Development of Postsurgical Pyoderma Gangrenosum with New Keloid after Keloid Resection.

ABSTRACT: Keloids are a dermal fibroproliferative disorder and can arise from trauma, acne, vaccination, and herpes zoster. Pyoderma gangrenosum (PG) is a painful ulcerative skin disorder that is associated with neutrophilic dysfunction. However, the pathophysiologies of keloids and PG are not fully understood. The authors encountered an unusual case of a 24-year-old woman who presented with an anterior chest keloid that bore an ulcer. The keloid was resected along with the ulcer, and histology revealed the ulcer to be a neutrophilic PG ulcer. A year after surgery, another ulcer developed in the scar. The ulcer met the PARACELSUS criteria of a postsurgical PG ulcer. After treatment with systemic prednisone and adalimumab for 250 days, the ulcer re-epithelialized. However, relapsed keloids were then observed at the PG site. Corticosteroid taping may be the safest therapy for patients with a history of PG. Conversely, if there is suspicion that a patient is prone to keloid development, diagnostic biopsies and surgical management of PG ulcers should be avoided or conducted with care.

Clinical efficacy of crushed prednisolone and hydrocolloid powder in the primary treatment of peristomal pyoderma gangrenosum and correlation to in vitro drug release data.

We evaluated the primary application of crushed prednisolone combined with hydrocolloid powder for clinically diagnosed peristomal pyoderma gangrenosum (PPG). We present our data on this cohort and follow-up of our previous patients. Of the 23 patients who were commenced on this regime, 18 healed (78%). Twenty-two patients commenced on this regime as the primary treatment for their PPG, and for one, it was a rescue remedy after failed conventional therapy. Four patients with significant medical comorbidities failed to heal and one had their stomal reversal surgery before being fully healed. The proposed treatment regime for PPG is demonstrated to be effective, inexpensive and able to be managed in the patient's usual home environment. In vitro drug release analysis was undertaken, and data are presented to provide further insights into the efficacy of this regime.

An Unusual Case Presentation of Non-Pathergy Induced Severe Pyoderma Gangrenosum Localized to the Perianal and Intragluteal Regions.

Pyoderma gangrenosum is a rare neutrophil based disorder presenting as a painful sterile ulcer usually below the knee. The disease is also linked to comorbid conditions including inflammatory bowel disease (IBD) and pathergy. Mainstay treatment begins with high dose steroids, either topical for limited disease or systemic for extensive or rapidly progressing disease. This report presents a patient who had perianal and intragluteal cleft pyoderma gangrenosum, not related to IBD or pathergy, where high dose steroids were contraindicated due to history of steroid induced psychosis.

[Pyoderma gangrenosum after orthopedic conservative treatment]. / Pyoderma gangrenosum après traitement conservateur orthopédique.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis. Half of the cases are associated with an immune dysfunction and are frequently triggered by pathergy such as a tissular aggression via surgery or burn wounds. A patient with ulcerative colitis presented a PG at the site of an iontophoresis patch for tendinopathy. Treatment in a specialized burn center, corticosteroid therapy and adapted local care contributed to a favourable evolution. PG remains a diagnosis of exclusion and inflammatory phenomena must be differentiated from infectious causes such as necrotizing fasciitis to initiate immunosuppressive treatment. Being rare and difficult to diagnose and to treat as well as associated with potentially severe sequelae, a multidisciplinary team is required for the management of PG.

Le Pyoderma gangrenosum (PG) est une dermatose neutrophilique rare. Il est, dans la moitié des cas, associé à une maladie dysimmunitaire et il est fréquemment déclenché par un phénomène de pathergie, défini comme une agression tissulaire par une intervention chirurgicale ou encore une brûlure. Une patiente avec une rectocolite ulcéro-hémorragique a développé un PG sur le site d'application d'un patch d'ionophorèse pour une tendinopathie. Un traitement par une corticothérapie, un traitement immunosuppresseur local et des soins locaux adaptés ont permis une évolution favorable. Le PG reste un diagnostic d'exclusion et les phénomènes inflammatoires doivent être différenciés de phénomènes infectieux, comme la fasciite nécrosante, afin d'initier rapidement des immunosuppresseurs. Comme il s'agit d'une pathologie rare avec un diagnostic difficile, que des séquelles peuvent être catastrophiques et qu'un traitement immunosuppresseur complexe doit être instauré, une équipe pluridisciplinaire est requise pour la prise en charge de cette pathologie.

