Pyoderma Gangrenosum: Diagnostic Criteria, Subtypes, Systemic Associations, and Workup

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis with variable clinical features. The classic presentation is an ulceration with an erythematous to violaceous undermined border. Extracutaneous manifestations may occur. Associated systemic diseases include inflammatory bowel disease, inflammatory arthritides, and hematologic disorders. The pathophysiologic mechanism of disease is not completely known but likely related to the cumulative impact of inflammation, immune-mediated neutrophilic dysfunction, and genetic predisposition. Incidence is between 3 and 10 people per million but may be greater due to under recognition. In this article, we will discuss the diagnostic criteria, disease subtypes, systemic associations, and workup.

Urinary retention associated with herpes zoster infection

BACKGROUND

Herpes zoster infection particularly involving the sacral dermatomes has been associated with bladder and bowel dysfunction, most commonly urinary retention.

CASE REPORTS

We report two patients who developed acute urinary retention, one of whom also had constipation, within days of herpes zoster skin lesions of the S2-S4 dermatomes.

CONCLUSIONS

Herpes zoster is a reversible cause of neurogenic bladder and bowel dysfunction and should be considered in a patient that presents with acute urinary retention and/or constipation. Sensory abnormalities and flaccid detrusor paralysis are most likely involved in the pathogenesis.

Atypical melanocytic nevi. Clinical and histopathologic predictors of residual tumor at reexcision

BACKGROUND

The appropriate method for surgical management of melanocytic lesions with disordered architecture and melanocytic atypia (formerly dysplastic nevi) has been controversial. Physicians often reexcise these lesions after primary removal because of their potential relation to malignant melanoma. The outcomes of these reexcisions and the original biopsy specimens have not been previously examined.

OBJECTIVE

The purpose of this study was to examine reexcision specimens and their respective original specimens to determine whether there were any characteristics predictive of the presence of residual nevus cells (RNCs) on reexcision.

METHODS

One hundred eighty-nine reexcision specimens of atypical melanocytic lesions were evaluated for this study. The original specimens were examined for specific histopathologic features without knowledge of the findings on reexcision. Clinical characteristics were also examined.

RESULTS

Of the 189 reexcision specimens, 47 (24.9%) contained RNCs. The proportion of specimens with RNC on reexcision was significantly greater if the original lesion was removed by punch biopsy rather than by shave or elliptical excision (38.3% vs 22.0% vs 10.5%, respectively; p < 0.03). Lesions located on the chest had a higher likelihood of RNCs than those on the back or leg (52.2% vs 21.7%; p = 0.009; 52.2% vs 9.7%, p < 0.002, respectively). Mean age was greater in those with RNCs at reexcision than those without (43.6 vs 37.9 years, respectively; p < 0.0001). The proportion of specimens with RNCs at reexcision was greater in those that had both lateral margins involved than in those that had nevus cells in either one or neither of the lateral margins in the original biopsy specimens (39.7% vs 24.0% vs 7.8%, respectively; p = 0.0005). One of the 189 reexcision specimens (0.5%) contained melanoma, although the original histopathologic diagnosis was an atypical melanocytic nevus.

CONCLUSION

We identified several clinical and histopathologic factors that are strongly associated with the presence of RNCs on reexcision.

The labial melanotic macule

A series of 41 cases of melanotic lesions of the lip from 1980 to 1984 are reported. These lesions occur preponderantly in young white women on the lower lip. The term labial melanotic macule is suggested for these lesions.

Cutaneous polyarteritis nodosa in a patient with ulcerative colitis

Skin disease is common in patients with inflammatory bowel disease. Described herein is a child with ulcerative colitis and cutaneous polyarteritis nodosa. Review of the literature suggests cutaneous polyarteritis must be considered as another skin lesion associated with inflammatory bowel disease. Cutaneous polyarteritis tends to run a chronic relapsing course independent of bowel disease, however.

Vulvar disorders in the prepubertal female

Inspection of the vulva should be a routine part of well child care. Detection of poor perineal hygiene permits the establishment of good hygiene practices, which may prevent development of vulvovaginitis. Condylomata acuminata, molluscum contagiosum, herpetic vulvitis, and vulvovaginitis secondary to Neisseria gonorrhoeae, Gardnerella vaginalis, Chlamydia trachomatis, and Trichomonas vaginalis arouse suspicion of child sexual abuse, which must be addressed. Atopic dermatitis, psoriasis, lichen planus, and lichen sclerosis et atrophicus are often chronic and early diagnosis with appropriate treatment and follow-up contributes to the acceptance of the disease by parent and child. Early detection of the rare neoplasms of the vulva is essential to improved survival.

Cutaneous signs of systemic disease

In this article we have discussed briefly some of the important diseases in which a thorough skin examination is of help in evaluation and diagnosis of patients in an emergency department. Changes in the skin, for instance, may be the first clue of an internal malignancy. Disorders associated with gastrointestinal bleeding, endocrine abnormalities, and/or epilepsy can have prominent cutaneous manifestations. Thus, an awareness of the unusual findings is of value to the emergency medicine physician.

Hyperkeratosis of the nipple and areola

Hyperkeratosis of the nipple and areola is a rare condition. We report two cases of hyperkeratosis of the nipple and areola occurring in men with no underlying endocrinopathy or synthetic estrogenic drug therapy. Both patients demonstrated prompt resolution of the hyperkeratosis of the nipples with a keratolytic gel. Because our cases were not associated with ichthyosis or epidermal nevus, they best fit into the category of nevoid hyperkeratosis of the nipples.

