoderma gangrenosum as differential diagnosis of infection after surgery.
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Affiliation(s)
- Victor Coste
- Infectious Disease Department, Nord Franche-Comté Hospital, Trevenans, France
| | | | | | - Johanna Clerc
- Pathology Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Albin Chevet Noel
- Plastic Surgery Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Vincent Gendrin
- Infectious Disease Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Anne Ducournau
- Dermatology Department, Nord Franche-Comté Hospital, Trevenans, France
| | - Souheil Zayet
- Infectious Disease Department, Nord Franche-Comté Hospital, Trevenans, France
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Owen BS, Pacult MA, Lee BS. Pyoderma Gangrenosum Masquerading as Wound Infection in the Early Postoperative Period After Lumbar Spine Deformity Correction Surgery. Cureus 2022; 14:e25545. [PMID: 35800799 PMCID: PMC9246455 DOI: 10.7759/cureus.25545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/05/2022] Open
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45
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Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments. Am J Clin Dermatol 2022; 23:615-634. [PMID: 35606650 PMCID: PMC9464730 DOI: 10.1007/s40257-022-00699-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 12/12/2022]
Abstract
Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving cutaneous ulcers with undermined, irregular, erythematous-violaceous edges. Pyoderma gangrenosum pathogenesis is complex and involves a profound dysregulation of components of both innate and adaptive immunity in genetically predisposed individuals, with the follicular unit increasingly recognized as the putative initial target. T helper 17/T helper 1-skewed inflammation and exaggerated inflammasome activation lead to a dysregulated neutrophil-dominant milieu with high levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-1α, IL-8, IL-12, IL-15, IL-17, IL-23, and IL-36. Low-evidence studies and a lack of validated diagnostic and response criteria have hindered the discovery and validation of new effective treatments for pyoderma gangrenosum. We review established and emerging treatments for pyoderma gangrenosum. A therapeutic algorithm based on available evidence is also provided. For emerging treatments, we review target molecules and their role in the pathogenesis of pyoderma gangrenosum.
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Ronicke M, Baur A, Kirr M, Erdmann M, Erfurt-Berge C, Ostalecki C. Epidermotropie von Immunzellen unterscheidet Pyoderma gangraenosum vom Ulcus cruris venosum. J Dtsch Dermatol Ges 2022; 20:619-628. [PMID: 35578412 DOI: 10.1111/ddg.14708_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
HINTERGRUND UND ZIELE Pyoderma gangraenosum ist eine ulzerierende, autoinflammatorische Erkrankung. Es gibt keine eindeutigen histopathologischen Merkmale zur Differenzierung von anderen Ursachen chronischer Wunden wie dem Ulcus cruris venosum. Ziel dieser Studie war es, histopathologische Merkmale von Pyoderma gangraenosum und Unterschiede zu venösen Ulzerationen zu detektieren. PATIENTEN UND METHODIK Acht Gewebeproben von Pyoderma gangraenosum, zwölf Proben von Ulcus cruris venosum und sechs Proben von gesunder Haut wurden einer immunhistologischen Multi-Antigen-Analyse unterzogen. Das Immuninfiltrat und seine räumliche Verteilung wurden anhand von Fluoreszenzbildern mit einer Gewebezytometriesoftware analysiert. ERGEBNISSE Die dichte epidermale Präsenz von CD45RO+ -T-Gedächtnis-Zellen und die Rarefizierung von CD1a+ -Langerhans-Zellen in der Epidermis waren Marker für Pyoderma gangraenosum, welche auch auf eine epidermale Immunreaktion schließen lassen. Darüber hinaus konnte dermal eine hohe Anzahl CD11c+ CD68+ pro-inflammatorischer M1-Makrophagen nachgewiesen werden. Diese überstieg die Anzahl der in venösen Ulzerationen beobachteten Makrophagen deutlich. SCHLUSSFOLGERUNGEN Die histopathologischen Unterschiede zwischen Pyoderma gangraenosum und Ulcus cruris venosum können zur Unterscheidung der beiden Erkrankungen herangezogen werden und somit eine wichtige Hilfe zur schnellen Einleitung einer adäquaten Therapie sein. Darüber hinaus deuten unsere Daten auf einen antigengesteuerten Prozess in der Epidermis hin, möglicherweise unter Beteiligung von CD1a+ Langerhans-Zellen.
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Affiliation(s)
- Moritz Ronicke
- Hautklinik, Universitätsklinikum Erlangen.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nürnberg, Erlangen.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen
| | - Andreas Baur
- Hautklinik, Universitätsklinikum Erlangen.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nürnberg, Erlangen.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen
| | | | - Michael Erdmann
- Hautklinik, Universitätsklinikum Erlangen.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nürnberg, Erlangen.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen
| | - Cornelia Erfurt-Berge
- Hautklinik, Universitätsklinikum Erlangen.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nürnberg, Erlangen.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen
| | - Christian Ostalecki
- Hautklinik, Universitätsklinikum Erlangen.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen
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Ronicke M, Baur A, Kirr M, Erdmann M, Erfurt-Berge C, Ostalecki C. Epidermotropism of inflammatory cells differentiates pyoderma gangrenosum from venous leg ulcers. J Dtsch Dermatol Ges 2022; 20:619-627. [PMID: 35487858 DOI: 10.1111/ddg.14708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Pyoderma gangrenosum is an ulcerative autoinflammatory disease, lacking distinct histopathological characteristics to differentiate from other ulcerating conditions, like venous leg ulcers. The objective of this study was therefore to find histopathological characteristics of pyoderma gangrenosum in a head-to-head comparison to venous leg ulcers. PATIENTS AND METHODS Eight tissue samples of pyoderma gangrenosum, twelve samples of venous leg ulcers and six samples of healthy skin were stained using an immunohistological multi antigen staining technology. The immune infiltrate and its spatial distribution were analyzed with contextual tissue cytometry software using fluorescence images. RESULTS The dense epidermal presence of CD45RO+ memory T cells and the rarefication of CD1a+ Langerhans cells in the epidermis were defining markers for pyoderma gangrenosum, implicating an epidermal immune reaction. In addition, high numbers of CD11c+ CD68+ pro-inflammatory M1 macrophages were detected in the dermis, significantly extending the numbers seen in venous leg ulcers. CONCLUSIONS The histopathological differences found between pyoderma gangrenosum and venous leg ulcer can be used to distinguish between the two diseases and thus provide an important aid for the rapid initiation of adequate therapy. In addition, our data hint at an antigen-driven process in the epidermis, possibly involving CD1a+ Langerhans cells.
