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Kamal K, Xia E, Li SJ, Alavi A, Cogen AL, Firooz A, Marzano AV, Kaffenberger BH, Sibbald C, Fernandez AP, Callen JP, Dissemond J, Gontijo JRV, Shams K, Gerbens LA, French LE, Gould LJ, Bissonnette R, Shaigany S, Tolkachjov S, Yamamoto T, Wei-Ting Huang W, Ortega-Loayza AG, Mostaghimi A. Eligibility Criteria for Active Ulcerative Pyoderma Gangrenosum in Clinical Trials: A Delphi Consensus on Behalf of the UPGRADE (Understanding Pyoderma Gangrenosum: Review and Assessment of Disease Effects) Group. J Invest Dermatol 2024; 144:1295-1300.e6. [PMID: 38110114 DOI: 10.1016/j.jid.2023.12.006] [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: 09/15/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 12/20/2023]
Abstract
At present, there are no standardized guidelines for determining patient eligibility for pyoderma gangrenosum (PG) clinical trials. Thus, we aim to determine which clinical features, histopathological features, or laboratory features should be included in active ulcerative PG clinical trial eligibility criteria for treatment-naïve patients and patients already treated with immunomodulating medications (treatment-exposed patients). This study employed 4 rounds of the Delphi technique. Electronic surveys were administered to 21 international board-certified dermatologists and plastic surgeon PG experts (June 2022-December 2022). Our results demonstrated that for a patient to be eligible for a PG trial, they must meet the following criteria: (i) presence of ulcer(s) with erythematous/violaceous undermining wound borders, (ii) presence of a painful or tender ulcer, (iii) history/presence of rapidly progressing disease, (iv) exclusion of infection and other causes of cutaneous ulceration, (v) biopsy for H&E staining, and (vi) a presence/history of pathergy. These criteria vary in importance for treatment-naïve versus treatment-exposed patients. Given the international cohort, we were unable to facilitate live discussions between rounds. This Delphi consensus study provides a set of specific, standardized eligibility criteria for PG clinical trials, thus addressing one of the main issues hampering progress toward Food and Drug Administration approval of medications for PG.
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Affiliation(s)
- Kanika Kamal
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Xia
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sara J Li
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Tufts Univeresity School of Medicine, Boston, Massachusetts, USA
| | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anna L Cogen
- Divison of Dermatology, University of Washington, Seattle, Washington, USA
| | - Alireza Firooz
- Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Benjamin H Kaffenberger
- Department of Dermatology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Cathryn Sibbald
- Division of Pediatric Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Anthony P Fernandez
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio, USA; Department of Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeffrey P Callen
- Division of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Joachim Dissemond
- Department of Dermatology, Venereology and Allergology, University Medical Center Essen, Essen, Germany
| | | | - Kave Shams
- Inflammatory Skin Disease Group, Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Louise A Gerbens
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Lars E French
- Department of Dermatology and Allergy, University Hospital, Ludwig Maximilian University (LMU) Munich, Munich, Germany; Dr. Philip Frost Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Lisa J Gould
- Department of Surgery, South Shore Hospital, South Weymouth, Massachusetts, USA
| | | | - Sheila Shaigany
- Department of Dermatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Stanislav Tolkachjov
- Epiphany Dermatology, Dallas, Texas, USA; Department of Dermatology, University of Texas at Southwestern, Dallas, Texas, USA; Texas A&M College of Medicine, Dallas, Texas, USA; Baylor University Medical Center, Dallas, Texas, USA
| | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - William Wei-Ting Huang
- Department of Dermatology, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Suoniemi L, Salmi T, Huhtala H, Kaartinen I, Kiiski J, Kimpimäki T. The role of split-thickness skin grafting in the treatment of vasculitic and pyoderma gangrenosum ulcers in a multidisciplinary wound centre. Int Wound J 2024; 21:e14943. [PMID: 38899689 DOI: 10.1111/iwj.14943] [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: 03/20/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Vasculitic and pyoderma gangrenosum ulcers are traditionally treated with immunosuppressants, and the role of surgery in the treatment of these atypical ulcers remains unclear. This study aimed to investigate the need for surgical intervention as well as the outcome and safety of skin grafting in the treatment of 46 patients with vasculitic ulcers and 34 with pyoderma gangrenosum ulcers using data recorded in the validated Wound Registry. Of the 80 patients with atypical ulcers, 14% (n = 11) were treated surgically; these patients were older (p = 0.039), had lower mobility status (p = 0.002), and more often pulmonary diseases, rheumatoid arthritis, and previous arterial procedures (p = 0.007; p = 0.031; p = 0.031, respectively) than those treated conservatively. Of 181 ulcers, 15% (n = 27) were surgically treated, 78% once and 22% multiple times. During follow-up, 92.3% of both surgically and conservatively treated ulcers with available data healed. Of the surgically treated ulcers, median healing time after first surgical procedure was 96 days, and post-surgical complications were considered mild or unrelated to surgery. Our results suggest that if surgery is indicated, skin grafting is a safe and efficient treatment method provided that multidisciplinary approach is applied.
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Affiliation(s)
- Laura Suoniemi
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Teea Salmi
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Ilkka Kaartinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Tampere, Finland
| | - Juha Kiiski
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Tampere, Finland
| | - Teija Kimpimäki
- Department of Dermatology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Dhir B, Sinha S, Sardana K, Goutam P, Ahuja A. Concurrent pyoderma gangrenosum and tuberculosis: Diagnosis, treatment complexities and exploring cyclosporine's role - A literature review. Indian J Dermatol Venereol Leprol 2024; 0:1-4. [PMID: 38841943 DOI: 10.25259/ijdvl_637_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 01/07/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Bhawuk Dhir
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital (ABVIMS and RML Hospital), Baba Kharak Singh Marg, Connaught Place, New Delhi, India
| | - Surabhi Sinha
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital (ABVIMS and RML Hospital), Baba Kharak Singh Marg, Connaught Place, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital (ABVIMS and RML Hospital), Baba Kharak Singh Marg, Connaught Place, New Delhi, India
| | - Priyanka Goutam
- Department of Dermatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital (ABVIMS and RML Hospital), Baba Kharak Singh Marg, Connaught Place, New Delhi, India
| | - Arvind Ahuja
- Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital (ABVIMS and RML Hospital), Baba Kharak Singh Marg, Connaught Place, New Delhi, India
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Appoo A, Christensen BL, Somayaji R. Examining the Association between Immunosuppressants and Wound Healing: A Narrative Review. Adv Skin Wound Care 2024; 37:261-267. [PMID: 38648239 DOI: 10.1097/asw.0000000000000127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To review how different classes of immunosuppressants affect wound healing. DATA SOURCES A literature search was conducted in PubMed, Google Scholar, and the University of Calgary Health Sciences Library. STUDY SELECTION The researchers initially screened article titles using key words such as "immunosuppressive medication," "wound healing," and "immunosuppression." Articles in which the title and/or abstract contained these key words, that addressed wound healing related to immunosuppressant medications, and were published after 2000 were included in the review. When human data were not available for an immunosuppressant (class), animal studies were included. DATA EXTRACTION The 61 included articles underwent full text review and summarization. DATA SYNTHESIS All included studies were summarized descriptively including immunosuppressive mechanism of action, study participants or subjects, and evidence of effects on wound healing. CONCLUSIONS Corticosteroids and mechanistic target of rapamycin inhibitors most consistently demonstrate detrimental effects on wound healing. For other classes of immunosuppressants, evidence is limited with varying effects on wound healing described. Larger, high-quality studies are required to better understand the effects of immunosuppressants, including those with new mechanisms of action, to identify those with the most impact on wound healing.
