Pyoderma Gangrenosum: A Report of 27 Patients

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

STUDY LIMITATIONS

Retrospective nature of the present study.

CONCLUSIONS

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

Clinical, epidemiological, and therapeutic hallmarks of pyoderma gangrenosum: a case series of 35 patients

BACKGROUND

Over the past few decades, advances in medical research and diagnostic tools have shed light on some aspects of pyoderma gangrenosum (PG). Nevertheless, the multifactorial etiology, pathogenesis, and optimal management strategies for PG need to be further investigated. To address these knowledge gaps and contribute to a better understanding of this complex dermatological disorder, we collected epidemiological, clinical, and therapeutic aspects of a case series of PG patients occurring in our department over the past 10 years.

METHODS

We performed a single-centered, retrospective, observational study analyzing all cases with a diagnosis of PG observed at the Dermatology clinic of the Fondazione Policlinico A. Gemelli IRCCS Catholic University from January 1, 2013, to January 1, 2023. For each case, we retrieved demographic data, the presence of other skin and systemic conditions, and the histopathological and clinical characteristics of PG, such as clinical variant, number of lesions, disease localization, previous therapy, response to treatment, and occurrence of relapse.

RESULTS

We included 35 patients, 22 females and 13 males with a mean age of 40.0 years. Twenty patients (57.1%) had multiple localizations of disease, and the most commonly involved site was the lower limbs (85.7%). The lesions were mainly associated with inflammatory bowel diseases (51.4%) and hidradenitis suppurativa (37.1%). Clinical resolution with complete re-epithelialization was achieved in 25 patients (71.4%) with an average time of 20.8 months. On average, patients who underwent therapy with biological drugs had better outcomes.

CONCLUSIONS

PG is a severe, rare, and pleomorphic disease associated with a broad spectrum of conditions. Corticosteroids remain the primary first-line approach for severe forms, but using biological immunosuppressants is promising.

Clinicopathological Profile of Pyoderma Gangrenosum: A 10-Year Retrospective Study from a Tertiary Care Center in South India

Background

Pyoderma gangrenosum (PG) is a reactive neutrophilic inflammatory dermatosis with a varied clinicopathologic presentation. It commonly manifests as rapidly progressive painful ulcers, mimicking varied conditions including infections, vasculitis, and malignancies, and is a diagnosis of exclusion. There are scarce data on PG from the Indian subcontinent.

Aim and Objectives

The aim of the study was to study the clinicopathologic profile of patients with PG and their underlying systemic associations.

Materials and Methods

A retrospective observational study was done between 2011 and 2021, and patients diagnosed as PG based on the diagnostic tool proposed by Maverakis et al. were recruited and their demographic, clinical, and histological findings were obtained.

Results

Among 54 patients with suspected PG, 17 patients (eight males and nine females) fulfilled the diagnostic criteria, and the mean age of disease onset was 32.1 years (range: 3-60 years). Ulcerative variant was the most common type (9/17, 52.9%), and 29.4% had systemic associations including autoinflammatory syndromes. The onset at atypical sites such as face and hand were noted in one patient each. Histopathology revealed a polymorphous dermal infiltrate with neutrophilic predominance in the majority (94.1%). Systemic steroids (dose ranging from 0.5-1 mg/kg prednisolone equivalent) were used in 11/17 (64.7%) patients. The commonly used alternative drugs included clofazimine (47%), minocycline (29%), thalidomide (23.5%), adalimumab and mycophenolate mofetil in 17.6% each, dapsone and ciclosporine in 11.7% each. Remission was achieved between two weeks and three months in 10 (58.8%) patients after treatment initiation and two mortalities (11.7%) were recorded.

Conclusion

PG can affect any age group and may be localized to rarer, atypical sites. The possibility of underlying autoinflammatory conditions should be considered in addition to the evaluation of other disorders like inflammatory bowel disease, hematological disorders, and rheumatological disorders.

Postoperative Pyoderma Gangrenosum Following Carpal Tunnel Surgery: A Case Report and Review of the Literature

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by painful ulcerated lesions. Postoperative PG, which typically begins with erythema and severe pain within two weeks after surgery, progresses into ulcerated lesions. It is often misdiagnosed as it resembles necrotizing skin infections, resulting in delayed treatment. Cases of postoperative PG located in the upper extremity are uncommon. In this case report, we discuss a male patient who developed postoperative PG after carpal tunnel surgery.

