Two-Year Delayed Healing of an Endovascular Access Site Related to an Unusual Etiology.

In this case report, the authors describe a patient who underwent an endovascular abdominal aortic aneurysm repair complicated by more than a 2-year delay in healing of the left inguinal fold access site. Providers initially suspected a chronic infection or foreign body reaction, but eventually the patient was diagnosed with superficial granulomatous pyoderma. Once the correct etiology was determined and appropriate treatment begun, the access site healed within 3 weeks.

Fluorescence biomodulation in the management of canine interdigital pyoderma cases: a prospective, single-blinded, randomized and controlled clinical study.

BACKGROUND: Interdigital pyoderma is a common multifactorial, inflammatory disease of the canine interdigital skin. Lesions commonly become infected secondarily. In addition to management of the underlying cause, management of the chronic inflammatory changes in the interdigital skin created by secondary infection and by the release of keratin into deep tissues is required. Fluorescence biomodulation appears to modulate the inflammatory process in dermatological disorders and has shown promise in preliminary studies evaluating its use in superficial and deep pyoderma in dogs. HYPOTHESIS/OBJECTIVES: To evaluate the effect of a fluorescence biomodulation (FB) system used in conjunction with systemic antibiotic on clinical manifestations of canine interdigital pyoderma (CIP), compared to dogs treated with antibiotic alone. ANIMALS: Thirty-six dogs diagnosed with CIP. METHODS AND MATERIALS: Dogs were randomly allocated to treatment groups of either antibiotic alone (Group A) or antibiotic plus twice-weekly FB application (Group B). Dogs were scored over a 12 week period on the basis of two measured parameters: a global lesion score composed of four different lesions types and neutrophil engulfing bacterial scores. RESULTS: A statistically significant decrease was seen by Week 3 in both measured parameters for Group B compared to Group A. The mean time-to-resolution of lesions was 4.3 weeks in Group B and 10.4 weeks in Group A. CONCLUSION AND CLINICAL IMPORTANCE: The FB system shows promise as an adjunct therapy to systemic antibiotic use in the management of CIP.

Pyoderma Vegetans Misdiagnosed as Verrucous Carcinoma.

Pyoderma vegetans, a rare disorder of the skin, is considered a highly specific marker for inflammatory bowel disease, especially ulcerative colitis. It is clinically characterized by large verrucous plaques with elevated borders and multiple pustules. Here, the authors report the case of a 33-year-old man who was misdiagnosed as having verrucous carcinoma for 4 years.

[Pyoderma in dogs]. / Pyodermie beim Hund.

Bacterial infections associated with cutaneous commensal organisms like Staphylococcus pseudintermedius are frequently encountered in small animal practice. In this review, pathogenesis, clinical signs, and topical and systemic therapeutic options are discussed.

[Therapeutic bacterial vaccine Immunovac in complex treatment of patients with chronic pyoderma].

AIM: Assessment of therapeutic effect and immunologic parameters during use of Immunovac vaccine for complex treatment of chronic forms of pyoderma. MATERIALS AND METHODS: Ninety-five patients with different clinical forms of chronic pyoderma (furunculosis, hydradenitis, chronic ulcerative and ulcerative-vegetans pyoderma, folliculitis, impetigo etc.) were studied. Fifty-nine patients received immunotherapy with Immunovac vaccine together with basic therapy and 36 patients comprised control group treated only with basic therapy. Studied immunologic parameters were as follows: assessment of functional activity of lymphocytes, determination of lymphocyte subpopulations by flow cytometry, total immunoglobulins classes A, G, M by radial immunoduffusion, affinity of antibodies by enzyme immunoassay, levels of IFNalpha and IFNgamma. RESULTS: Use of Immunovac vaccine in complex treatment of patients with chronic forms of pyoderma enhanced clinical effect of basic therapy, which expressed in decrease of severity and frequency of disease relapses irrespective to clinical form and severity of pyoderma. Therapeutic effect during use of Immunovac vaccine amounted 84.7%, whereas in control group it was 41.6% after 12 months of follow-up. Increase of functional activity of neutrophils, subpopulation of lymphocytes with markers CD4+, CD8+, CD72+, affinity of antibodies as well as induced production of IFNalpha and IFNgamma was revealed. Correction of immunologic parameters correlated with positive results of patients treatment. CONCLUSION: Inclusion of bacterial polycomponent vaccine Immunovac in complex treatment of patients with chronic pyoderma promotes enhancement of therapeutic effect of basic therapy and correction of immunologic parameters.