Linear eccrine nevus with comedones

We report herein a case of a linear nevus comedonicus associated with tumors of sweat gland origin. We propose the term "linear eccrine nevus with comedones" as a suitable title for this disorder. Several similar cases in the literature are reviewed.

A quantitative study of melanocytes in Becker's nevus

A case of Becker's nevus is presented. Dopa-oxidase stains performed on involved and on noninvolved nearby skin revealed a substantial increase in the number of melanocytes in the nevus.

Vesicular pemphigoid

The vesicular variant of bullous pemphigoid (BP) is a clinical entity in which the principal types of lesions are multiple small tense vesicles in a symmetric distribution, rather than large, more randomly distributed bullae. We present a patient who developed an intensely pruritic eruption which clinically was suggestive of typical dermatitis herpetiformis (DH), but subsequently developed large bullae typical of BP. Histologic and immunofluorescence findings, as well as initial response to systemic corticosteroids, were typical of BP. In addition, our patient required the administration of methotrexate to maintain clearance of lesions while prednisone was being tapered, a problem which has not been mentioned in the other patients, described in the literature with vesicular variants of BP.

Eczematous dermatitis caused by Dermanyssus americanus

A patient is presented herein with an acute generalized eczematoid eruption. The onset occurred in late spring and was caused by the American bird mite, Dermanyssus americanus. A review of mite infestations is presented. We suggest that puzzling cutaneous eruptions be evaluated closely as being possibly caused by mites.

Methotrexate in psoriasis. A brief review of indications, usage, and complications of methotrexate therapy

Methotrexate is widely used by dermatologists in the treatment of recalcitrant psoriasis. Despite potentially serious side effects, including hepatic cirrhosis, the drug is relatively safe and remarkably effective when carefully administered to selected patients.

Kaposi's sarcoma with extensive silent internal involvement

A case of Kaposi's sarcoma is presented in which extensive diagnostic studies failed to detect the cardiac, pulmonary, intestinal and nodal involvement that was found to be present at autopsy.

Cutaneous horns: a histopathologic study

We report a series of 230 cutaneous horns, of which fewer than one fourth were frankly malignant. Actinic keratoses were the lesions most commonly found underlying cutaneous horns (37.39%). Cutaneous horns overlying a benign lichenoid keratosis, epidermolytic hyperkeratosis, trichilemmoma, an epidermal inclusion cyst, and a benign fibroma are reported. Three cases were nondiagnosable because of inadequate biopsies that were too superficial to show the base of the lesion.

Zosteriform inflammatory metastatic carcinoma

A 57-year-old man presented with chest wall lesions and swelling of his left arm. The rapid onset of vesicular lesions in a dermatomal distribution resulted in an initial diagnosis of herpes zoster. Cutaneous biopsy revealed adenocarcinoma and further evaluation revealed a primary source of pulmonary adenocarcinoma. Lymphatic spread of tumor cells is the most likely source of the zosteriform skin lesions, but other possibilities are discussed.

Cutaneous angiosarcoma of the hip

An elderly patient is presented who developed a fatal angiosarcoma of the hip about ten years after surgery and radiation for a uterine malignancy. She developed a metastasis of the uterine tumor, requiring additional radiation, which led to aseptic necrosis of the hip and chronic joint and soft tissue infection of the hip from a joint prosthesis. Subsequently she developed chronic lymphedema of the hip and finally the cutaneous angiosarcoma in this area. Any or all of these factors might bear a causative relationship to the angiosarcoma, but none can be proved.

Neurocutaneous syndromes

The neurocutaneous syndromes are a diverse group of diseases characterized by widespread abnormalities in structures of ectodermal origin, including the skin, eye, and central and peripheral nervous systems. These syndromes are particularly interesting to the clinician because they often present with cutaneous signs at birth or very early in life. These skin markers may be clues to widespread abnormality that may later develop in the nervous system and other areas of the body, making early diagnosis from careful assessment of cutaneous signs a particularly challenging task. Six of the most common of these syndromes are reviewed.

Inflammatory linear verrucose epidermal nevus

We treated three patients with inflammatory linear verrucose epidermal nevus. The lesions were either verrucose or psoriasiform and all had an inflammatory component. Histologic features included psoriasiform acanthosis with spongiosis and parakeratosis. Features that distinguish this entity and the differential diagnoses are discussed.

Macrodactyly and epidermal nevus

A case is presented of a child with the two congenital anomalies of macrodactyly and epidermal nevus. Macrodactyly was noted at birth; nevus unius lateris became apparent at three months. The chance association of these two rare anomalies as individual sporadic occurrences is exceedingly unlikely. The case is presented as a possible syndrome entity, if other case documentation exists.

Topical 5-fluorouracil treatment of superficial basal cell epithelioma. A light and electron microscopic study

A 27-year-old patient developed superficial basal cell epitheliomas approximately 20 years after taking Fowler's solution. One of the lesions was successfully treated with topical 2% 5-fluorouracil soultion under occlusion. Sequential biopsies of the lesion before, during and after therapy were examined by light and electron microscopy, and the changes at various stages are described. Changes occurred only in tumor cells and adjacent epidermis, and only after occlusion of 5-FU. After one week of occlusive therapy, focal discontinuities in the basal lamina and intercellular spaces were wider with reduction and condensation of tonofilaments. Mitochondrial degeneration was seen along with irregularities in nucleoli. These changes were most prominent after two weeks of occlusive therapy, and many degenerating keratinocytes were seen detached from other cells. One month after cessation of therapy, the entire area was excised, and no evidence of tumor was seen.