Pyoderma Gangrenosum of the Hand: Unique Experience and Literature Review.

BACKGROUND: Pyoderma gangrenosum (PG) is a reactive, noninfectious, neutrophilic dermatosis. Diagnosis of PG is based on exclusion, due to lack of availability of a confirmatory test. PG is not caused by infection or gangrene. Misdiagnosis or delayed diagnosis of PG can lead to devastating results. CASE PRESENTATION: In this report, we present a patient with a delayed diagnosis of PG lesion on right hand. Despite initial surgical treatment, the wound was aggravated, and amputation was considered; however, it was eventually treated successfully with an autologous split thickness skin graft. CONCLUSIONS: Knowledge of the PG is essential to actively consider PG in early stage to help facilitate immediate treatment and avoid unnecessary interventions that may worsen the outcome.

Negative-pressure wound therapy as an adjunct to treating pyoderma gangrenosum.

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.

Management of Postsurgical Pyoderma Gangrenosum Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Role for a Dermal Regeneration Template.

INTRODUCTION: Pyoderma gangrenosum (PG) is a relatively uncommon necrotizing and ulcerative cutaneous disorder. It is often associated with a systemic inflammatory disease but may also present following trauma to the skin due to pathergy. Given its rare occurrence and nonspecific histology, PG is primarily a diagnosis of exclusion, which often results in delayed treatment. Very few cases of PG following autologous breast reconstruction have been reported in the literature, particularly in the absence of systemic disease. CASE REPORT: Presented is the case of a 62-year-old female with a history of ductal carcinoma in situ who underwent a left breast mastectomy with immediate deep inferior epigastric perforator flap breast reconstruction complicated by fever and leukocytosis as well as erythema, edema, and bullae involving the mastectomy flaps. Initially, necrotizing soft-tissue infection was suspected, and 2 debridements were performed. A diagnosis of PG was made on postoperative day 7, and the patient responded favorably to high-dose prednisone. Reconstruction was performed with a bilayer wound matrix and delayed skin grafting. Despite significant loss of mastectomy skin flap, the free flap was preserved. CONCLUSIONS: Although PG is a rare complication, it should be considered in the differential diagnosis for patients with atypical presentation of infection following breast reconstruction, even in the absence of systemic inflammatory disease. Early diagnosis and multidisciplinary management may prevent unnecessary surgical intervention and enable flap preservation. Furthermore, bilayer wound matrix placement may be useful as an intermediate reconstruction to determine if it is safe to proceed with skin grafting to avoid further pathergy. The findings in this case suggest that final reconstruction may be safely performed sooner than noted in the literature.

[A Case of Penile Pyoderma Gangrenosum Treated by Urethrocutaneostomy without Penectomy].

We herein report a case of penile pyoderma gangrenosum that was successfully treated with prednisolone and by urethrocutaneostomy without penectomy. A man in his 50s visite dour department because of painful urination. Pyuria and redness of the external urethral meatus were present. Treatment for urethritis with antibiotics did not improve his symptoms, and a painful ulcer and fistula formation between the glans and urethra subsequently developed. Microbiological cultures revealed no growth, and punch biopsy showed only nonspecific inflammation, leading to a diagnosis of penile pyoderma gangrenosum. We initiated prednisolone (PSL) at 40 mg once daily following placement of an indwelling suprapubic cystostomy tube for dysuria. However, the treatment was ineffective. Therefore, the dosage of PSL was increased to 65 mg once daily. The ulcer disappeared， but urethral stricture remained. Six hundred days after PSL treatment, we performed urethrocutaneostomy. The patient became free of the cystostomy and was able to urinate spontaneously. In recent years, there has been an increasing number of reports of penile preservation in the treatment of penile pyoderma gangrenosum, but knowledge regarding which patients require urethral surgery is lacking. Urologists should keep in mind increased susceptibility to infection, pathergy and possible recurrence, when considering urethral surgery for penile pyoderma gangrenosum.