An unusual presentation of blastomycosislike pyoderma (pyoderma vegetans) and a review of the literature.

We report a case of blastomycosislike pyoderma (BLP), also known as pyoderma vegetans, in a 75-year-old woman. The patient initially presented with multiple lesions, some classic and others with highly uncharacteristic morphology. The appearance of unusual purulent hornlike lesions on both cheeks delayed recognition of the disease. The diagnosis of BLP is contingent on the fulfillment of 6 diagnostic criteria and the disease is highly refractory to current treatment strategies. We review the present understanding of disease pathology and available therapeutic modalities.

Reduced antimicrobial prescribing during autogenous staphylococcal bacterin therapy: a retrospective study in dogs with pyoderma.

Autogenous staphylococcal bacterins are commonly mentioned as treatment for canine recurrent pyoderma but little is known about their efficacy. This retrospective study describes use and assesses efficacy of an autogenous Staphylococcus (pseud)intermedius bacterin in dogs with pyoderma. Frequency and duration of systemic antimicrobial therapy were compared 12 months before and after starting bacterin (Wilcoxon signed-rank test) with data extracted from general practice medical histories.

Necrobiosis lipoidica with superimposed pyoderma vegetans.

Necrobiosis lipoidica (NL) is a granulomatous inflammatory skin disease strongly associated with diabetes mellitus (DM). Red-brown papules expanding into plaques with erythematous indurated borders on the lower extremities are characteristic of NL. Diagnosis is made clinically; however, biopsy of lesions confirms the diagnosis. Untreated NL may ulcerate and lead to further complications, but progression to superimposed pyoderma vegetans (PV) is not a known occurrence.

[Clinical ethics consultation - an integrative model for practice and reflection]. / Ethikberatung in der Klinik - ein integratives Modell für die Praxis und ihre Reflexion.

Broad evidence exists that health care professionals are facing ethical difficulties in patient care demanding a spectrum of useful ethics support services. Clinical ethics consultation is one of these forms of ethics support being effective in the acute setting. An authentic case is presented as an illustration. We introduce an integrative model covering the activities being characteristic for ethics consultation and going beyond "school"-specific approaches. Finally, we formulate some do's and don'ts of ethics consultation that are considered to be key issues for successful practice.

A narrative review of dermatologic protocols for primary care medical service trips in Latin America and the Caribbean.

BACKGROUND: Skin disorders are prevalent on primary care medical service trips in Latin America and the Caribbean and commonly include scabies, superficial mycoses, and pyoderma. There have been no previous attempts to describe protocols that international volunteer clinicians use in managing these patients. The purpose of this study was to collect North American clinical protocols used by sending organizations in their volunteer operations in Latin America and the Caribbean, summarize the most common pharmacologic and nonpharmacologic management strategies, and compare these to published international practice recommendations. METHODS: A systematic web search was used to identify North American medical service trip-sending organizations. Clinical protocols were downloaded from their websites, and organizations were directly contacted to request protocols that were not published online. The protocols obtained were summarized, analyzed thematically, and compared to existing international guidelines. RESULTS: Of 225 organizations contacted, 112 (49.8%) responded, and 31 of these (27.7%) claimed to possess protocols for their trips, of which 20 were obtained and analyzed. Ten (50%) protocols discussed scabies, eight (40%) discussed superficial mycoses, and five (25%) discussed pyoderma. The protocols discussed clinical assessment, pharmacologic and nonpharmacologic management with variable degrees of accuracy and thoroughness, and with important omissions when compared to international guidelines. None were the product of systematic literature searches, and most were not referenced. CONCLUSIONS: To avoid ineffective treatment and related harms, context-specific clinical guidelines are needed for volunteer clinicians practicing in remote international settings, and such guidelines should be based on best evidence and stakeholder consensus.

