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Montagnon CM, Fracica EA, Patel AA, Camilleri MJ, Murad MH, Dingli D, Wetter DA, Tolkachjov SN. Pyoderma gangrenosum in hematologic malignancies: A systematic review. J Am Acad Dermatol 2019; 82:1346-1359. [PMID: 31560977 DOI: 10.1016/j.jaad.2019.09.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/15/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pyoderma gangrenosum (PG) is a devastating neutrophilic dermatosis that may be associated with trauma or systemic diseases. The associations, characteristics, and temporal relationship of PG with hematologic malignancies are not well understood. OBJECTIVE We performed a systematic review of PG associated with hematologic malignancies using data from case reports, case series, and retrospective studies. METHODS We searched MEDLINE, EMBASE, Scopus, and Web of Science from each database's inception to December 12, 2018. Two reviewers independently selected studies and extracted data. RESULTS Two hundred seventy-nine publications met the inclusion criteria (340 cases). Myelodysplastic syndrome (MDS) was the most commonly reported hematologic malignancy associated with PG, followed by monoclonal gammopathy of undetermined significance and acute myeloid leukemia. The mean age of patients was 56.5 years, with males being more common. There was a predominance of the ulcerative PG subtype and multifocal distributions across all hematologic malignancies. The majority of MDS cases preceded PG, which was reversed for MGUS. LIMITATIONS The data were limited by reporting bias because PG subtypes rely on the rendered diagnosis reported. In addition, the classification for hematologic malignancies has evolved since 1978. CONCLUSION Patients with PG should be evaluated for hematologic malignancies, with MDS being the most common.
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Affiliation(s)
| | | | - Archna A Patel
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota
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Vacas AS, Torre AC, Bollea-Garlatti ML, Warley F, Galimberti RL. Pyoderma gangrenosum: clinical characteristics, associated diseases, and responses to treatment in a retrospective cohort study of 31 patients. Int J Dermatol 2017; 56:386-391. [DOI: 10.1111/ijd.13591] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 01/25/2017] [Accepted: 08/02/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Aldana S. Vacas
- Department of Dermatology; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | - Ana C. Torre
- Department of Dermatology; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | | | - Fernando Warley
- Department of Internal Medicine, Research Unit; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
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Abstract
Cutaneous complications are common in patients with leukemia. However, the cause is not always immediately clear, as there are often numerous potential etiologies. Thrombocytopenia or coagulopathy can result in ecchymoses or petechiae, whereas extramedullary (EM) involvement by leukemia can present as a rash. Leukemia can also result in skin manifestations via indirect means, including several types of paraneoplastic phenomena. Moreover, various agents routinely used to treat leukemia-most notably cytarabine (cytosine arabinoside)-can precipitate quite profound skin eruptions. Finally, infections, including fungal invasion of the skin, can be responsible for rashes, as can the vast array of antimicrobials that are administered to leukemia patients.
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Affiliation(s)
| | | | - Raghava Induru
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC
| | - Jonathan M Gerber
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC.
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4
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DeFilippis E, Feldman S, Huang W. The genetics of pyoderma gangrenosum and implications for treatment: a systematic review. Br J Dermatol 2015; 172:1487-1497. [DOI: 10.1111/bjd.13493] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2014] [Indexed: 12/22/2022]
Affiliation(s)
- E.M. DeFilippis
- Center for Dermatology Research; Department of Dermatology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
| | - S.R. Feldman
- Center for Dermatology Research; Department of Dermatology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
- Department of Pathology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
- Department of Public Health Sciences; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
| | - W.W. Huang
- Center for Dermatology Research; Department of Dermatology; Wake Forest School of Medicine, Medical Center Boulevard; Winston-Salem NC 27157 U.S.A
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Bullous pyoderma gangrenosum associated with pancytopenia of unknown origin. Postepy Dermatol Alergol 2014; 31:272-6. [PMID: 25254015 PMCID: PMC4171674 DOI: 10.5114/pdia.2014.40980] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/05/2014] [Accepted: 01/25/2014] [Indexed: 11/17/2022] Open
Abstract
Pyoderma gangrenosum (PG) is a neutrophilic dermatosis of unknown origin. Clinically it starts with a pustule, nodule or bulla that rapidly progresses and turns into a painful ulcer with raised, undermined borders. The etiopathogenesis of PG remains unknown. However it is frequently associated with systemic diseases such as inflammatory bowel disease (IBD), haematological disorders or arthritis. The latest multicentric retrospective analysis published by Ghazal et al. shows that anaemia has been observed very often in German patients suffering from PG (in 45.6% of 259) so this disorder is supposed to be a possible cofactor in the pathogenesis of PG. According to its progressive course, patients require intensive diagnostic procedures and rapid initiation of the treatment. In this article, we report a case of bullous pyoderma gangrenosum in association with pancytopenia of unknown origin, according to its diagnostic and therapeutic difficulties.