Pyoderma Gangrenosum after Cardiac Surgery.

BACKGROUND: Pyoderma gangrenosum after cardiac surgery is a rare, noninfectious ulcerating skin disease mimicking sternal wound infection. METHODS: A systematic search of literature for pyoderma gangrenosum complicating cases of cardiac surgery was conducted between September 1985 and September 2020 on PubMed and Cochrane databases. A systematic review and detailed overview of clinical presentation, diagnostic, treatment, and outcome is provided. RESULTS: A total of 15 studies enclosing 15 patients suffering from pyoderma gangrenosum following cardiac surgery were identified. Onset of symptoms was observed after a median of 5 days. Patients were predominantly male (81.3%) with a median age of 64 years. Typical clinical presentation mimicked sternal site infection, mainly by means of mediastinitis. Specific signs were rapid progression, erythematous to violaceous color of the wound border, accompanied by unspecific symptoms including fever, malaise, and severe pain. Additionally, pathergy (development of ulcers at the sites of minor cutaneous trauma) was reported frequently. Biopsy is mandatory with a cutaneous neutrophilic inflammation confirming the diagnosis. Initial treatment mostly (75.0% of reported cases) was misled, addressing suspicion of surgical site infection. After correct diagnosis, the treatment was switched to an immunosuppressive therapy. Full sternal wound closure took between 5 weeks and 5 months. Reported case mortality was 12.5% in actually low-risk surgeries. CONCLUSION: Despite pyoderma gangrenosum has typical signs, it remains an exclusion diagnosis. The treatment is completely opposite to the main differential diagnosis-the typical surgical site infection. Knowledge about diagnosis and treatment is essential in the context of avoiding fatal mistreatment.

Successful treatment of classic pyoderma gangrenosum with intralesional infliximab injection: A case report.

Pyoderma gangrenosum (PG) is a rare dermatological disease characterized by the rapid development of painful skin ulcers. While systemic infliximab is considered a standard treatment for patients with PG, herein, we report our success with the use of intralesional infliximab in a 40-year-old woman with systemic lupus erythematosus (SLE) and PG.

Intravenous immunoglobulin treatment for refractory pyoderma gangrenosum.

BACKGROUND: Intravenous immunoglobulins (IVIG) have been increasingly used for various inflammatory dermatoses with success. Small case series and case reports suggest a role for IVIG in the management of refractory pyoderma gangrenosum (PG). OBJECTIVE: The objective was to study the characteristics of PG patients treated with IVIG and the efficacy and safety of IVIG for patients with refractory PG. METHODS: An analysis was performed of all patients with PG treated with IVIG from 2012 to 2022 at an Australian tertiary hospital seeing a high volume of PG patients. RESULTS: We identified 12 patients, 9 females and 3 males, with median age of 61 years (29-77) at IVIG commencement. All patients were taking systemic corticosteroid therapy prior to IVIG treatment, and all had been treated with a steroid-sparing agent-including ten patients who had been treated with a biologic agent. IVIG was used with corticosteroids in one patient, concurrently with a steroid-sparing agent in nine patients and with a biologic agent in eight patients. Eleven patients demonstrated treatment response to IVIG-six with excellent response and five with good response. Three patients had complete healing of their most active ulcer. One patient did not respond to IVIG. Nine patients were able to wean their prednisolone dose and one patient was able to cease prednisolone. Four adverse events were recorded, and only one patient had to cease treatment due to aseptic meningitis and headaches. CONCLUSION: Our experience suggests that IVIG may be an efficacious treatment for patients with refractory PG due to its pleiotropic and immunomodulatory effects, particularly for patients with malignancy or other systemic conditions where high-dose immunosuppressive agents are contraindicated.

Periorbital Pyoderma Gangrenosum Associated With a Cocaine-Induced Midline Destructive Lesion: Case Report and Review of the Literature.

A 72-year-old woman with a history of chronic cocaine use presented 9 months after a dog bite with a large facial ulceration and absent sinonasal structures. Biopsies were negative for infectious, vasculitic, or neoplastic pathologies. The patient was lost to follow up for 15 months and returned with a significantly larger lesion despite abstinence from cocaine. Additional inflammatory and infectious workup was negative. Intravenous steroids were administered with clinical improvement. Therefore, she was diagnosed with pyoderma gangrenosum and cocaine-induced midline destructive lesion due to cocaine/levamisole. Pyoderma gangrenosum is a rare dermatologic condition that uncommonly involves the eye and ocular adnexa. Diagnosis involves clinical examination, response to steroids, exclusion of infectious or autoimmune conditions, and identifying potential triggers including cocaine/levamisole. This report highlights a rare presentation of periorbital pyoderma gangrenosum causing cicatricial ectropion associated with concomitant cocaine-induced midline destructive lesion and reviews important aspects of clinical manifestations, diagnosis, and management of pyoderma gangrenosum and cocaine/levamisole autoimmune phenomenon.