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.

Orthopaedic Trauma-Induced Pyoderma Gangrenosum: A Case Report.

CASE: We present a case of a 60-year-old polytraumatized man who developed postoperative pyoderma gangrenosum (PG) after his initial stabilization procedures, mimicking a postoperative infection. This caused a delay in diagnosis, leading to progression of his wounds and a delay in initiation of the appropriate treatment. Once his PG was appropriately treated, his clinical status and wounds improved. He underwent successful wound coverage by plastic surgery and has been recovering from his injuries. CONCLUSION: Prompt identification and initiation of treatment for postoperative PG is critical to avoid exacerbation of wounds and subsequent morbidity to the patient.

Surgical Management of Lower Extremity Pyoderma Gangrenosum With Viable Cryopreserved Umbilical Tissue: A Case Series.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare skin disease that often presents as a uniquely painful and necrotic ulceration of the lower extremity. Pyoderma gangrenosum is often misdiagnosed and can have deleterious consequences to the patient, as there is no gold standard treatment and it can be difficult to manage. Surgery for these wounds is controversial, as pathergy can develop, worsening the ulceration. Advanced wound care products such as cellular- and/or tissue-based products (CTPs) are effective in helping stagnant chronic wounds reach full closure. Amnion/chorion-based skin substitutes that have been cryopreserved and contain viable cells have been shown to promote more cell recruitment and reduce inflammation. OBJECTIVE: This case series presents evidence of using a cryopreserved umbilical cord tissue with living cells in adjunctive treatment of wounds associated with PG. MATERIALS AND METHODS: This report presents 3 different clinical scenarios of lower extremity PG treated surgically with viable cryopreserved umbilical tissue (vCUT). RESULTS: All 3 patients were successfully treated with vCUT and resulted in complete healing. CONCLUSIONS: To the best of the authors' knowledge, this is the first case series demonstrating the ability of vCUT to heal these difficult-to-treat ulcers. In addition, it may be an effective modality to adjunctive management of PG.

Hemiarthroplasty in a patient with femoral neck fracture and pyoderma gangrenosum: a case report and review of the literature.

BACKGROUND: Pyoderma gangrenosum is a rare ulcerating skin disease of unknown etiology, making its coincidence with orthopedic trauma a rare challenge. Patients are at risk of progression of the existing lesions and development of new lesions upon skin injury when surgical procedures are performed. To our knowledge, this is the first report in the literature of disease unrelated surgery during active pyoderma gangrenosum. CASE PRESENTATION: We present a case of femoral neck fracture in a Caucasian patient with concurrent pyoderma gangrenosum localized in the axilla. Hemiarthroplasty was safely performed after disease activity was reduced with systemic corticosteroids. Tissue-protective wound closure was used together with perioperative corticosteroids and antibiotics. No signs of pyoderma gangrenosum developed at the surgical wound site, and the axillary lesions showed constant improvement until healing with scar tissue. CONCLUSIONS: In our patient, the preoperative steroid treatment, perioperative antibiotics, and soft tissue protective surgical technique led to successful management of this rare coincidence.

Perioperative management of pyoderma gangrenosum.

Pyoderma gangrenosum (PG) classically presents with an acute inflammatory stage, characterized by rapid evolution of painful ulcerations. The pathergy associated with PG lesions complicates disease management. Although PG is commonly treated with immunosuppression, some patients have refractory noninflammatory ulcers. In this subpopulation, there are case reports of successful surgical treatment. However, there is no consensus on optimal perioperative treatment for patients with PG undergoing surgery of any kind, PG related or otherwise. Therefore, we conducted a comprehensive literature review describing perioperative management practices and risk factors that may predict response to surgical intervention. We identified 126 cases of surgical intervention in patients with active PG; among these, only 16.7% experienced postoperative disease progression. No perioperative treatments or clinical risk factors were identified as statistically significant predictors of disease recurrence. Although limited by case series design and publication bias, this study is a valuable means of hypothesis generation for this rare condition.