Recalcitrant Ulcerative Pyoderma Gangrenosum of the Leg Responsive to Tildrakizumab: A Case Report

Elevated levels of inflammatory mediators—including the interleukin IL-23—are implicated in the pathogenesis of pyoderma gangrenosum (PG), an autoinflammatory neutrophilic dermatosis characterized by rapidly enlarging, suppurative ulcers and cribriform scarring. Here, we present the first case report of significant response of isolated ulcerative PG with tildrakizumab, a biologic agent directed against the p19 subunit of IL-23, in an elderly woman with extensive treatment-refractory PG on her left leg. Tildrakizumab (100 mg subcutaneously at weeks 0 and 4, then every 8 weeks, and eventually increased in frequency to every 6 weeks), combined with acetic acid soaks each morning and chemical debridement every evening with 3% hydrogen peroxide, resulted in progressive decrease in ulcer size and depth, re-epithelialization, and recovery of sensory perception. This report describes the dramatic clinical response of ulcerative PG on the leg with tildrakizumab.

Multifocal Pyoderma Gangrenosum with an Underlying Hemophagocytic Lymphohistiocytosis: Case Report and the Review of the Literature

Pyoderma gangrenosum (PG) is an uncommon, serious, ulcerating skin disease of uncertain etiology. It manifests as a noninfectious, progressive necrosis of the skin characterized by sterile neutrophilic infiltrates. It seems to be a disorder of the immune system. PG is associated with certain underlying conditions in at least 50% of cases. Therefore, it is important to look carefully for comorbidities in every patient with PG and treat them adequately to improve the prognosis. Here, we demonstrate a 35-year-old man diagnosed with multifocal PG and hemophagocytic lymphohistiocytosis (HLH) with fatal outcome, despite combined, long-term, intensive dermatological and hematological treatment with high doses of steroids, cyclosporin, intravenous immunoglobulins (IVIG), HLH-2004 protocol with intravenously administered etoposide, and anakinra. This case is presented owing to the extremely rare coexistence of PG and HLH and the related diagnostic and therapeutic difficulties. It is also worth underlying that the diagnosis of HLH should perhaps be considered in the presence of a high percentage of double-negative T lymphocytes (DNTs) in flow cytometry, after excluding the diagnosis of lymphoma and leukemia. In this article we have also performed and present the critical literature review of local and systemic options in the management of PG lesions based on a detailed search of the PubMed database.

The surgical approach to Pyoderma gangrenosum: A retrospective monocenter study

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

Applying Intravenous Immunoglobulin and Negative-Pressure Wound Therapy to Treat Refractory Pyoderma Gangrenosum: A Case Report

Pyoderma gangrenosum (PG) is a rare chronic neutrophilic dermatosis that causes undermining ulcers. Unfortunately, standardization of PG treatment remains a challenge. In this article, we describe a case in which a 69-year-old man presented with a painful ulcer on the right lower leg. The diagnosis of PG was made after excluding other diseases. He had a history of PG on his left lower leg 2 years earlier and was cured by the treatment of systemic corticosteroids and cyclosporin A for 43 days. However, such a treatment was not effective this time. Hence, we applied intravenous immunoglobulin and negative-pressure wound therapy, and the patient was cured. Altogether, this case supports the use of intravenous immunoglobulin as an effective adjuvant for refractory PG, and indicates negative-pressure wound therapy as a treatment option to advance ulcer healing under adequate immunosuppression.

Clinical and histological patterns and treatment of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis for which accurate epidemiological data are limited and therapy remains a challenge. The primary study’s aim was to examine all cases of PG observed in our department over a 6-year period in order to describe the relevant characteristics and outcome under therapy. Fourteen patients were included (5 women, 9 men). The average age of our patients was 40,15 years. The classical, ulcerative form was found in 10 cases (71.42%), the pustular form in 4 cases (27.57%) and PG was multifocal in 4 cases. The PG was located preferentially to the lower limbs. Histological examination was realized in all patients and objectified inflammatory infiltrate composed of polymorphonuclear neutrophils in all cases with vasculitis in 4 cases. Six patients (42.85%) had associated disease at diagnosis of PG, including inflammatory bowel disease in two cases (14.28%), a blood disease in 2 cases (14.28%), lymph node tuberculosis and inflammatory arthritis in 1 case (7%). The most frequent first-line treatments were oral corticosteroids (7 cases) and other treatments used were colchicine in 2 cases, topical corticosteroids in 3 cases with good clinical evolution. Our study confirms that PG is a rare disease, associated in almost half of cases with systemic disease already present at diagnosis; in our Moroccan background, it is most often inflammatory bowel disease, hematological or solid cancer and tuberculosis.