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Affiliation(s)
- Aria Appoo
- Aria Appoo is Medical Student, University of Oxford, United Kingdom. At the University of Calgary, Alberta, Canada, Brandon L. Christensen, MD, is Resident Physician, Division of Infectious Diseases, and Ranjani Somayaji, BScPT, MD, MPH, is Assistant Professor, Departments of Medicine, Microbiology, Immunology and Infectious Disease and Community Health Sciences. Acknowledgments: Alberta Innovates High School Youth Research Summer (HYRS) Program provided an educational stipend to the lead author for her work on this and other projects. The authors have disclosed no other financial relationships related to this article. Submitted February 1, 2023; accepted in revised form May 23, 2023
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Tan MG, Tolkachjov SN. Treatment of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:183-192. [PMID: 38423680 DOI: 10.1016/j.det.2023.12.002] [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 is a rare neutrophilic dermatosis that results in painful cutaneous ulcers and is frequently associated with underlying hematologic disorders, inflammatory bowel disease, or other autoimmune disorders. Pathogenesis involves an imbalance between proinflammatory and anti-inflammatory mediators, leading to tissue damage from neutrophils. First-line treatment options with the greatest evidence include systemic corticosteroids, cyclosporine, and tumor necrosis factor alpha inhibitors. Other steroid-sparing therapies such as dapsone, mycophenolate mofetil, intravenous immunoglobulin, and targeted biologic or small molecule inhibitors also have evidence supporting their use. Wound care and management of underlying associated disorders are critical parts of the treatment regimen.
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Affiliation(s)
- Marcus G Tan
- Division of Dermatology, University of Ottawa, 737 Parkdale Avenue, 4th Floor Dermatology, Ottawa, ON K1Y1J8, Canada.
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology, Department of Dermatology, Baylor University Medical Center, University of Texas at Southwestern, Texas A&M University School of Medicine, 1640 FM 544, Suite 100, Lewisville, TX 75056, USA
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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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Kipers T, Tolkachjov SN. Postoperative and Peristomal Pyoderma Gangrenosum: Subtypes of Pyoderma Gangrenosum. Dermatol Clin 2024; 42:171-181. [PMID: 38423679 DOI: 10.1016/j.det.2023.12.001] [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
Postoperative pyoderma gangrenosum and peristomal pyoderma gangrenosum are 2 subtypes of pyoderma gangrenosum. The diagnosis is made as a clinicopathologic correlation when assessing a rapidly progressing ulcer with irregular and undermined borders following a surgical procedure, trauma, or the creation of a stoma. Familiarity with the associated risk factors and distinguishing features of these disorders can facilitate prompt recognition, proper diagnosis, and the initiation of treatment. Management usually involves the use of corticosteroids and steroid-sparing agents as immunomodulators to shift the inflammatory neutrophilic dermatoses to chronic noninflammatory wounds and eventual healing.
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Affiliation(s)
- Théodora Kipers
- School of Medicine, Texas A&M University School of Medicine, 5536 Tremont Street, Dallas, TX 75214, USA
| | - Stanislav N Tolkachjov
- Mohs Micrographic & Reconstructive Surgery, Epiphany Dermatology; Department of Dermatology, Baylor University Medical Center; University of Texas at Southwestern; Texas A&M University School of Medicine, 1640 FM 544, Suite 100, TX 75056, USA.
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Salado-Rasmussen K, Alsing KK, Mårtensson NL, Burian EA, Larsen HK. Penile Pyoderma Gangrenosum, a Rare Encounter in STI Healthcare: A Case Report and a Review of the Literature. Acta Derm Venereol 2024; 104:adv32160. [PMID: 38551377 PMCID: PMC11000657 DOI: 10.2340/actadv.v104.32160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/27/2024] [Indexed: 04/02/2024] Open
Abstract
Abstract is missing (Short communication)
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Affiliation(s)
- Kirsten Salado-Rasmussen
- Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark;Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Køhler Alsing
- Copenhagen Wound Healing Center, Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark.
| | - Nina Løth Mårtensson
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Pathology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Ewa Anna Burian
- Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Helle Kiellberg Larsen
- Department of Dermato-Venereology, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Köken Avşar A, Demirci Yıldırım T, Sarı İ. Tofacitinib therapy for severe pyoderma gangrenosum in a patient with enteropathic arthritis: a case-based review. Rheumatol Int 2024:10.1007/s00296-024-05560-1. [PMID: 38488863 DOI: 10.1007/s00296-024-05560-1] [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] [Accepted: 02/11/2024] [Indexed: 03/17/2024]
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that is associated with systemic inflammatory conditions. Currently, there is no universally accepted standard therapy for PG, but immunosuppressive (IS) treatment seems essential. We report a patient here who was successfully treated with tofacitinib despite being PG-refractory to multiple anti-tumor necrosis factor alpha (anti-TNF) therapies and conventional IS. In addition, we performed a comprehensive review of all cases of PG treated with JAK inhibitors. We identified 27 cases treated with JAK inhibitors. Approximately 80% of the patients achieved complete recovery within a median of 12 weeks, even though 17 patients (63%) had received biologics before JAKinib treatment. Notably, this recovery could appear as early as 2 weeks. JAK inhibitors may prove useful in the future, particularly for treating immunosuppressive and steroid-resistant pyoderma gangrenosum, according to recent case reports.
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Affiliation(s)
- Aydan Köken Avşar
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
| | - Tuba Demirci Yıldırım
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - İsmail Sarı
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Li F, Zhao J, Duan H, Zhang H, Zhang L, Zhao L, Wen Y, Gu X. Pyoderma gangrenosum complicated with hematological malignancies: Two case reports. Medicine (Baltimore) 2024; 103:e37159. [PMID: 38457569 PMCID: PMC10919523 DOI: 10.1097/md.0000000000037159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/12/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic skin disease. The diagnosis of PG is mainly based on clinical manifestations. Therefore, the clinical features of PG are important for confirming the diagnosis of this disease. Herein, the clinical data of 2 young males with PG complicated with hematological malignancies were reported, and the literature were reviewed. CASE PRESENTATION The first case was a 22-year-old male who was admitted due to a systemic rash, headache, and fever. Physical examination showed black scabs on the skins of the extremities, trunk, scalp, and face. Biopsy of the skin lesion showed epidermal edema, spongy formation, neutrophil infiltration, acute and chronic inflammatory cell infiltration in the dermis, showing purulent inflammation with epidermal erosion. The bone marrow biopsy showed obviously active proliferation of nucleated cells, granulocytes at various stages, abnormal morphological neutrophils, and occasionally observed young red blood cells. The diagnosis of PG and chronic myelomonocytic leukemia (CMML-0) was made. The second case was a 28-year-old male who presented a swollen, painful right calf following injury and then developed ulcers on skin and soft tissues. Bone marrow biopsy showed obviously active nucleated cell proliferation, suggesting a myeloid tumor. He was also diagnosed with PG and hematological malignancies. They both received hormone and antiinfection therapy. After treatment, their body temperature, infection, and skin lesions were improved. However, both of them were readmitted and had a poor prognosis. CONCLUSIONS PG may be associated with hematological malignancies. For patients with typical skin lesions and obvious abnormal blood routines, it is necessary to investigate the possibility of PG with hematological malignancies.