Granulocyte and monocyte adsorption apheresis (GCAP) for refractory skin diseases caused by activated neutrophils and psoriatic arthritis: evidence that GCAP removes Mac-1-expressing neutrophils.

In the present study, we have shown that granulocyte and monocyte adsorption apheresis (GCAP), an extracorporeal apheresis instrument whose column contains cellulose acetate (CA) beads, is useful for skin diseases attributable to activated granulocytes and psoriatic arthritis (PsA). We assessed the clinical effectiveness of GCAP and investigated the mechanisms underlying the adsorption of pathogenic granulocytes. The effect of GCAP was assessed in 14 patients with neutrophilic dermatoses and 16 with PsA. The mechanisms by which the instrument adsorbs activated granulocytes were investigated using an in vitro mini-column system that mimics the GCAP. Skin lesions and arthropathy improved in 22 of 29 patients (75.9%) and 14 of 18 (77.8%), respectively. Mac-1 (CD11b/CD18) expression on the peripheral neutrophils, increased compared with normal subjects, was reduced by GCAP. In the mini-column system, CA beads adsorbed 50% neutrophils; and adsorption was inhibited significantly by treating plasma with EDTA and blood cells with antihuman CD11b monoclonal antibody. GCAP was useful for treating neutrophilic dermatoses and PsA. GCAP adsorbs Mac-1-expressing neutrophils to the CA beads by the binding of complement component (iC3b) on CA beads and CD11b expressed on activated neutrophils.

Pyoderma vegetans developed on chronic leg ulcer.

Pyoderma vegetans is a rare disorder that more commonly affects middle-aged persons, with a male predilection. It is characterized by vegetating lesions that coalescence into a plaque with eroded surface, covered by purulent discharge and crusts. The etiology of this disease is not known with certainty, but it is often associated with bacterial infections in immunocompromised patients. We report the case of a 73-year-old men who presented to the Iasi Dermatology Clinic with a large, irregular, relatively well-defined dermohypodermic ulcer, with infiltrated sclerosing borders, accompanied by pain, with the floor covered in the Northern part by a proliferative, vegetative bleeding area, and the rest by a yellowish secretion and cellular debris, located on the left leg. Bacteriological examination of ulcer secretion identified Pseudomonas aeruginosa. Anatomopathological examination confirmed the development of Pyoderma vegetans on chronic leg ulcer. Under specific treatment for chronic leg ulcer and eradication of infectious focus the outcome was favorable both in terms of trophic ulcer scar- ring and Pyoderma vegetans healing.

Pyoderma gangrenosum at the parastomal site in patients with Crohn's disease.

Pyoderma gangrenosum is a rare idiopathic skin condition often associated with other diseases, including Crohn's disease. We believe this is the first report of cases in which pyoderma gangrenosum was identified at the parastomal site in patients with Crohn's disease. Four episodes of the condition occurred in three patients. In these patients, pyoderma gangrenosum first appeared after two to three surgical procedures and between ten months and five years after the initial surgery. The disease course varied from resolution within two months with corticosteroid therapy to resolution only after revision or relocation of the stoma with resection of recurrent disease segments. Parastomal pyoderma gangrenosum at the ileostomy site in patients with Crohn's disease may be more common than previously thought. Optimal treatment has not yet been established, and treatment needs to be tailored for each patient.