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Miyata T, Yashiro M, Hayashi M, Kamata K, Katsuoka K. Bullous pyoderma gangrenosum of the bilateral dorsal hands. J Dermatol 2012; 39:1006-9. [PMID: 23039059 DOI: 10.1111/j.1346-8138.2012.01672.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 07/24/2012] [Indexed: 02/02/2023]
Abstract
Pyoderma gangrenosum (PG) shows characteristic non-infectious ulcers that are commonly associated with systemic diseases such as inflammatory bowel diseases, myeloproliferative disorders or aortitis syndrome. The typical clinical appearance is undermining ulcers with reddish and irregular borders on the legs. As PG has these notable signs, the diagnosis is relatively easy and its treatment depends on the severity of underlying complications. We report a case of a 60-year-old Japanese man, diagnosed with bullous PG, who also had been suffering from myeloperoxidase antineutrophil cytoplasmic antibody-positive microscopic polyangiitis and pulmonary aspergillosis. This case displayed soft whitish ulcers that existed on the rough ulcer base, with irregular borders, on his bilateral dorsal hands. Initially, it seemed to be cutaneous secondary aspergillosis because the host was already infected with pulmonary aspergillosis in both lungs. The differential diagnosis of PG from aspergillosis was from the sterile bullae or neutrophilic bullae on his right forearm, which evolved into ulcers in a few days. This case was finally diagnosed as bullous PG and a topical glucocorticoid was very effective to epithelize the ulcers in 2-3 weeks.
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Affiliation(s)
- Toshiko Miyata
- Department of Dermatology, Kitasato University School of Medicine, Sagamihara, Japan.
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7
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Sakiyama M, Kobayashi T, Nagata Y, Fujimoto N, Satoh T, Tajima S. Bullous pyoderma gangrenosum: a case report and review of the published work. J Dermatol 2012; 39:1010-5. [PMID: 22974277 DOI: 10.1111/j.1346-8138.2012.01676.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 08/01/2012] [Indexed: 11/29/2022]
Abstract
Pyoderma gangrenosum (PG) is an ulcerative skin disorder characterized by neutrophilic infiltrations. PG is generally classified into four types: (i) ulcerative; (ii) pustular; (iii) bullous; and (iv) vegetative. Among them, bullous PG is known as a rare type. Herein, we report a case of bullous PG together with a summary of the 12 PG cases treated in our department over the previous 15 years, and we review 38 well-documented bullous PG cases (65.8% female; aged 18-80 years [mean ± standard deviation, 51.6 ± 16.8]) in the published work, including the present case, from 1972-2011. Although the disease most frequently associated with PG is inflammatory bowel disease, bullous PG is most commonly associated with hematological disorders (25/38, 65.8%), which indicates the characteristic pathophysiology specific to bullous PG.
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Affiliation(s)
- Masayuki Sakiyama
- Department of Dermatology, National Defense Medical College, Tokorozawa, Japan.
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Fox LP, Geyer AS, Husain S, Grossman ME. Bullous pyoderma gangrenosum as the presenting sign of fatal acute myelogenous leukemia. Leuk Lymphoma 2009; 47:147-50. [PMID: 16321840 DOI: 10.1080/10428190500254299] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Bullous pyoderma gangrenosum begins as a bulla, nodule or nonulcerated erythematous plaque that blisters or ulcerates to form a superficial ulcer surrounded by a hemorrhagic, bullous border, which is surrounded by a blue-gray halo. Bullous pyoderma gangrenosum is most commonly associated with hematologic malignancies, specifically, acute myelogenous leukemia (AML). We report a patient whose initial presentation with bullous pyoderma gangrenosum prompted the appropriate diagnostic evaluation and confirmation of AML, which was ultimately fatal. We emphasize that a thorough hematologic investigation, including bone marrow biopsy, should be performed in all patients who present with lesions clinically suggestive of bullous pyoderma gangrenosum because the skin lesion may be the only indicator of the underlying hematologic disorder.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Fatal Outcome
- Female
- Humans
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Lymphoma, B-Cell/complications
- Lymphoma, B-Cell/diagnosis
- Lymphoma, B-Cell/drug therapy
- Middle Aged
- Myelodysplastic Syndromes/complications
- Myelodysplastic Syndromes/diagnosis
- Myelodysplastic Syndromes/drug therapy
- Pyoderma Gangrenosum/diagnosis
- Pyoderma Gangrenosum/drug therapy
- Pyoderma Gangrenosum/etiology
- Skin Diseases, Vesiculobullous/diagnosis
- Skin Diseases, Vesiculobullous/drug therapy
- Skin Diseases, Vesiculobullous/etiology
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Affiliation(s)
- Lindy Peta Fox
- Department of Dermatology, Yale University School of Medicine, New Haven, CT 06520-8059, USA.