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Affiliation(s)
- Fen Li
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Jie Zhao
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Huanan Duan
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Haixi Zhang
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Lin Zhang
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Liangyun Zhao
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Yan Wen
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
| | - Xuezhong Gu
- Department of Hematology, The First People’s Hospital of Yunnan Province, Yunnan Province Clinical Research Center for Hematologic Disease, Yunnan Province Clinical Center for Hematologic Disease, Kunming, 650032 Yunnan, China
- Department of Hematology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032 Yunnan, China
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Łyko M, Ryguła A, Kowalski M, Karska J, Jankowska-Konsur A. The Pathophysiology and Treatment of Pyoderma Gangrenosum-Current Options and New Perspectives. Int J Mol Sci 2024; 25:2440. [PMID: 38397117 PMCID: PMC10889749 DOI: 10.3390/ijms25042440] [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: 01/05/2024] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
Pyoderma gangrenosum (PG) is an uncommon inflammatory dermatological disorder characterized by painful ulcers that quickly spread peripherally. The pathophysiology of PG is not fully understood; however, it is most commonly considered a disease in the spectrum of neutrophilic dermatoses. The treatment of PG remains challenging due to the lack of generally accepted therapeutic guidelines. Existing therapeutic methods focus on limiting inflammation through the use of immunosuppressive and immunomodulatory therapies. Recently, several reports have indicated the successful use of biologic drugs and small molecules administered for coexisting diseases, resulting in ulcer healing. In this review, we summarize the discoveries regarding the pathophysiology of PG and present treatment options to raise awareness and improve the management of this rare entity.
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Affiliation(s)
- Magdalena Łyko
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland;
| | - Anna Ryguła
- Student Research Group of Experimental Dermatology, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland; (A.R.); (M.K.); (J.K.)
| | - Michał Kowalski
- Student Research Group of Experimental Dermatology, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland; (A.R.); (M.K.); (J.K.)
| | - Julia Karska
- Student Research Group of Experimental Dermatology, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland; (A.R.); (M.K.); (J.K.)
- Department of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Alina Jankowska-Konsur
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 50-368 Wroclaw, Poland;
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Jacobson ME, Rick JW, Gerbens LAA, Baghoomian W, Gould LJ, Marzano AV, Chen DM, Oakes DL, Dissemond J, Yamamoto T, Shinkai K, Nolan B, Lobato D, Thomas KS, Ortega-Loayza AG. A core domain set for pyoderma gangrenosum trial outcomes: an international eDelphi and consensus study from the UPGRADE initiative. Br J Dermatol 2024; 190:392-401. [PMID: 37952167 DOI: 10.1093/bjd/ljad420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/24/2023] [Accepted: 11/16/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a rare ulcerative skin condition with no current standardized outcomes or outcome measures. With a rich investigational therapeutic pipeline, standardization of outcomes and improvement of data quality and interpretability will promote the appropriate and consistent evaluation of potential new therapies. Core outcome sets (COS) are agreed, standardized sets of outcomes that represent the minimum that should be measured and reported in all clinical trials of a specific condition. OBJECTIVES To identify and reach a consensus on which domains (what to be measured) should be included in the Understanding Pyoderma Gangrenosum: Review and Analysis of Disease Effects (UPGRADE) core domain set for clinical trials in PG. METHODS Collaborative discussions between patients and PG experts, and a systematic review of the literature identified items and prospective domains. A three-round international eDelphi exercise was performed to prioritize the domains and refine the provisional items (consensus: ≥ 70% of participants rating a domain as 'extremely important' and < 15% of participants voting 'not important'), followed by an international meeting to reach consensus on the core domain set (consensus: < 30% disagreement). Item-generation discussions and consensus meetings were hosted via online videoconferences. The eDelphi exercise and consensus voting were performed using Qualtrics survey software. Participants were adults with PG, healthcare professionals, researchers and industry representatives. RESULTS Collaborative discussions and systematic reviews yielded 115 items, which were distilled into 15 prospective domains. The eDelphi exercise removed the three lowest-priority domains ('laboratory tests', 'treatment costs' and 'disease impact on family') and ranked 'pain', 'quality of life' and 'physical symptoms' as the highest-priority prospective domains. Consensus was reached on the domains of 'pain', 'quality of life' and 'clinical signs'. The domain of 'disease course/disease progression' narrowly failed to reach consensus for inclusion in the core set (32% of participants voted 'no'). Refinement of this domain definition will be required and presented for consideration at future consensus meetings. CONCLUSIONS The UPGRADE core domain set for clinical trials in PG has been agreed by international multistakeholder consensus. Future work will develop and/or select outcome measurement instruments for these domains to establish a COS.
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Affiliation(s)
- Michael E Jacobson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Jonathan W Rick
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection, and Immunity, Amsterdam, the Netherlands
| | - Wenelia Baghoomian
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Lisa J Gould
- South Shore Health Center for Wound Healing, Weymouth, MA, USA
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Diana M Chen
- Genentech Incorporated, South San Francisco, CA, USA
| | - Debbie L Oakes
- South Shore Health Center for Wound Healing, Weymouth, MA, USA
| | - Joachim Dissemond
- Department of Dermatology, Venerology, and Allergology, University of Essen-Duisburg, Essen, Germany
| | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
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13
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Gordon H, Burisch J, Ellul P, Karmiris K, Katsanos K, Allocca M, Bamias G, Barreiro-de Acosta M, Braithwaite T, Greuter T, Harwood C, Juillerat P, Lobaton T, Müller-Ladner U, Noor N, Pellino G, Savarino E, Schramm C, Soriano A, Michael Stein J, Uzzan M, van Rheenen PF, Vavricka SR, Vecchi M, Zuily S, Kucharzik T. ECCO Guidelines on Extraintestinal Manifestations in Inflammatory Bowel Disease. J Crohns Colitis 2024; 18:1-37. [PMID: 37351850 DOI: 10.1093/ecco-jcc/jjad108] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Hannah Gordon
- Department of Gastroenterology, Barts Health NHS Trust, London, Centre for Immunobiology, Blizard Institute, Faculty of Medicine, Barts & The London Medical School, Queen Mary University of London, UK
| | - Johan Burisch
- Gastrounit, medical division, Hvidovre Hospital, University of Copenhagen, Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Hvidovre Hospital, University of Copenhagen, Denmark
| | - Pierre Ellul
- Department of Medicine, Division of Gastroenterology, Mater Dei Hospital, Msida, Malta
| | | | - Konstantinos Katsanos
- Department of Gastroenterology and Hepatology, Division of Internal Medicine, University and Medical School of Ioannina, Ioannina, Greece
| | - Mariangela Allocca
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | - Giorgos Bamias
- GI Unit, 3rd Academic Department of Internal Medicine, National and Kapodistrian University of Athens, Sotiria Hospital, Athens, Greece
| | - Manuel Barreiro-de Acosta
- University Hospital Santiago De Compostela CHUS, Department of Gastroenterology - IBD Unit, Santiago De Compostela, Spain
| | - Tasanee Braithwaite