Identification of a neutrophil chemotactic inhibitor in a patient with recurrent pyoderma.

Host defense mechanisms were studied in a patient with recurrent pyoderma of the scalp. Evaluation of the patient's inflammatory response demonstrated normal yeast phagocytosis, normal capillary tube migration, normal results from a nitroblue tetrazolium dye test, and significantly decreased neutrophil chemotactic response (NC). The impaired NC was associated with a heat labile plasma inhibitor. Chromatography of the patient's and of normal human plasma demonstrated three distinct protein peaks. Chemotactic inhibitory activity was found in the third peak of the patient's plasma but not in the control plasma. Normal in vitro NC was restored when greater than 40% normal human plasma was added to the column fractions that contained the inhibitor. Based on these findings, a subsequent exacerbation of the patient's pyoderma was treated with fresh frozen plasma, and dramatic clinical improvement occurred within 72 hours.

Pyoderma faciale. A review and report of 20 additional cases: is it rosacea?

BACKGROUND AND DESIGN: Pyoderma faciale was originally described by O'Leary and Kierland in 1940. It is characterized by the sudden onset of monstrous coalescent nodules and confluent draining sinuses confined to the face of young women in their early 20s. This report summarizes our results in 20 cases. The women were 15 to 46 years old (mean, 25 years). RESULTS: All women were flushers and blushers. Histopathologic examination revealed a dense perivascular and periadnexial infiltrate, including granulocytes, eosinophils with epithelioid granulomas, and septal and lobular panniculitis. No consistent laboratory abnormalities were found. After much therapeutic experimentation, we developed an effective treatment plan, based on a combination of oral isotretinoin and corticosteroids. CONCLUSION: We regard it as an extreme form of rosacea and suggest it be renamed rosacea fulminans in analogy with its counterpart, acne fulminans.

Present status of pyoderma gangrenosum. Review of 21 cases.

This article summarizes the management of 22 cases of pyoderma gangrenosum over the past four years at the hospital of the University of Pennsylvania, Philadelphia. Eighteen patients with pyoderma gangrenosum were studied using the most sensitive routine laboratory method for detection of monoclonal immunoglobulins, immunofixation electrophoresis. Four cases of IgA gammopathy were detected, confirming previous reports of the incidence of monoclonal gammopathy in pyoderma gangrenosum. High-dose glucocorticoid therapy (pulse therapy) is an effective treatment for some severe, refractory cases of pyoderma gangrenosum. Eight patients were treated with pulse therapy. Six responded favorably, and none had serious complications.

Pyoderma gangrenosum in childhood.

A review of our records disclosed eight children with pyoderma gangrenosum. All had associated inflammatory bowel disease, and four had arthritis. In three patients the bowel disease was severe and required resection of portions of the affected bowel. The cutaneous lesions had a chronic course (average duration, 2 1/2 years), and systemic therapy was required in seven cases. Previously reported cases of pyoderma gangrenosum in children are reviewed, and the management of this skin disorder in childhood is discussed.

Pyoderma pathophysiology and management.

Cutaneous infections with Staphylococcus aureus, Streptococcus pyogenes, and Pseudomonas aeruginosa are major complications of epidermolysis bullosa. Application of impermeable occlusive dressings over denuded skin colonized with these bacteria results in rapid multiplication and the hazard of severe pyoderma. Approaches to the prophylactic treatment of these infections during the long-term management of epidermolysis bullosa are considered.

Pyoderma gangrenosum and related disorders.

Pyoderma gangrenosum (PG) is an uncommon ulcerative cutaneous condition with distinctive clinical characteristics and a frequent association with systemic diseases. Most frequently among the associated disease list are: inflammatory bowel disease, arthritis, and a variety of hematologic disorders. There is no specific treatment of PG; however, the effective treatment of an accompanying systemic disease, local therapy, and/or the use of topical or systemic agents known to be useful in neutrophil disorders, have been beneficial in most patients.