A Case of Pyoderma Gangrenosum after Partial Small Bowel Resection.

ABSTRACT: Pyoderma gangrenosum (PG) is a rare, noninfectious inflammatory disease of unknown etiology that affects the skin and mucous membranes. The development of PG after partial small bowel resection is very rare and can initially resemble an infectious complication, although it is an inflammatory disease.This report presents the case of a 55-year-old man who underwent partial small bowel resection for incomplete intestinal obstruction and developed postoperative infection-like manifestations, including redness and swelling of the incision, severe pain, and yellow-green turbid fluid from the drainage tube. After completing a skin biopsy that suggested massive neutrophil infiltration, multiple secretion cultures for Pseudomonas aeruginosa (+), and systemic screening without other comorbidities, a diagnosis of postoperative PG and P aeruginosa infection was determined.Early detection of this complication is essential for patient recovery because primary surgical treatment, which is contraindicated in such cases, can worsen PG. Therefore, PG should be treated conservatively with corticosteroids.

Peristomal cutaneous Crohn's disease by contiguity.

Peristomal ulcer is a frequent complication that, in most cases, is mild and responds to topical treatment. In much less frequent cases, it is associated with other pathologies, such as Crohn's disease, requiring in these cases systemic treatment, including surgery. The differential diagnosis between Cutaneous Inflammatory Bowel Disease and Pyoderma Gangrenosum is interesting, although both are managed in a similar way.

Pyoderma Gangrenosum in a Young Nigerian Male with Severe Ulcerative Colitis: A Case Report.

Pyoderma gangrenosum manifests as recurrent deep ulceration of the skin and is associated with a variety of disorders. We report a 40-year-old man who developed ulcers on the flexor surface of his right lower limb following a trauma 10 years prior to the current presentation. He was diagnosed with ulcerative colitis 20 years ago, and was previously placed on sulfasalazine and prednisolone. He also developed an enterocutaneous fistula at the right iliac fossa following an appendectomy he had 16 years previously. Mayo score of his ulcerative colitis was severe (11/12), and he received three courses of intravenous infliximab at irregular intervals as it was difficult to access Infliximab in Nigeria. He was stepped down to tablet Mesalazine after the third course due to cost considerations, and skin grafting was done for the extensive leg ulcer to achieve wound healing after failed steroid and sulfasalazine therapy.

Le pyoderma gangrenosum se manifeste par des ulcères profonds récurrents de la peau et est associé à divers troubles. Nous rapportons le cas d'un homme de 40 ans qui a développé des ulcères sur la face antérieure de sa jambe droite suite à un traumatisme survenu 10 ans avant la présentation actuelle. Il a été diagnostiqué d'une rectocolite hémorragique il y a 20 ans et avait précédemment été traité par sulfasalazine et prednisolone. Il a également développé une fistule entérocutanée à la fosse iliaque droite suite à une appendicectomie subie 16 ans auparavant. Le score de Mayo de sa rectocolite hémorragique était sévère (11/12), et il a reçu trois cures d'infliximab par voie intraveineuse à des intervalles irréguliers en raison de la difficulté d'accès à l'infliximab au Nigeria. Il est passé à la mésalazine en comprimés après la troisième cure en raison de considérations budgétaires, et une greffe de peau a été réalisée pour l'ulcère étendu de la jambe afin d'obtenir une cicatrisation après l'échec du traitement par stéroïdes et sulfasalazine. Mots-clés: pyoderma gangrenosum, Rectocolite hémorragique, Infliximab, Africain, Ulcères aphteux.

Pyoderma gangrenosum: A systematic review of the molecular characteristics of disease.