- School of Immunology and Microbiology, King's College London, The Medical Eye Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Thomas Greuter
- Division of Gastroenterology and Hepatology, GZO - Zurich Regional Health Center, Wetzikon, Division of Gastroenterology and Hepatology, University Hospital Lausanne - CHUV, Lausanne, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Harwood
- Centre for Cell Biology and Cutaneous Research, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Department of Dermatology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Pascal Juillerat
- Gastroenterology, Clinic for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland; Crohn and Colitis Center, Gastro-entérologie Beaulieu SA, Lausanne, Switzerland
| | - Triana Lobaton
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent; Department of Gastroenterology, Ghent University Hospital, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus Liebig University Giessen, Bad Nauheim, Germany
| | - Nurulamin Noor
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gianluca Pellino
- Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona UAB, Barcelona, Spain; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania 'Luigi Vanvitelli', Naples, Italy
| | - Edoardo Savarino
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology Unit, Azienda Ospedale Università di Padova, Padua, Italy
| | - Christoph Schramm
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandra Soriano
- Gastroenterology Division and IBD Center, Internal Medicine Department, Azienda Unità Sanitaria Locale - IRCCS, 42122 Reggio Emilia, Italy
| | - Jürgen Michael Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt/Main, Department of Gastroenterology and Clinical Nutrition, DGD Clinics Sachsenhausen, Frankfurt/Main, Germany
| | - Mathieu Uzzan
- Department of Gastroenterology, Hôpital Henri Mondor, APHP, Créteil, France
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital, Zurich, Switzerland
| | - Maurizio Vecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stephane Zuily
- Vascular Medicine Division and French Referral Center for Rare Auto-Immune Diseases, Université de Lorraine, INSERM, DCAC and CHRU-Nancy, Nancy, France
| | - Torsten Kucharzik
- Department of Gastroenterology, Lüneburg Hospital, University of Münster, Lüneburg, Germany
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14
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Guliyeva G, Janis JE. Postsurgical Pyoderma Gangrenosum Requiring Plastic Surgical Intervention: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5505. [PMID: 38250211 PMCID: PMC10798700 DOI: 10.1097/gox.0000000000005505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/03/2023] [Indexed: 01/23/2024]
Abstract
Pyoderma gangrenosum is a neutrophilic dermatosis characterized by immune dysfunction and pathergy. Thus, it is frequently seen in patients with underlying systemic illnesses or postoperatively. For the performance of the debridement or closure of the resultant defect, plastic surgeons are often involved in the care of pyoderma patients. However, both procedures may exacerbate the injury. Therefore, plastic surgeons must be familiar with the presentation of postsurgical pyoderma to avoid further damage and safely repair related soft tissue defects. A systematic search of the PubMed/Medline database was performed using the following keywords: "pyoderma gangrenosum" and "surgery." This online database search has identified 656 studies published between 1958 and 2022. Only reconstructed cases of postsurgical pyoderma gangrenosum were selected. Twenty-eight patients who developed pyoderma after dermatologic, plastic, orthopedic, cardiovascular, general, or obstetric surgery were included in this study. The average time to the PG presentation and diagnosis was 5.5 and 17 days, respectively. Diagnostic scoring tools were not used, and the diagnosis was primarily based on histopathology after repeated treatment failures. The patients received split- or full-thickness skin grafts, local, pedicled, and free flaps. An estimated 82.1% underwent skin grafting, whereas 42.9% underwent flap reconstruction. In addition, 21.4% got both the graft and flap. Accurate diagnosis of PSPG, prevention of further surgical injury, and timely medical management are vital for improving patient outcomes. Reconstruction can be performed, if required. However, despite the availability of different reconstructive techniques, there is no standard approach to the management of the PSPG.
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Affiliation(s)
- Gunel Guliyeva
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
| | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, Ohio
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15
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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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16
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Goldschmidt-Clermont PJ, Plasencia K, Goldschmidt AJ, White IA. First Case of Severe Pain and Inflammation Reduction by Application of Purified Amniotic Fluid on Active Lesions of a Patient with Pyoderma Gangrenosum. ANNALS OF CASE REPORTS 2023; 8:1566. [PMID: 38455377 PMCID: PMC10919578 DOI: 10.29011/2574-7754.101566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
We report the first case of severe pain and inflammation reduction by application of purified amniotic fluid on active lesions of a patient with pyoderma gangrenosum. We describe the impact of every third-day skin applications of a sterile fraction (4ml) from human purified amniotic fluid (ViX001) obtained from thoroughly screened volunteers at the time of planned c-section at the term of normal pregnancies. The product ViX001 was generated through a proprietary process and kept in frozen one or two milliliters cryovials (protein content was ~1mg/ml) and thawed just prior to applications. Pain improvement was recorded after each application, and inflammation suppression was confirmed by serial pictures of the lesions. While our findings need to be reproduced with a larger cohort of patients, preferably at an earlier stage of the disease, it is instructive that ViX001 reduced severe pain and inflammation for a patient with advanced pyoderma gangrenosum. Pyoderma gangrenosum is a dreadful skin condition consisting of noninfectious neutrophilic dermatosis that progresses to necrotic ulcers with a characteristic purple edge and extremely painful raw subdermal tissue exposure.
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Affiliation(s)
| | - Kenda Plasencia
- Department of Nursing, Baptist Hospital, Baptist Health South Florida, FL 33176, USA
| | | | - Ian A White
- Neobiosis LLC, UF Sid Martin Innovate Biotechnology Institute, Alachua, FL 32615, USA
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17
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Shatnawi NJ, Al-Zoubi NA, Al-Bakkar LA, Gharaibeh LM, Hamouri S. Nonhealing Leg Ulcer as the Presentation of Sarcoidosis: A Case Report. INT J LOW EXTR WOUND 2023; 22:742-747. [PMID: 34374584 DOI: 10.1177/15347346211037850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic leg ulcers (CLUs) are common, with increasing prevalence in the elderly population. Circulatory dysfunctions are responsible for 90% to 95% of all causes, while 5% to 10% of CLUs are associated with underlying chronic systemic disorders. Sarcoidosis is a complex multisystemic disease characterized by noncaseating granulomas affecting mainly the pulmonary system, with cutaneous manifestation in 25% to 30% of cases. However, ulcerative sarcoidosis (US) is a rare form of cutaneous sarcoidosis. Pyoderma gangrenosum (PG) is an uncommon, chronic inflammatory noninfectious skin disease affecting different body parts. The ulcerative form of PG is rarely reported in association with sarcoidosis.We aim to report a 44-year-old female patient with a history of hypertension and varicose veins, presenting with a CLU for more than 18 months. Ulcer tissue biopsy showed noncaseating granuloma with abscess formation suggestive of sarcoidosis; however, PG could not be ruled out. Mediastinal lymph node biopsy was consistent with sarcoidosis. The leg ulcer had complete healing within 4 months by local wound management, negative pressure wound therapy, and split-thickness skin grafting without immunosuppressive treatment to achieve wound healing.