Pioderma gangrenoso após mamoplastia redutora: desafios diagnóstico e terapêutico / Pyoderma gangrenosum after reduction mammoplasty: diagnostic and therapeutic challenges

O pioderma gangrenoso (PG) é doença inflamatória da pele, que pode se desenvolver espontaneamente, associado a certas doenças sistêmicas e neoplásicas, ou ao trauma cirúrgico, incluindo os das mamas. Há relatos cada vez mais frequentes, considerando o aumento desse procedimento nos dias atuais. A manifestação clínica das úlceras é característica e deve ser lembrada nas evoluções cicatriciais desfavoráveis com intensa reação inflamatória, perdas teciduais, secreção sanguinolenta e/ ou purulenta, fundo granuloso e bordas elevadas. Relatase o caso de paciente que teve pioderma gangrenoso após mamoplastia redutora. Respondeu ao corticosteroide sistêmico, e vem evoluindo sem recidivas até o momento.

Pyoderma gangrenosum (PG) is an inflammatory disease of the skin that may develop spontaneously. It is associated with certain systemic and neoplastic diseases, including those of the breasts. PG is also associated with surgical trauma. It has been increasingly reported, along with the increase in the incidence of reduction mammoplasty procedures. The clinical manifestation of ulcers is characteristic of PG and it should be considered in cases of poor healing with intense inflammatory reaction, tissue loss, bloody and/ or purulent secretion, granular background, and lesions with high edges. We describe a patient who developed PG after reduction mammoplasty. She has since responded to systemic corticosteroids and has had no relapse to date.

Case Study on Management of Postsurgical Pyoderma Gangrenosum After Spinal Surgery.

BACKGROUND: Postsurgical pyoderma gangrenosum (PSPG) is a rare autoimmune, neutrophilic dermatosis that results with the occurrence of pyoderma gangrenosum (PG) within surgical incisions. Presenting symptoms include erythema and pain at the surgical incision with wound dehiscence. The clinical appearance of the PSPG wound (similar to PG) shows raised with dusky red or violaceous (violet-colored) wound edges and undermining with little or no evidence of granulation tissue. "Pathergy" is the term used to describe worsening of the wound in response to trauma such as debridement. Postsurgical pyoderma gangrenosum should be suspected in postoperative wounds, which continue to become progressively worse despite broad-spectrum antibiotics, good wound care, and surgical debridement. CASE: A clinical case study of a patient with PSPG from spine surgery is described. CONCLUSION: Postsurgical pyoderma gangrenosum should be suspected in postoperative wounds, which continue to become progressively worse despite broad-spectrum antibiotics, good wound care, and surgical debridement.

Postoperative pyoderma gangrenosum after spinal fusion with instrumentation: case report.

Pyoderma gangrenosum (PG) is a rare inflammatory dermatosis that is most often associated with inflammatory bowel disease, but which can occur as a pathergic reaction around surgical incisions. The authors report the case of a patient who developed postoperative PG over the course of several months after undergoing extensive spinal instrumentation between the T4 and iliac levels. This is only the second such case occurring after spine surgery to be reported. The authors additionally review the literature to characterize treatment approaches and outcomes for this condition. The case highlights a potentially severe adverse effect of surgery that can be difficult to recognize and causes delays in effective treatment. It also demonstrates the importance of multidisciplinary collaboration in the effective care of patients.

A case of pyoderma gangrenosum in hand surgery.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that can take many clinical forms. Its diagnosis is difficult and often delayed. We report the case of a 36-year-old man with PG complicating a chemical burn of the wrist. This mode of atypical onset delayed the diagnosis and the initiation of appropriate treatment. This was not sufficient since the patient's hand was amputated at his request because of unbearable pain, and failed treatment. Surgeons should be aware of this pathology in cases of rapidly progressing ulcers, especially if aggravated by repeated debridement.

