Pyoderma Gangrenosum: A Critical Appraisal.

GENERAL PURPOSE: To provide information about pyoderma gangrenosum (PG), including pathophysiology, diagnostic criteria, and treatment. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to: ABSTRACT: Pyoderma gangrenosum (PG) is an uncommon cutaneous disease, presenting with recurrent painful ulcerations most commonly on the lower extremities. The diagnosis is made according to a typical presentation, skin lesion morphology, skin biopsy, histopathology, and the exclusion of other etiologies. Classically, PG presents with painful ulcers with well-defined violaceous borders; other variants including bullous, pustular, and vegetative/granulomatous can also occur. Treatment of PG involves a combination of topical and systemic anti-inflammatory and immunosuppressive medications, wound care, antimicrobial agents for secondary infections, and treatment of the underlying etiology. This article is a continuing education review of the literature with a focus on the clinical application of the pathophysiology, diagnosis, and treatment of this challenging disease.

[Chronic wounds: differential diagnosis]. / Diferencijalna dijagnoza kronicnih rana.

Wound is a disruption of anatomic and physiologic continuity of the skin. According to the healing process, wounds are classified as acute and chronic wounds. A wound is considered chronic if standard medical procedures do not lead to the expected healing, or if the wound does not heal within six weeks. Chronic wounds are classified as typical and atypical. Typical wounds include ischemic, neurotrophic and hypostatic wounds. Diabetic foot and decubitus ulcers stand out as a specific entity among typical wounds. About 80 percent of chronic wounds localized on lower leg are the result of chronic venous insufficiency, in 5-10 percent the cause is of arterial etiology, whereas the remainder are mostly neuropathic ulcers. About 95 percent of chronic wounds manifest as one of the above-mentioned entities. Other forms of chronic wounds are atypical chronic wounds, which can be caused by autoimmune disorders, infectious diseases, vascular diseases and vasculopathies, metabolic and genetic diseases, neoplasm, external factors, psychiatric disorders, drug related reactions, etc. Numerous systemic diseases can present with atypical wounds. The primary cause of the wound can be either systemic disease itself (Crohn's disease) or aberrant immune response due to systemic disease (pyoderma gangrenosum, paraneoplastic syndrome). Although atypical wounds are a rare cause of chronic wounds, it should always be taken in consideration during diagnostic procedure.

Pattern of dermatoses in Iraqi children.

The prevalence of paediatric dermatoses has risen in Iraq from 33.5% in 1987 to 40.9% in 2010. The objective of this study was to document the pattern of dermatoses in Iraqi children attending the outpatient clinic of a teaching hospital in Baghdad, Iraq. We conducted a cross-sectional study of 663 children under the age of 12 years who attended for dermatological consultation during 2008. The study showed that the prevailing dermatoses were as follow: infectious (32.3%), eczematous (20.8%), pigmentary (17.8%), papulosquamous (14.2%), drug-induced (4.5%), nutritional deficiency (1.8%) and miscellaneous (8.6%). The studied patterns of dermatoses were similar to that reported in other developing countries.

Changes in the classification and management of skin and soft tissue infections.

Although skin and soft tissue infections (SSTIs) are extremely common in both primary and secondary care, there is a lack of validated evidence-based schemes for the classification of clinical presentation or severity, and there are few data available on treatment outcomes. The commonly used 'Eron classification' is based on the consensus views of an expert panel, while the Clinical Resource Efficiency Support Team (CREST) 'Guidelines on the Management of Cellulitis in Adults' have not been validated in clinical trials. In the current issue of JAC, investigators at Ninewells Hospital in Dundee, Scotland, report a retrospective study of patients with SSTIs who were treated with antibiotics. The patients were stratified into four classes of clinical severity, based on the presence or absence of sepsis and co-morbidity, and their standardized early warning score. The empirical treatment received by patients in each class was compared with the recommendations of the CREST guidelines. The findings do not make comfortable reading. Overall, 43% of patients (and 65% at the mildest end of the clinical spectrum) were overtreated, while mortality (at 30 days) and inadequate antimicrobial therapy increased with severity class. Strikingly, 35 different empirical antimicrobial prescribing regimens were noted. These findings, which are likely to reflect the situation in many hospitals, show that SSTIs remain a significant cause of mortality and that empirical therapy is bordering on the haphazard, with significant under treatment of severely ill patients.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.

[Skin and soft tissue infections: current therapeutic options]. / Infezioni della cute e dei tessuti molli: opzioni terapeutiche.