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Affiliation(s)
| | | | | | | | - Shadi Hamouri
- Jordan University of Science and Technology, Irbid, Jordan
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18
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Wang N, Yu C, Wang W, Yang Q. Certolizumab treatment of localized pyoderma gangrenosum in a pregnant patient. J DERMATOL TREAT 2023; 34:2276044. [PMID: 37905433 DOI: 10.1080/09546634.2023.2276044] [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: 08/14/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023]
Abstract
THE PURPOSE OF THE ARTICLE Pyoderma gangrenosum (PG) is an ulcerating neutrophilic dermatosis with an incidence of 3-10 patients per million. PG equally affects patients of both sexes and of any age. Of these patients, 50-75% are associated with auto-immune disease. The lower extremities are the most commonly affected body parts. Minor trauma to the skin may result in the development of new lesions. Patients complain of chronic, nonhealing ulcers with associated pain. Treatment starts with systemic or intralesional corticosteroids, however, no official treatment protocol currently exists. Recent success has been found with biologic agents such as TNF-a inhibitor, although the treatment efficacy in these reports is limited. As for the pregnant patient, the drug selection is difficult. In this report, we want to assess the efficiency of certolizumab in the pregnant patient. RESULTS We report a case of a patient with PG, who responded well to certolizumab, 400 mg as a booster dose, followed by 200 mg biweekly for 8 weeks. The lesions gradually resolved and followed up for 5months without side effect. In addition, we reviewed the literature and compared the current treatment efficiency in the treatment of PG. CONCLUSION Certolizumab may be a promising therapeutic option for patients with severe PG.
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Affiliation(s)
- Na Wang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
- Shandong Provincial Medical Center for Dermatovenereology, Jinan, Shandong, China
| | - Changping Yu
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
- Shandong Provincial Medical Center for Dermatovenereology, Jinan, Shandong, China
| | - Weiwei Wang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
- Shandong Provincial Medical Center for Dermatovenereology, Jinan, Shandong, China
| | - Qing Yang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
- Shandong Provincial Medical Center for Dermatovenereology, Jinan, Shandong, China
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19
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Yu JJ, Ma LY, Xu WL, Mei C, Zhou XP, Ye L, Tong HY. [Report of six cases of myeloid tumors combined with pyoderma gangrenosum and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:945-948. [PMID: 38185526 PMCID: PMC10753263 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Indexed: 01/09/2024]
Affiliation(s)
- J J Yu
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China Department of Hematology, Xiangshan Hospital of the First Affiliated Hospital of Zhejiang University, Ningbo 315700, China
| | - L Y Ma
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China
| | - W L Xu
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China Department of Hematology, Zhejiang Provincial People's Hospital, Hangzhou 310014, China
| | - C Mei
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China
| | - X P Zhou
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China
| | - L Ye
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China
| | - H Y Tong
- Department of Hematology, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China
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20
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Diaz MJ, Natarelli N, Wei A, Rechdan M, Botto E, Tran JT, Forouzandeh M, Plaza JA, Kaffenberger BH. Cutaneous Manifestations of Rheumatoid Arthritis: Diagnosis and Treatment. J Pers Med 2023; 13:1479. [PMID: 37888090 PMCID: PMC10608460 DOI: 10.3390/jpm13101479] [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: 08/23/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder characterized by inflammatory arthritis and periarticular structural damage. Available evidence suggests that RA results from complex interactions between genetic susceptibility (e.g., HLA-DRB1), environmental factors (e.g., smoking), and immune dysregulation. Alongside joint-related symptoms, individuals with RA may also experience a wide array of skin issues, including the development of nodules, neutrophilic dermatoses, vasculitis, and vasculopathy. Treatment strategies for these manifestations vary but routinely involve corticosteroids, disease-modifying anti-rheumatic drugs, and biologics, with individualized approaches guided by disease severity. In this review, we provide comprehensive insights into the skin-related issues associated with RA, outlining their clinical characteristics and histopathological findings. Our aim is to facilitate early diagnosis and personalized treatment to improve the quality of life of affected individuals.
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Affiliation(s)
- Michael J. Diaz
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Nicole Natarelli
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA
| | - Aria Wei
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Michaela Rechdan
- College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Elizabeth Botto
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA
| | - Jasmine T. Tran
- School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Mahtab Forouzandeh
- Department of Dermatology, University of Florida, Gainesville, FL 32606, USA
| | - Jose A. Plaza
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH 43221, USA
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21
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Yeung KCY, O'Connor EM, Hull PR. Pyoderma gangrenosum. BMJ 2023; 382:e075863. [PMID: 37673429 DOI: 10.1136/bmj-2023-075863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Affiliation(s)
- Katie C Y Yeung
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Emily M O'Connor
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Peter R Hull
- Division of Clinical Dermatology and Cutaneous Science, Dalhousie University, Halifax, Nova Scotia, Canada
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22
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Yamamoto T, Yamasaki K, Yamanaka K, Komine M, Kawakami T, Yamamoto O, Kanekura T, Higuchi T, Takahashi T, Matsushima Y, Kikuchi N. Clinical guidance of pyoderma gangrenosum 2022. J Dermatol 2023; 50:e253-e275. [PMID: 37311717 DOI: 10.1111/1346-8138.16845] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 06/15/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.
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23
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Dissemond J, Marzano AV, Hampton PJ, Ortega-Loayza AG. Pyoderma Gangrenosum: Treatment Options. Drugs 2023; 83:1255-1267. [PMID: 37610614 PMCID: PMC10511384 DOI: 10.1007/s40265-023-01931-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.
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Affiliation(s)
- Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Philip J Hampton
- Department of Dermatology, Newcastle Dermatology, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science, University, Portland, OR, USA
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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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Kao AS, King AD, Bardhi R, Daveluy S. Targeted therapy with ixekizumab in pyoderma gangrenosum: A case series and a literature overview. JAAD Case Rep 2023; 37:49-53. [PMID: 37492426 PMCID: PMC10363659 DOI: 10.1016/j.jdcr.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Affiliation(s)
- Andrew S. Kao
- Wayne State University School of Medicine, Detroit, Michigan
| | - Andrew D. King
- Department of Dermatology, Wayne State University School of Medicine, Detroit, Michigan
| | - Redina Bardhi
- Wayne State University School of Medicine, Detroit, Michigan
| | - Steven Daveluy
- Department of Dermatology, Wayne State University School of Medicine, Detroit, Michigan
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26
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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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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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Jordan A, Fullen D, Minhas D. A Case of a Curious Skin Lesion. Gastroenterology 2022; 164:e1-e5. [PMID: 36513137 DOI: 10.1053/j.gastro.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Ariel Jordan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Douglas Fullen
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - Deeba Minhas
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Rheumatology, University of Michigan, Ann Arbor, Michigan
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29
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Dozier L, Ceresnie M, Habashy J, Kerdel F. Improvement of refractory pyoderma gangrenosum with adjunctive maggot debridement therapy. Int J Dermatol 2022. [DOI: 10.1111/ijd.16531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 10/10/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Lauren Dozier
- Department of Dermatology Larkin Community Hospital/Lake Erie College of Osteopathic Medicine Graduate Medical Education South Miami FL USA
| | | | - Jacquiline Habashy
- Department of Dermatology Larkin Community Hospital/Lake Erie College of Osteopathic Medicine Graduate Medical Education South Miami FL USA
| | - Francisco Kerdel
- Department of Dermatology Larkin Community Hospital/Lake Erie College of Osteopathic Medicine Graduate Medical Education South Miami FL USA
- Department of Dermatology Florida International University Miami FL USA
- Florida Academic Dermatology Center Coral Gables FL USA
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30
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Birkner M, Schalk J, von den Driesch P, Schultz ES. Computer-Assisted Differential Diagnosis of Pyoderma Gangrenosum and Venous Ulcers with Deep Neural Networks. J Clin Med 2022; 11:jcm11237103. [PMID: 36498674 PMCID: PMC9740900 DOI: 10.3390/jcm11237103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
(1) Background: Pyoderma gangrenosum (PG) is often situated on the lower legs, and the differentiation from conventional leg ulcers (LU) is a challenging task due to the lack of clear clinical diagnostic criteria. Because of the different therapy concepts, misdiagnosis or delayed diagnosis bears a great risk for patients. (2) Objective: to develop a deep convolutional neural network (CNN) capable of analysing wound photographs to facilitate the PG diagnosis for health professionals. (3) Methods: A CNN was trained with 422 expert-selected pictures of PG and LU. In a man vs. machine contest, 33 pictures of PG and 36 pictures of LU were presented for diagnosis to 18 dermatologists at two maximum care hospitals and to the CNN. The results were statistically evaluated in terms of sensitivity, specificity and accuracy for the CNN and for dermatologists with different experience levels. (4) Results: The CNN achieved a sensitivity of 97% (95% confidence interval (CI) 84.2−99.9%) and outperformed dermatologists, with a sensitivity of 72.7% (CI 54.4−86.7%) significantly (p < 0.03). However, dermatologists achieved a slightly higher specificity (88.9% vs. 83.3%). (5) Conclusions: For the first time, a deep neural network was demonstrated to be capable of diagnosing PG, solely on the basis of photographs, and with a greater sensitivity compared to that of dermatologists.