Pyoderma Gangrenosum After Abdominal Free Tissue Transfer for Breast Reconstruction: Case Series and Management Guidelines.

INTRODUCTION: Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery. METHODS: This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included. RESULTS: Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days. CONCLUSIONS: Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

Unilateral granuloma annulare in association with pyoderma gangrenosum and chronic lymphocytic leukemia.

Granuloma annulare (GA) is a fairly common inflammatory skin condition with a range of clinical subtypes. We describe an unusual case of unilateral GA confined to the thigh on a previously amputated limb. A man in his 80s with a past medical history of below-knee amputation of the left leg owing to severe leg ulcers from pyoderma gangrenosum, chronic lymphocytic leukemia, and dyslipidemia developed a slowly spreading eruption on the distal stump spreading proximally. On physical examination, he had numerous non-scaly violaceous papules and annular plaques from the stump to the lateral, medial, and anterior thigh. Histology confirmed a diagnosis of GA. The extensive, chronic lesions make this presentation of GA very unusual in that it shares features of both localized and generalized forms. Moreover, the temporal and spatial association with pyoderma gangrenosum is unique and may reflect a related inflammatory pathway.

Pioderma gangrenoso em pós-operatório de mamoplastia redutora: relato de caso / Pyoderma gangrenosum following reduction mammoplasty: a case report

O pioderma gangrenoso (PG) é uma dermatose neutrofílica inflamatória, de etiologia desconhecida. O PG é idiopático em 25-50% dos casos. Em aproximadamente 50% dos casos tem sido descrita a associação com doenças sistêmicas, tais como: doença de Crohn, gamopatias monoclonais, artrites soropositivas, colagenoses, doença de Behcet, granulomatose de Wegener, doenças mieloproliferativas e infecciosas, principalmente hepatites e Aids. Clinicamente, apresenta quatro variantes: ulcerada, bolhosa, vegetante e pustulosa. A forma mais frequente é a ulcerativa, que se inicia com pápula ou nódulo e evolui rapidamente para lesões ulceradas e dolorosas. Em até 25% dos casos de PG, o surgimento de novas lesões pode ser desencadeado por traumas, tais como picadas de insetos, injeções intravenosas e biópsia - fenômeno conhecido por patergia. Nesse trabalho, é apresentado um caso de PG extenso das mamas em pós-operatório de mamoplastia redutora, de difícil diagnóstico; iniciado na evolução pós-operatória em outro serviço. Devido à quebra da relação médico-paciente, vem procurar nosso serviço. Apresentou ótima resposta ao tratamento com corticoterapia (corticoterapia intra e perilesionais com triancinolona) no ato do desbridamento, e introdução de corticoterapia via oral (prednisona) em esquema escalonado de desmame.

Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis of unknown etiology and is idiopathic in 25%- 50% cases. In approximately 50% of PG cases, an association with systemic diseases, such as Crohn's disease, monoclonal gammopathies, seropositive arthritis, collagenosis, Behcet's disease, Wegener's granulomatosis, and myeloproliferative and infectious diseases (mainly hepatitis and AIDS), has been described. Clinically, PG presents four variants: ulcerated, bullous, vegetative, and pustular. The most frequent form is ulcerative, which begins as a papule or nodule and evolves rapidly into ulcerated and painful lesions. In approximately 25% of PG cases, the onset of new lesions can be triggered by traumas such as insect bites, intravenous injections, and biopsy, a phenomenon known as pathergy. Here, we present a case of extensive PG of the breasts following reductive mammoplasty surgery. It was a difficult case to diagnose and was initiated in the postoperative period of another service. Due to the breakdown of the doctor-patient relationship, the patient approached us for assistance. The patient showed an excellent response to corticotherapy (intra and perilesional corticotherapy with triamcinolone) during debridement and oral steroid (prednisone) therapy in the weaning phase.