In the present review, the authors focus on skin and soft tissue infections (SSTIs), a set of commonly observed pathologies which can present different features in terms of site and localization, clinical characteristics, and the aetiological agent responsible; their severity is related to the depth of the affected sites. After a brief introduction to the diverse classification criteria which are currently adopted by various authors, the aetiology and role of the most frequently occurring pathogen, Staphylococcus aureus, often methicillin-resistant is discussed, as well as the possible therapeutic options. We first present the internationally recommended guidelines, and stress that SSTI management has to conform to different criteria, in accordance with the different clinical settings: mild infections require simple and cost-saving treatments while severe infections make timely and aggressive treatments mandatory. The review then reports the recent data concerning the efficacy of new antimicrobials for treating SSTIs. In particular, results observed with linezolid, tigecycline, and daptomycin are discussed.

[LSD score. A new classification system for peristomal skin lesions]. / LSD-Score. Ein neues Klassifikationssystem für peristomale Hautläsionen.

BACKGROUND: Peristomal skin lesions are frequent complications of ostomy; however, there is no generally accepted nomenclature and classification system. OBJECTIVE: An interdisciplinary German expert panel (GESS) composed of ten members, developed an innovative semiquantitative classification system for peristomal skin lesions for further stratification of ostomy therapy. This score is based on criteria which can be assessed by stomal therapists and treating physicians. RESULTS: The new peristomal skin lesion score grades three categories: lesion (L), status of ostomy (S) and disease (D). The L category describes the integrity of the skin as normal (L0), lesion with sustained integrity of skin (L1), integrity destroyed (L2) and local infection (L3). The S category rates the complexity of ostomy therapy as normal (S0), increased (S1) and high but not sufficiently effective (S2). The additional letters for categorization O. R. P. H. E. US describe anatomical pathologies of the stoma itself: ostomy stenosis (O), retraction (R), prolapse (P), hernia (H), edema (E) and unfavorable site (US). A systemic disorder is either absent (D0), irrelevant (D1) or relevant (D2). The LSD score is the basis for a management algorithm. CONCLUSION: The LSD score is comprehensive, standardized and holistic. Its straightforward use by health professionals can improve the consistency of the description of skin lesions and enhance the quality of ostomy therapy.

Enfrentamiento de las infecciones de piel en el adulto / Managing adult skin infections

En la actualidad, las infecciones de piel y partes blandas forman parte de un alto porcentaje de las consultas en salud. Estas van desde infecciones leves, donde el manejo se realiza con tratamiento tópico, hasta aquellas con severo compromiso sistémico, requiriendo terapia antibiótica sistémica e incluso el desbridaje quirúrgico. En general, son producto de un desbalance entre los mecanismos de defensa de la barrera cutánea y los factores de virulencia y patogenicidad de los microorganismos que la afectan. Se pueden clasificar según distintos criterios, como por ejemplo, profundidad, gravedad, microorganismos involucrados y si estas son purulentas o no. El reconocer estas entidades clínicas es de suma importancia para llevar a cabo un adecuado tratamiento en los pacientes que presentan estas afecciones, ya que los diagnósticos erróneos llevan a las múltiples consultas con el consiguiente aumento de costos asociados en atención en salud.

Currently, skin and soft tissue infections are part of a high percentage of health consultations. These range from mild infections, where management is performed with topical treatment, to those with severe systemic compromise requiring systemic antibiotic therapy and even surgical debridement. In general, they are the product of an imbalance between the defense mechanisms of the skin barrier and the virulence and pathogenicity factors of the microorganisms that affect it, which can vary from bacterial, viral, fungal and parasites agents. Skin and soft tissue infections can be classified according to different criteria, such as depth, severity, microorganisms involved and whether they are purulent or not. Recognizing these clinical entities is of utmost importance to carry out adequate treatment in patients with these conditions, since erroneous diagnoses lead to multiple consultations with the consequent increase in costs associated with health care

The use of fluoroquinolones in the treatment of skin infections.

Fluoroquinolones have been studied for both uncomplicated and complicated skin and skin structure infections. Their broad spectrum, rapid bactericidal activity, extensive tissue penetration, excellent bioavailability and ease of administration have made these drugs a common choice for many infectious diseases, including skin infections. Extensive research has shown the fluoroquinolones to be as effective as beta-lactam antibiotics in managing a spectrum of diseases including erysipelas, cellulitis, impetigo, surgical wounds and diabetic foot infections. However, resistance to the fluoroquinolones has increased among the staphylococci, streptococci, Enterobacteriaceae and other important Gram-negative bacilli. Resistance has been linked directly to the widespread use of these compounds. Despite their appeal in the treatment of both uncomplicated and complicated skin infections, the fluoroquinolones should be reserved as alternatives to beta-lactams and other antibiotics or as empirical therapy in complicated infections until pathogens have been identified and drug regimens can be focused.