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Affiliation(s)
- Mattias Birkner
- Institute of Medical Physics, Paracelsus Medical University Nuremberg, City Hospital of Nuremberg, 90419 Nürnberg, Germany
- Correspondence:
| | - Julia Schalk
- Department of Dermatology, Paracelsus Medical University Nuremberg, City Hospital of Nuremberg, 90419 Nürnberg, Germany
| | - Peter von den Driesch
- Department of Dermatology, Klinikum Stuttgart, Bad Cannstatt, 70174 Stuttgart, Germany
| | - Erwin S. Schultz
- Department of Dermatology, Paracelsus Medical University Nuremberg, City Hospital of Nuremberg, 90419 Nürnberg, Germany
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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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Chu Y, Liu T, Bai J, Fang H, Qiao J. Successful Treatment of a Patient with Pyoderma Gangrenosum, Plaque Psoriasis and Palmoplantar Pustulosis with Adalimumab. Clin Cosmet Investig Dermatol 2022; 15:1991-1995. [PMID: 36164556 PMCID: PMC9508993 DOI: 10.2147/ccid.s373115] [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: 05/06/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare autoinflammatory skin disorder, which is characterised by rapidly developing and tender cutaneous ulcers. The treatment of PG is challenging. Palmoplantar pustulosis (PPP) is also an autoinflammatory dermatosis with sterile pustules on the palms and/or the soles. We demonstrated a 68-year-old patient with coexisting autoinflammatory diseases including PG, 1-year history of plaque psoriasis and PPP, recovered after treatment with adalimumab. We also reviewed published reports of PG-associated autoinflammatory syndromes with adalimumab.
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Affiliation(s)
- Yuqi Chu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Taoming Liu
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Juan Bai
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Hong Fang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
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Mulholland O, Middleton D, Hunter H. Negative-pressure wound therapy as an adjunct to treating pyoderma gangrenosum. J R Coll Physicians Edinb 2022; 52:260-262. [DOI: 10.1177/14782715221126768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Negative-pressure wound therapy has been shown to be effective in re-epithelialisation in recalcitrant pyoderma gangrenosum. This case documents a patient whose co-morbidities limited the standard treatment options and required an alternative management plan. The STOP GAP randomised control trial found that both oral prednisolone and ciclosporin were equally effective in the treatment of pyoderma gangrenosum. However, in this case, the patient had type 2 diabetes and prednisolone resulted in persistently elevated blood glucose levels. Lower doses were ineffective and it was subsequently stopped once other treatments showed a clinical improvement. A recent diagnosis of breast cancer prevented the use of ciclosporin and other immunosuppressive treatments. After multidisciplinary discussion, involving breast surgeons, oncology, dermatology and tissue viability, doxycycline was commenced alongside a portable negative-pressure device with twice weekly tissue viability input. The introduction of this device resulted in a rapid reduction in the wound size and facilitated healing with an excellent outcome.
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Affiliation(s)
| | - David Middleton
- Department of Dermatology, Belfast City Hospital, Belfast, UK
| | - Helen Hunter
- Department of Dermatology, Belfast City Hospital, Belfast, UK
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34
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Perforator propeller flap for coverage of Achilles region defects caused by pyoderma gangrenosum. JPRAS Open 2022; 33:139-144. [PMID: 35935517 PMCID: PMC9352399 DOI: 10.1016/j.jpra.2022.06.008] [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] [Received: 12/14/2021] [Accepted: 06/27/2022] [Indexed: 11/24/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a rare neutrophilic inflammatory skin disease. Systemic corticosteroid and immunosuppressive agents are the mainstay treatment. PG usually precludes a surgical approach due to pathergy phenomenon. Recent literatures show skin grafting and negative pressure wound therapy are safe if performed under adequate immunosuppression. We present a case of a 61-year-old male patient suffered from PG induced left posterior leg wound with Achilles tendon exposure. We made timely diagnosis and treated him with adequate immunosuppression therapy followed by perforator propeller flap for wound coverage. This case report emphasizes the need for high index of suspicion for PG diagnosis. Furthermore, with adequate immunosuppression, operative intervention may not be an absolute contraindication for PG.
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35
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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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36
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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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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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39
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Michel D, Dege T, Kneitz H, Stumpf M, Goebeler M, Schmieder A. Pyoderma gangraenosum als diagnostische und therapeutische
interdisziplinäre Herausforderung. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1798-5164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDas Pyoderma gangraenosum (PG) ist eine neutrophile Dermatose unklarer Genese,
die sowohl in Assoziation zu hämatologischen und neoplastischen
Systemerkrankungen, chronisch-entzündlichen Darmerkrankungen und
autoinflammatorischen Syndromen als auch idiopathisch auftreten kann. Sowohl die
Diagnosestellung wie auch die Therapie des PG stellen aufgrund seiner
Seltenheit, des Fehlens großer randomisierter kontrollierter Studien und
der unzureichend verstandenen Pathogenese eine Herausforderung in der klinischen
Praxis dar. Diese Übersichtsarbeit beschreibt und diskutiert aktuelle
Erkenntnisse, die das PG als autoinflammatorische Erkrankung beschreiben. Durch
eine Dysregulation von T-Lymphozyten und myeloiden Zellen wie den neutrophilen
Granulozyten kommt es zur Entstehung von Pusteln und
großflächigen Ulzera. Klassische Therapieansätze
umfassen eine anti-inflammatorische topische Therapie, eine Analgesie sowie die
systemische Gabe von Immunmodulantien oder -suppressiva. Neuere, bisher nicht
zugelassene Therapieoptionen sind der Einsatz von Biologika und
JAK-Inhibitoren.