Rheumatoid arthritis and pyoderma gangrenosum: a population-based case-control study

BACKGROUND

The association between pyoderma gangrenosum (PG) and rheumatoid arthritis (RA) was not investigated in the setting of controlled studies. The risk of PG among patients with RA is not established.

OBJECTIVE

The study aims to evaluate the magnitude of the association between RA and the subsequent development of PG. Additionally, we aimed to characterize patients with RA-associated PG relative to other patients with PG.

METHODS

A population-based case-control study was conducted comparing PG patients (n = 302) with age-, sex-, and ethnicity-matched control subjects (n = 1497) with respect to the presence of RA. Logistic regression models were utilized for univariate and multivariate analyses.

RESULTS

The prevalence of RA was greater in patients with PG than in control subjects (4.7% vs. 1.5%, respectively; P < 0.001). More than threefold increase in the odds of PG with RA (OR, 3.29; 95% CI, 1.66-6.50) was noted. This association retained its statistical significance following a sensitivity analysis excluding RA cases diagnosed up to 2 years prior to PG (OR, 2.72; 95% CI, 1.25-5.91) and after adjusting for confounding factors (adjusted OR, 2.80; 95% CI, 1.23-5.86). RA preceded the diagnosis of PG in the majority of patients by a mean (SD) latency of 9.2 (7.4) years. Patients with RA-associated PG were older relative to the remaining patients with PG (62.2 [15.0] vs. 53.4 [20.9] years, respectively; P = 0.006).

CONCLUSIONS

RA increases the odds of developing PG by more than threefold. Physicians managing patients with RA should be aware of this increased burden. Patients with RA may be advised to avoid additional precipitating factors of PG. Key Points • The odds of developing PG are increased by more than threefold in patients with RA. • PG followed the diagnosis of RA in the majority of patients with these coexistent conditions by an average latency of 9.2 years. • Patients with RA-associated were older relative to other patients with PG at the onset of PG.

Pyoderma Gangrenosum Associated with Sunitinib: A Case Report

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that presents with painful, sterile ulcers. Drug-induced PG is a rare condition; propylthiouracil, granulocyte colony-stimulating factor, and sunitinib are drugs that have been implicated to date. This article presents a case of PG associated with sunitinib.

Biologics in Microangiopathic Wounds

In the last decades the possibility to diagnose a skin ulcer has greatly improved. We learnt that a consistent percentage of nonhealing ulcers may be caused by a microangiopathic disorder that has not been properly investigated and cured. Pathogenetically, we can distinguish 2 main groups: (1) ulcers due to inflammatory microangiopathy, mainly including cutaneous small and medium vessel vasculitis, pyoderma gangrenosum, and connective tissue diseases, and (2) ulcers due to occlusive microangiopathy. The group of microangiopathic occlusive ulcers is more heterogeneous and includes different disorders ranging from livedo vasculopathy to calciphylaxis, hydroxyurea-induced ulcers, antiphospholipid antibodies ulcers, and various other types. These conditions can induce thromboses or anatomo-functional occlusion of cutaneous microvessels. Despite different physiopathologic mechanisms, the ulcer resulting from a primitive microangiopathy may receive basic treatments that are in the complex similar to other pathogenetically different wounds, including MOIST-based local therapy and elastic compression when it is not contraindicated. Persistent inflammatory processes are increasingly demonstrated as responsible for the chronicity of many skin ulcers. New data concerning the biological phases of wound healing and the molecules that play crucial roles in this process suggested the use of new specific therapies. Some of them such as growth factors and platelet-rich plasma are prevalently used as topical biologic agents with variable benefits. In recent years, a new class of systemic anti-inflammatory molecules, better known as biologic drugs, have been introduced in the cure of chronic inflammatory diseases that can induce microangiopathic injuries and ulcerative complication. They enlarged the therapeutic options in case of nonresponder microangiopathic ulcers and could represent a future model of “pathogenetically based” therapy of skin ulcers.

Underlying Systemic Diseases in Pyoderma Gangrenosum: A Systematic Review and Meta-Analysis

BACKGROUND

There is little consensus regarding the prevalence and distribution of underlying systemic diseases among patients with pyoderma gangrenosum.

OBJECTIVE

The objective of this study was to synthesize existing data on the prevalence of associated systemic diseases in patients with pyoderma gangrenosum.