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Campbell S, Cripps S, Jewell DP. Therapy Insight: pyoderma gangrenosum—old disease, new management. ACTA ACUST UNITED AC 2005; 2:587-94. [PMID: 16327838 DOI: 10.1038/ncpgasthep0339] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2005] [Accepted: 09/27/2005] [Indexed: 11/08/2022]
Abstract
Well-designed studies that help guide physicians to apply the optimal therapeutic strategy for the management of pyoderma gangrenosum are lacking in the literature. A multidisciplinary approach is paramount for the effective management of this condition, with close involvement of a wound-care specialist and a microbiologist. Treatment should be stepwise in nature. Local wound care, avoidance of trauma and the application of local steroid or tacrolimus ointment are the first-line treatments. Steroid therapy is the most widely published effective therapy for achieving resolution of pyoderma gangrenosum, although there is growing evidence for the efficacy of infliximab in refractory cases. Other therapies such as dapsone and clofazamine should be left as third-line agents for refractory pyoderma gangrenosum, while novel treatments such as granulocyte apheresis should only be used under trial conditions, to gain an objective evaluation of their efficacy. This article reviews the published treatment strategies in current use, and aims to guide the effective management of pyoderma gangrenosum.
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Affiliation(s)
- Simon Campbell
- Pharmacy Department, John Radcliffe Hospital, Headington, Oxford, UK.
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Krauze E, Brzezińska-Wcisło L, Kamińska-Winciorek G, Wygledowska-Kania M, Sygula E. Pyoderma gangrenosum coexisting with acute myelogenous leukaemia. J Eur Acad Dermatol Venereol 2005; 19:589-92. [PMID: 16164714 DOI: 10.1111/j.1468-3083.2005.01202.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The frequency of occurrence of malignant neoplasms in the cases of pyoderma gangrenosum is not exactly determined, but it can be assessed to be at 7%. The aim of the study was to report a 26-year-old male patient with pyoderma gangrenosum coexisting with acute myelogenous leukaemia. The first skin lesions on both tibia occurred in June 2001. Prior to the proper diagnosis of pyoderma gangrenosum, the patient was treated surgically. Because of the dramatic dermatological and general condition in November 2001, the patient was admitted to the Dermatological Department of the Silesian Medical Academy in Katowice where the diagnosis of pyoderma gangrenosum was established. On the clinical and biochemical picture, the diagnosis of pyoderma gangrenosum within acute myelogenous leukaemia was made. Initially, cyclosporin A 200 mg orally per day in the therapy of pyoderma gangrenosum was administered to achieve a slight clinical improvement. Although chemotherapy leukaemia was performed, the patient died after 4 months of the confirmation of the acute myelogenous leukaemia diagnosis.
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Affiliation(s)
- E Krauze
- Dermatological Departament of Silesian Medical Academy, 40-027 Katowice, ul. Francuska 20/24, Poland.
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Abstract
Collaboration between specialists is necessary for good practice of medicine. The dermatological examination, mainly based on visual characteristics, can greatly help other specialisms when confronted with a seemingly futile skin anomaly. We discuss the various cutaneous features of some metabolic and infectious diseases, the pitfalls in diagnosing lupus erythematosus without knowledge of skin disease and the relationship of dermatological diseases as cutaneous vasculitis, pyoderma gangrenosum, Sweet's syndrome, pemphigus and more to internal disease.
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Affiliation(s)
- E Van Hecke
- Department of Dermatology, Universitair Ziekenhuis Gent, De Pintelaan 185, B-9000 Gent.
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12
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Roustan G, Salas C, Cabrera R, Simón A. Neutrophilic eccrine hidradenitis unassociated with chemotherapy in a patient with acute myelogenous leukemia. Int J Dermatol 2001. [DOI: 10.1046/j.1365-4362.2001.11775.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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