Pyoderma gangrenosum is a painful recurrent ulcerative neutrophilic dermatosis in which the pathogenesis is incompletely defined. Current evidence suggests that PG is associated with dysregulation of components of both the innate and adaptive immune system with dysregulation of neutrophil function and contribution of the Th17 immune axis. PG can be present in numerous heterogeneous clinical presentations and be associated with multiple inflammatory conditions including rheumatoid arthritis, inflammatory bowel disease and hidradenitis suppurativa. However, no critical evaluation of the observed molecular characteristics in PG studies in association with their clinical findings has been assessed. Additionally, emerging evidence suggests a potential role for other cell types and immune pathways including B cells, macrophages, autoantibodies and the complement system in PG, although these have not yet been integrated into the pathogenesis of disease. This systematic review aims to critically evaluate the current molecular observations regarding the pathogenesis of PG and discuss associations with clinical characteristics as well as the evidence supporting novel cell types and immune pathways in PG.

Leukocytoclastic vasculitis presenting clinically as bullous pyoderma gangrenosum following leucovorin, fluorouracil and oxaliplatin chemotherapy: a rare case report and literature review.

There are no published cases about bullous pyoderma gangrenosum induced by leucovorin, fluorouracil and oxaliplatin (FOLFOX) chemotherapy. With the increasing incidence of gastric and colorectal cancers and the increased usage of targeted therapies, some cutaneous adverse effects may become common. An 84-year-old male presented to our clinic with multiple ulcerative plaques covered with hemorrhagic crusts on both extremities after several FOLFOX chemotherapy sessions for gastric cancer and liver metastasis. Two weeks later, multiple bullae also appeared, especially on the acral areas. The histopathology examination was compatible with acute leukocytoclastic vasculitis. The FOLFOX chemotherapy regimen is increasingly administered considering the rising incidence of gastrointestinal cancers. Hence, our understanding of its possible side effects and complications must be heightened.

Dermatological Conditions Inducing Acute and Chronic Pain.

Pain is a common condition in dermatology. The aim of this review is to analyse the characteristics of pain in dermatology. Some skin diseases are conventionally known to cause pain; e.g. ulcers, pyoderma gangrenosum and herpes zoster. Common dermatoses, such as psoriasis or atopic dermatitis, can also cause significant pain. Some conditions are characterized by neuropathic pain and/or pruritus, without visible primary lesions: e.g. the neurocutaneous diseases, including small fibre neuropathies. Patients often fear pain in skin surgery; however, surgical procedures are rather well tolerated and any pain is mainly due to administration of local anaesthetic. Some therapies may also be uncomfortable for the patient, such as photodynamic therapy or aesthetic procedures. Thus, pain in dermatology is common, and its aetiology and characteristics are very varied. Knowledge of the different situations that cause pain will enable dermatologists to propose suitable analgesic solutions.

Childhood-onset Takayasu arteritis presenting as pyoderma gangrenosum-like vasculitic ulceration: Three case reports and a literature review.

We report a small case series of childhood-onset Takayasu arteritis (c-TA) presenting as pyoderma gangrenosum (PG)-like vasculitic ulceration. The cutaneous vasculitic ulcers in systemic vasculitis are rare and severe, sometimes leading to delayed diagnosis and treatment. We summarised the clinical features and highlighted the warning signs of c-TA associated with PG-like vasculitic ulceration.

Treatment of Pediatric Pyoderma Gangrenosum With Modified Negative Pressure Wound Therapy and Intralesional Corticosteroids: A Case Report.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare ulcerative skin disease; its etiology is unknown, though it is often associated with autoimmune diseases. Pyoderma gangrenosum results in significant morbidity and exquisite pain that affects health-related quality of life. Wound healing is delayed, and patients often experience relapse. Pyoderma gangrenosum is susceptible to pathergy and deterioration with surgical intervention or other trauma; therefore, treatment includes atraumatic wound care, infection management, and local or systemic immunosuppression. CASE: We describe the use of modified negative pressure wound therapy (NPWT) with intralesional and topical steroids for the treatment of PG in a 15-year-old female patient with ulcerative colitis and a staged J-pouch ileoanal reconstruction. The patient and her family refused all systemic therapy due to prior steroid-associated weight gain. She was unable to tolerate conscious dressing changes, further complicating the treatment plan. Procedural interventions such as NPWT have been used previously for PG; however, they can cause wound pathergy and subsequent wound deterioration. Modified NPWT in conjunction with topical and intralesional steroids induced wound healing without producing pathergy. CONCLUSION: Timely recognition of PG is crucial to appropriate delivery of care. Modified NPWT and localized corticosteroid treatment were key to promoting wound healing in this case of pediatric PG.