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Affiliation(s)
- Moritz Ronicke
- University Hospital Erlangen, Dermatological Department, Ulmenweg 18, Erlangen, 91054, Germany.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nuremberg, Ulmenweg 18, Erlangen, 91054, Germany.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
| | - Andreas Baur
- University Hospital Erlangen, Dermatological Department, Ulmenweg 18, Erlangen, 91054, Germany.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nuremberg, Ulmenweg 18, Erlangen, 91054, Germany.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
| | | | - Michael Erdmann
- University Hospital Erlangen, Dermatological Department, Ulmenweg 18, Erlangen, 91054, Germany.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nuremberg, Ulmenweg 18, Erlangen, 91054, Germany.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
| | - Cornelia Erfurt-Berge
- University Hospital Erlangen, Dermatological Department, Ulmenweg 18, Erlangen, 91054, Germany.,Deutsches Zentrum für Immuntherapie (DZI), FAU Erlangen-Nuremberg, Ulmenweg 18, Erlangen, 91054, Germany.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
| | - Christian Ostalecki
- University Hospital Erlangen, Dermatological Department, Ulmenweg 18, Erlangen, 91054, Germany.,Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Germany
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48
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Kim J. Uncovering a prominent association between pyoderma gangrenosum and hidradenitis suppurativa. Wound Repair Regen 2022; 30:297-298. [PMID: 35415857 DOI: 10.1111/wrr.13016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jaehwan Kim
- Department of Dermatology, University of California, Davis, Sacramento, California, USA.,Dermatology Section, Veterans Affairs Northern California Health Care System, Mather, California, USA
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49
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Hung Y, Chung W, Tsai T, Chen C. Hemorrhagic bullous pyoderma gangrenosum following COVID‐19 vaccination. J Eur Acad Dermatol Venereol 2022; 36:e611-e613. [PMID: 35398933 PMCID: PMC9114894 DOI: 10.1111/jdv.18132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/09/2022] [Accepted: 04/07/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Yi‐Teng Hung
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
| | - Wen‐Hung Chung
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
| | - Tsung‐Fu Tsai
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
| | - Chun‐Bing Chen
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
- Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou Taoyuan Taiwan
- College of Medicine Chang Gung University Taoyuan Taiwan
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50
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Fischer AH, Jourabchi N, Khalifian S, Lazarus GS. Spectrum of diseases associated with pyoderma gangrenosum and correlation with effectiveness of therapy: new insights on the diagnosis and therapy of comorbid hidradenitis suppurativa. Wound Repair Regen 2022; 30:338-344. [PMID: 35385180 DOI: 10.1111/wrr.13014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) has been linked to various underlying systemic diseases; many associations are based on case reports or small case series, including hidradenitis suppurativa. Literature examining systemic therapies according to underlying comorbid condition is limited. OBJECTIVE To investigate comorbid diseases of PG and correlate disease associations with effectiveness of therapeutic interventions. METHODS Using Johns Hopkins medical records, 220 patients had an ICD-9 code of 686.01 for PG between 01/01/2006-06/30/2015, of whom 130 patients met rigorous inclusion/exclusion criteria for PG (non-peristomal). RESULTS The 130 PG patients in our study were 69% female, 58% Caucasian, and 35% African American. Documented comorbid conditions included inflammatory bowel disease (IBD; 35%), rheumatoid arthritis (RA; 12%), hidradenitis suppurativa (HS; 14%), monoclonal gammopathy (12%). PG patients with HS vs without HS were more likely to be African-American (83% vs 28%; P<0.001) and had an earlier mean age of PG onset (38 vs 48 years; P=0.02). Strikingly, 53% of female African-American patients with PG onset prior to age 40 had comorbid HS. Comorbid inflammatory bowel disease was observed in 38% of PG patients with RA, 28% of PG patients with HS, and 27% of PG patients with monoclonal gammopathy. Of the 32 patients who received infliximab for active PG, complete ulcer healing was observed in 83% (5/6) of patients with comorbid HS versus 31% (8/26) of patients without HS (Fisher exact P=0.03). CONCLUSIONS Screening patients for associated systemic disease for multiple related illnesses is essential. Effectiveness of systemic therapy may depend upon the underlying systemic disease; hidradenitis suppurativa may be a specific example. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexander H Fischer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Natanel Jourabchi
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saami Khalifian
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Dermatology, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald S Lazarus
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Duke University Medical Center, Durham, North Carolina, USA
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