METHODS

We performed a systematic review and meta-analysis of observational studies in MEDLINE, EMBASE, and Scopus (1823-2017). The quality of evidence was assessed using a modified Newcastle-Ottawa Scale. A meta-analysis was performed using random-effects models to estimate pooled prevalence rates with 95% confidence intervals.

RESULTS

Twenty-one eligible studies comprising 2611 patients with pyoderma gangrenosum were included in the quantitative synthesis. The overall random-effects pooled prevalence of associated systemic diseases was 56.8% (95% confidence interval 45.5-67.4). The leading underlying disease was inflammatory bowel disease (17.6%; 95% confidence interval 13.0-22.7), followed by arthritis (12.8%; 95% confidence interval 9.2-16.9), hematological malignancies (8.9%; 95% confidence interval 6.5-11.6), and solid malignancies (7.4%; 95% confidence interval 5.8-9.1). In 16.3% (95% confidence interval 7.7-27.1) of cases, the onset of pyoderma gangrenosum was attributed to the pathergy phenomenon.

CONCLUSIONS

More than half of patients with pyoderma gangrenosum present with a relevant underlying disease. Inflammatory bowel disease and arthritis are the most frequently associated diseases. Relative to the reported literature, the pooled prevalence of arthritis and hematological malignancies is lower, while the pooled prevalence of solid malignancies is higher. Owing to the high level of heterogeneity among most of the comparisons, results should be interpreted with caution.

Improvement of Ulcerations in Treatment-Resistant Chronic Scarring in a Patient with Pyoderma Gangrenosum After Improving Vascular Insufficiency, Gently Removing Necrotic Debris, and Decreasing Wound Fluid

BACKGROUND Classical pyoderma gangrenosum is a rare, inflammatory, neutrophilic dermatosis that commonly presents with severe ulcerations on the lower extremities and is often misdiagnosed and mistreated. Delay in treatments can lead to worsening of the ulcerations and allows for multiple comorbid factors. Pyoderma gangrenosum is most commonly treated with immunosuppressants or anti-inflammatory agents and is often worsened by surgical procedures due to the presence of pathergy. In acute cases, a course of anti-inflammatory treatments works well in alleviating symptoms and reducing ulcerations and residual scarring. However, in chronic cases with the presence of severe scarring and necrotic ulcerations, the simple implementation of systemic immunosuppressants is frequently ineffective alone. Although not mentioned in most case reports on pyoderma gangrenosum, the chronicity of its inflammatory component can lead to necrosis and scarring and subsequent vascular insufficiency. CASE REPORT We present a severe case of chronic ulcerative pyoderma gangrenosum in a patient who had treatment-resistant ulcerations and cribriform edematous scarring with subsequent vascular insufficiency of the right lower extremity. This patient, while receiving topical clobetasol, had marked improvement in the healing of his ulcerations only after starting a novel course of cadexomer iodine, compression stockings, and pentoxifylline. CONCLUSIONS The efficacy of non-anti-inflammatory treatments indicates that chronic pyoderma gangrenosum with extensive scarring is commonly associated with the comorbid factors of vascular insufficiency, necrotic debris, and extensive wound fluid. In cases of ulcerations in chronic pyoderma gangrenosum that are resistant to anti-inflammatory treatments alone, one should identify and address other compounding factors that may inhibit wound healing.

Topical Medical Cannabis: A New Treatment for Wound Pain-Three Cases of Pyoderma Gangrenosum

Pain associated with integumentary wounds is highly prevalent, yet it remains an area of significant unmet need within health care. Currently, systemically administered opioids are the mainstay of treatment. However, recent publications are casting opioids in a negative light given their high side effect profile, inhibition of wound healing, and association with accidental overdose, incidents that are frequently fatal. Thus, novel analgesic strategies for wound-related pain need to be investigated. The ideal methods of pain relief for wound patients are modalities that are topical, lack systemic side effects, noninvasive, self-administered, and display rapid onset of analgesia. Extracts derived from the cannabis plant have been applied to wounds for thousands of years. The discovery of the human endocannabinoid system and its dominant presence throughout the integumentary system provides a valid and logical scientific platform to consider the use of topical cannabinoids for wounds. We are reporting a prospective case series of three patients with pyoderma gangrenosum that were treated with topical medical cannabis compounded in nongenetically modified organic sunflower oil. Clinically significant analgesia that was associated with reduced opioid utilization was noted in all three cases. Topical medical cannabis has the potential to improve pain management in patients suffering from wounds of all classes.