PYODERMA GANGRENOSUM AS THE ONLY MANIFESTATION OF ASYMPTOMATIC NEWLY DIAGNOSED NONSPECIFIC ULCERATIVE COLITIS. CLINICAL CASE.

OBJECTIVE: The aim: To study the clinical case data for the feasibility of the obligatory inclusion of endoscopic methods of the gastrointestinal tract examination in patients with pyoderma gangrenosum of an unknown etiology. PATIENTS AND METHODS: Clinical case: A patient under our supervision was with a not previously treated pyoderma gangrenosum of the shin skin. In the process of differential diagnostics by colonoscopic examination, nonspecific ulcerative colitis was diagnosed without clinical intestinal manifestation. A prescribed pathogenetic treatment of nonspecific ulcerative colitis led to the healing of the ulcer on the leg and induction of colitis remission. Thus, the first manifestation of asymptomatic colitis was pyoderma gangrenosum. CONCLUSION: Conclusions: Patients with pyoderma gangrenosum should be aware of the possibility of NUC, even in the absence of gastrointestinal symptoms, to get an early diagnosis and adequate treatment, to avoid disease manifestation and further complications. The inclusion of obligatory endoscopic examination of the gastrointestinal tract will increase the diagnosis of the etiology of severe skin lesions and increase the detection of asymptomatic nonspecific ulcerative colitis.

Peristomal Pyoderma Gangrenosum Responding to Risankizumab.

ABSTRACT: Evidence to support available therapies for pyoderma gangrenosum (PG) is limited. Many patients do not respond to topical therapies such as tacrolimus or topical steroids. Currently favored oral systemic treatments (eg, cyclosporine and steroids) achieve complete remission in only 50% of patients and have unfavorable adverse effect profiles. There is a growing body of evidence to support biologic agents for the treatment of PG, but their exact role remains unclear. Here the authors present a patient with peristomal PG, the first reported case of PG responding to treatment with risankizumab, an anti-interleukin 23 monoclonal antibody. Risankizumab may represent an effective and relatively safe treatment for PG that merits additional exploration in prospective, controlled studies.

Tofacitinib, a useful option for the treatment of pyoderma gangrenosum in an ulcerative colitis patient.

Pyoderma gangrenosum (PG) is a difficult-to-manage ulcero-necrotizing dermatosis associated with inflammatory bowel disease (IBD). In this article, we report a refractory PG in a patient with severe ulcerative colitis (UC) that responded to tofacitinib 10 mg/12 h.

Characterization and prevalence of extraintestinal manifestations in a cohort of patients with inflammatory intestinal disease in Medellin, Colombia. / Caracterización y prevalencia de manifestaciones extraintestinales en una cohorte de pacientes con enfermedad inflamatoria intestinal en Medellín (Colombia).

INTRODUCTION: Extraintestinal manifestations (EIMs) are frequent in patients with inflammatory bowel disease (IBD). Our objective is to characterize and determine the prevalence of MEIs in our cohort of patients with IBD. PATIENTS AND METHODS: A retrospective study was carried out in adult patients with IBD at the Pablo Tobón Uribe Hospital in Medellín. Colombia. Articular MEIs, primary sclerosing cholangitis (PSC), both ophthalmological and dermatological, were considered. Absolute and relative frequencies were used. The Chi square test of independence was used to compare 2proportions and the odds ratio (OR) was estimated. RESULTS: Our registry has 759 patients with IBD, 544 present UC (71.6%), 200 CD (26.3%) and 15 unclassifiable IBD (1.9%); 177 patients with IBD (23.3%) presented EIMs, 123 of 544 (22.6%) with UC and 53 of 200 (26.5%) with CD (OR: 0.81, 95% CI: 0.55-1.17, P=0.31). Regarding the type of EIMs, the articular ones were the most frequent (13.5%), more in CD than in UC (20.0 vs. 11.3%, OR 1.94, 95% CI: 1.25-3.00, P=0.0037). Patients with IBD and EIMs used more antibodies against tumor necrosis factor (anti-TNFs), compared to those without EIMs (43.5 vs. 18.5%, OR 3.38, 95% CI: 2.31-4.90, P=0.0001). CONCLUSIONS: The prevalence of EIMs in our cohort is high (23.3%) and the most frequent type is joint. Anti-TNFs are most used when IBD and EIMs coexist. Our study provides valuable information on the association of EIMs and IBD in Latin America.