[Cutaneous semiology of febrile rashes in children]. / Sémiologie cutanée des éruptions fébriles de l'enfant.

Generalized eruptions with fever are a frequent problem in paediatric practice. Clinical type of skin lesions, distribution and associated signs and symptoms are sometimes specific enough for a definitive diagnosis. However non specific clinical findings do not allow an aetiologic conclusion in some instances. More than 50 infectious agents, drugs and numerous inflammatory diseases are known to cause rashes in childhood.

The classification and management of skin and soft tissue infections.

Skin and soft tissue infections (SSTIs) are a common problem in patients presenting to the emergency department, varying from mild local inflammation to necrotizing fasciitis. SSTI were the 2nd most common indication for antibiotic use in Europe in 2006. Currently, the National Institute of Clinical Excellence (a UK based independent organization responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health) has not published any guidelines for the classification and management of these patients. This is a review of the evidence around attempts at developing classification systems for SSTI and their management. It also considers the financial implications for both the patient and the healthcare system and the personal ramifications for patients.

[Skin and soft tissue infections: classification and epidemiology]. / Infezioni della cute e dei tessuti molli: classificazione ed epidemiologia.

In the present review, authors take into consideration the classification and the epidemiology of the skin and soft tissue infections (SSTIs), a set of commonly observed pathologies, which can present different features, relatively to site and localization, clinical characteristics, and aetiological agent, their severity being related to the depth of the interested sites. Given the variable presentation of SSTIs, an assessment of their incidence and prevalence is difficult. In general, the incidence of SSTIs has increased due to the ageing of the general population, the increased number of critically ill patients, the increased number of immunocompromised patients (HIV, cancer and organ transplant patients) and the recent emergence of multi-drug resistant pathogens.

Dermatologic manifestations of infection in the compromised host.

The skin occupies an important position in the prevention and evaluation of infection in patients who are immunocompromised. The skin can provide a portal of entry for both locally invasive and disseminated infection; and, not infrequently, skin lesions may be the first sign of disseminated infection from other primary sites. The first clinical principle in approaching this problem is that the skin must be protected from trauma, maceration, or alteration in its normal microbial flora. The second principle is that any lesion, no matter how innocuous, should be carefully evaluated in this patient population. Since the gross morphology of the lesion is so frequently modified by the altered inflammatory response of the immunocompromised patient, an aggressive biopsy approach is essential for diagnosis and therapy.

Necrotizing lesions of soft tissues: a review.

Necrotizing lesions of the soft tissues are grave entities not infrequently seen in daily surgical practice. They may occur with epidemic proportions after natural disasters, representing a serious challenge to the surgeon since they are characteristically associated with high mortality rates unless an early diagnosis is made and prompt aggressive surgical management is initiated. Necrotizing fasciitis is the currently accepted generic term to encompass into a single category the diverse syndromes of progressive gangrenous infections of the skin and subcutaneous tissues. Necrotizing fasciitis must be viewed as a clinical entity rather than a specific type of infection: it is a clinical infection most commonly caused by a mixed aerobic/anaerobic synergistic polymicrobial combination. Zygomycetes may appear as major causal organisms (mucormycosis) and they should be actively searched for. Initial diagnosis of necrotizing fasciitis is established through the characteristic physical signs. Gram stain, and, in some doubtful cases, through frozen-section tissue biopsy. Aggressive and urgent radical debridement is the key to survival, combined with wide-spectrum antibiotic therapy.

Distinguishing vesicular and pustular disorders in the neonate.

Vesicular and pustular disorders are common in the neonatal period. Most are benign, but several serious infectious and noninfectious diseases can present in the neonate. This review focuses on the clinical features of these disorders as well as recent advances in the field. The following diseases are discussed: erythema toxicum, transient neonatal pustular melanosis, miliaria, neonatal acne, eosinophilic folliculitis, mastocytosis, acropustulosis of infancy, incontinentia pigmenti, scabies, neonatal and congenital candidiasis, syphilis, neonatal herpes simplex infections, neonatal varicella, and staphylococcal infections.

[Classification of HIV-associated acquired immunologic deficiency syndrome]. / Klassifizierung des HIV-assoziierten erworbenen Immundefektsyndroms.

Regarding the staging of HIV infection, there are several classification systems, but neither of them has universally been accepted. We tested a new staging system with 4 parameters: HIV antibodies, CD4/CD8 ratio, absolute count of CD4 + lymphocytes, and absolute count of leukocytes. This classification indicates a regular progression of immunodeficiency, 294 blood specimens were used for immunological staging. The correlation between the immunological staging and the severity of the disease proved the usefulness of this classification system.