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Affiliation(s)
- Daniel Michel
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Tassilo Dege
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Hermann Kneitz
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Marco Stumpf
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
| | - Matthias Goebeler
- Dermatologie, Universitätsklinikum Würzburg Klinik und
Poliklinik für Dermatologie Venerologie und Allergologie,
Würzburg, Germany
| | - Astrid Schmieder
- Klinik für Dermatologie, Venerologie und Allergologie,
Universitätsklinikum Würzburg, Würzburg,
Germany
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40
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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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41
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Nazir A, Zafar A. Management of Idiopathic Pyoderma Gangrenosum With Azathioprine As the Primary Adjunct in an Asian Man: A Case Report. Cureus 2022; 14:e25177. [PMID: 35746991 PMCID: PMC9209338 DOI: 10.7759/cureus.25177] [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: 05/21/2022] [Indexed: 11/19/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a very rare, non-infectious, progressive inflammatory condition falling under the umbrella of neutrophilic dermatoses. It is an ulcerative condition with a wide variety of cutaneous manifestations and multiple clinical variants (classic ulcerative, pustular, bullous, and superficial granulomatous). Additionally, owing to similar patterns of mucocutaneous ulceration, it has certain overlaps with other neutrophilic diseases frequently observed in clinical practice. Pyoderma gangrenosum may occur in association with systemic conditions such as inflammatory bowel disease, hematological malignancies, or as a part of an inherited inflammatory syndrome. However, in rare cases, it may have an idiopathic origin as well. With no specific standardized diagnostic and treatment protocols in place, the management of pyoderma gangrenosum is primarily guided by pre-existing literature or is tailored according to the individual’s disease pattern, type, and associations. Currently, the pathophysiology of pyoderma gangrenosum remains elusive at best. All the aforementioned reasons contribute significantly to PG being labeled as a "diagnostic dilemma" or more commonly as a "diagnosis of exclusion" with frequent incidences of delayed diagnosis or misdiagnosis resulting in catastrophic delays in management. A 35-year-old Asian male presented with bilateral painful, violaceous ulcers with undermined edges involving the shins for the past three months. Routine investigations carried out were indicative of an underlying infection owing to a raised leucocyte count. Discharge from the lesion, however, showed no evidence of microbial growth. The ulcer progressively increased in size, despite optimal wound care and empirical treatment. Skin biopsy demonstrated central necrosis and ulceration of the epidermis and dermis with neutrophilic infiltrates. Phenomenon of pathergy was demonstrated following the formation of a new ulcer at the site of intravenous cannulation during hospital admission. Additionally, aggravation of pre-existing ulcers following their debridement was also indicative of a positive pathergy test. Ultimately, the diagnosis of pyoderma gangrenosum was made upon the successful exclusion of all the other differential diagnoses. Presence of an associated systemic disease could not be appreciated, leading to it being labeled as a case of idiopathic pyoderma gangrenosum. Supportive treatment with non-adhesive, moist dressings was initiated along with topical tacrolimus (0.1%) application. Treatment modalities utilized were steroids and azathioprine in divided doses owing to contraindications to the traditional option of cyclosporine. The patient showed a rapid response to steroids and azathioprine. The ulcers healed with characteristic cribriform scarring within three months of initiation of treatment.
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Dissemond J, Romanelli M. Inflammatory skin diseases and wounds. Br J Dermatol 2022; 187:167-177. [PMID: 35514247 DOI: 10.1111/bjd.21619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 12/12/2022]
Abstract
Inflammatory wounds of the skin can be caused by many different diseases. Of particular importance here are the very heterogeneous groups of vasculitides and vasculopathies. These are usually interdisciplinary relevant diseases that require extensive diagnostics in specialized centres. Clinically, these inflammatory wounds present as very painful ulcers that develop from necrosis and are surrounded by erythematous livid borders. The healing process is often difficult and protracted. Moreover, it considerably impairs the quality of life of the affected patients. In addition to clinical evaluation, histopathological examination of biopsies taken as early as possible is particularly important in diagnosis. Numerous differential diagnoses must be ruled out. Therapeutically, in addition to the often necessary systemic therapies, which include immunosuppressants (immunomodulating drugs and/or rheologics), appropriate topical wound treatment, usually in combination with compression therapy, should always be considered. Whenever possible, the causative factors should be diagnosed early and avoided or treated.
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Affiliation(s)
- Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Essen, Germany
| | - Marco Romanelli
- Department of Dermatology, University of Pisa, Pisa, Toscana, Italy
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Peterson DM, Damsky WE, Vesely MD. Fever, Hypotension, and a Worsening Necrotic Wound. JAMA 2022; 327:1496-1497. [PMID: 35311923 DOI: 10.1001/jama.2022.2806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - William E Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Matthew D Vesely
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
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Honigman A, Kelly RI. Pyoderma gangrenosum: A review of patient's demographics, disease and treatment in 118 patients. Australas J Dermatol 2022; 63:267-269. [PMID: 35437757 DOI: 10.1111/ajd.13840] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Anthony Honigman
- Department of Dermatology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Robert I Kelly
- Department of Dermatology, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, Victoria, Australia
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Cutaneous manifestations of monoclonal gammopathy. Blood Cancer J 2022; 12:58. [PMID: 35411042 PMCID: PMC9001632 DOI: 10.1038/s41408-022-00661-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 12/29/2022] Open
Abstract
Monoclonal gammopathy associated with dermatological manifestations are a well-recognized complication. These skin disorders can be associated with infiltration and proliferation of a malignant plasma cells or by a deposition of the monoclonal immunoglobulin in a nonmalignant monoclonal gammopathy. These disorders include POEMS syndrome, light chain amyloidosis, Schnitzler syndrome, scleromyxedema and TEMPI syndrome. This article provides a review of clinical manifestations, diagnostics criteria, natural evolution, pathogenesis, and treatment of these cutaneous manifestations.
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Weiss EH, Ko CJ, Leung TH, Micheletti RG, Mostaghimi A, Ramachandran SM, Rosenbach M, Nelson CA. Neutrophilic Dermatoses: a Clinical Update. CURRENT DERMATOLOGY REPORTS 2022; 11:89-102. [PMID: 35310367 PMCID: PMC8924564 DOI: 10.1007/s13671-022-00355-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/13/2022]
Abstract
Purpose of Review Neutrophilic dermatoses are defined by the presence of a sterile neutrophilic infiltrate on histopathology. This review focuses on the pathogenesis, epidemiology, clinicopathological features, diagnosis, and management of four disorders: Sweet syndrome, pyoderma gangrenosum, Behçet syndrome, and neutrophilic eccrine hidradenitis. Recent Findings Recent studies have provided insight into the complex pathogenesis of neutrophilic dermatoses. Evidence supports an intricate interplay of abnormal neutrophil function and inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic predisposition. Summary Neutrophilic dermatoses have diverse cutaneous and extracutaneous manifestations and may be associated with significant morbidity and mortality. Common underlying associations include infectious, inflammatory, and neoplastic disorders, as well as drug reactions. Emerging diagnostic and therapeutic frameworks identify an expanding role for biologic and targeted anti-inflammatory therapies.
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Yamasaki K, Yamanaka K, Zhao Y, Iwano S, Takei K, Suzuki K, Yamamoto T. Adalimumab in Japanese patients with active ulcers of pyoderma gangrenosum: Final analysis of a 52-week phase 3 open-label study. J Dermatol 2022; 49:479-487. [PMID: 35243682 PMCID: PMC9313851 DOI: 10.1111/1346-8138.16337] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 01/20/2022] [Accepted: 02/10/2022] [Indexed: 02/02/2023]
Abstract
In this 52-week, phase 3 open-label study, efficacy and safety of adalimumab were evaluated in Japanese patients with active ulcers due to pyoderma gangrenosum (PG) during a 26-week treatment period and another 26-week extension period. Patients received adalimumab 160 mg at week 0, 80 mg at week 2, and 40 mg every week from week 4. At week 26, 12 of 22 patients (54.5%, p < 0.001) achieved the primary efficacy endpoint of PG area reduction 100 (PGAR 100, complete skin re-epithelialization) for the target ulcer. Nine patients with Physician's Global Assessment (PGA) score of 1, 2, or 3, including four patients achieving PGAR 100, continued into the extension period. During the extension period, six of nine patients (66.7%) achieved PGAR 100 for the target PG ulcer at 52 weeks; one patient who achieved PGAR 100 before week 26 experienced a relapse 162 days after achieving this endpoint. Six patients achieved PGA 0 by week 52, and one patient reported new ulcers at day 57 of the extension period. Continued improvements from study baseline to week 52 were observed in pain (mean [95% CI] -4.0 [-6.5 to -1.5] numeric rating scale) and Dermatology Life Quality Index (-7.3 [-15.1 to 0.4]). In addition to the adverse events (AE) reported in 18 patients (including four serious AE) through week 26 (most commonly infections [n = 11]), there was one 1 additional AE (infection) during the extension period. These results suggest that adalimumab is effective and generally well tolerated in Japanese patients with active PG ulcers.
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Affiliation(s)
- Kenshi Yamasaki
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Yiwei Zhao
- AbbVie Inc., Cambridge, Massachusetts, USA
| | | | | | | | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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Williams HC, McPhee M, Layfield C. Celebrating 20 years of the
UK
Dermatology Clinical Trials Network: Part 1 – developing and delivering high quality independent clinical trials. Clin Exp Dermatol 2022; 47:1048-1059. [PMID: 35199857 PMCID: PMC9322597 DOI: 10.1111/ced.15140] [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] [Received: 01/26/2022] [Accepted: 02/13/2022] [Indexed: 11/29/2022]
Abstract
The UK Dermatology Clinical Trials Network (UK DCTN) was formed in 2002 with the aim of developing and supporting high‐quality independent national clinical trials that address prioritized research questions for people with skin disease. Its philosophy is to democratize UK dermatological clinical research and to tackle important clinical questions that industry has no incentive to answer. The network also plays a key role in training and capacity development. Its membership of over 1000 individuals includes dermatology consultants, trainees, dermatology nurses, general practitioners, methodologists and patients. Its organizational structures are lean and include a co‐ordinating team based at the Centre of Evidence‐Based Dermatology in Nottingham, and an executive with independent members to ensure probity and business progression. A prioritization panel and steering group enable a pipeline of projects to be prioritized and refined for external funding from independent sources. The UK DCTN has supported and completed 12 national clinical trials, attracting investment of over £15 million into UK clinical dermatology research. Trials have covered a range of interventions from drugs such as doxycycline (BLISTER), silk clothing for eczema (CLOTHES) and surgical interventions for hidradenitis suppurativa (THESEUS). Trial results are published in prestigious journals and have global impact. Genuine partnership with patients and carers has been a strong feature of the network since its inception. The UK DCTN is proud of its first 20 years of collaborative work, and aims to remain at the forefront of independent dermatological health technology assessment, as well as expanding into areas including diagnostics, artificial intelligence, efficient studies and innovative designs.
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Affiliation(s)
- Hywel C. Williams
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
| | - Margaret McPhee
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
| | - Carron Layfield
- Centre of Evidence Based Dermatology, Population and Lifespan Sciences, School of Medicine University of Nottingham Nottingham UK
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Goto H, Okada Y, Watanabe S, Danno K, Yamamoto S, Ishiura R, Nakayama Y, Mitsui K, Ueki A, Nakai Y, Narushima M, Yamanaka K. Successful Treatment of Ulcerative-Type Pyoderma Gangrenosum with a Combination Therapy of Oral Prednisolone, Vacuum-Assisted Closure, and Skin Grafting. Case Rep Dermatol 2021; 13:497-501. [PMID: 34899231 PMCID: PMC8613544 DOI: 10.1159/000519659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a relatively rare inflammatory skin disease that progressively causes necrotic ulceration mainly on the lower extremities and trunk. Systemic corticosteroid is considered a first-line treatment for PG as it facilitates wound healing; however, several cases where tumor necrosis factor-α inhibitors, adalimumab and infliximab, were administered showed good response. For intractable PG with a large ulcer or problematic epithelization, chemical or mechanical debridement of necrotic tissue in combination with skin grafting may be necessary to promote wound healing. Our report presents a case of intractable ulcerative PG requiring oral prednisolone and skin grafting. Although mechanical debridement was performed, granulation was poor; therefore, after the PG activity became quiescent, we utilized a vacuum-assisted closure (VAC) system to promote granulation and adaptation of the grafted skin. Although more cases are required for a definitive conclusion, the VAC system may be a choice for PG with large ulcers.
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Affiliation(s)
- Hiroyuki Goto
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
| | - Yoshimoto Okada
- Plastic and Reconstructive Surgery, Mie University Graduate School of medicine, Mie, Japan
| | - Seimi Watanabe
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
| | - Kanako Danno
- Plastic and Reconstructive Surgery, Mie University Graduate School of medicine, Mie, Japan
| | - Shinya Yamamoto
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
| | - Ryohei Ishiura
- Plastic and Reconstructive Surgery, Mie University Graduate School of medicine, Mie, Japan
| | - Yuichi Nakayama
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
| | - Kohei Mitsui
- Plastic and Reconstructive Surgery, Mie University Graduate School of medicine, Mie, Japan
| | - Ayaka Ueki
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
| | - Yasuo Nakai
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
| | - Mitsunaga Narushima
- Plastic and Reconstructive Surgery, Mie University Graduate School of medicine, Mie, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Mie University Graduate School of medicine, Mie, Japan
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Dermatologic Complications Following Cosmetic and Reconstructive Plastic Surgery: A Systematic Review of the Literature. Aesthetic Plast Surg 2021; 45:3005-3018. [PMID: 34231016 DOI: 10.1007/s00266-021-02362-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Plastic surgery procedures, including minimally invasive cosmetic procedures, continue to grow in popularity. Although dermatologic complications following plastic surgery procedures are rare, the authors have encountered several of these complications in their practice, including herpes simplex virus (HSV-1) and varicella zoster virus (VZV) infections, pyoderma gangrenosum (PG), contact dermatitis, and suture hypersensitivity. These cases prompted a systematic literature review of dermatologic complications following plastic surgery procedures. METHODS The authors conducted a systematic review of PubMed, MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Library to identify relevant articles published from 1975 to 2021. Articles were independently reviewed by the authors to determine whether studies met inclusion criteria. RESULTS The majority of articles that met inclusion criteria represented level V evidence. The most robust evidence in the literature was for PG, for which there were 63 total studies. Pyoderma gangrenosum was most frequently reported following breast surgery (85.1%), while HSV-1 infections were frequently seen following minimally invasive procedures (84.6%). VZV reactivation was reported after a range of interventions, including pedicled flap surgeries and laser treatments. Other complications, such as suture hypersensitivity, were less frequently reported in the literature, usually as isolated case reports. CONCLUSIONS Dermatologic complications represent a rare but serious concern following plastic surgery procedures. While most dermatologic complications resolve with appropriate treatment, sequelae of these conditions can be devastating to the patient's overall outcome. Plastic surgeons performing procedures at a high risk of these complications should recognize the diagnostic criteria to facilitate appropriate treatment. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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