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The Scar That Wouldn’t Heal. Nancy Fuller, M.D. November 23, 2005. 55 year old woman with skin lesion on back Referred to Derm for removal Dx: basal cell carcinoma Wide reexcision done after dx established Wound dehiscence 2 weeks later, treated with antibiotics with no improvement. - PowerPoint PPT Presentation
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The Scar That Wouldn’t Heal
Nancy Fuller, M.D.
November 23, 2005
55 year old woman with skin lesion on back Referred to Derm for removal Dx: basal cell carcinoma Wide reexcision done after dx established Wound dehiscence 2 weeks later, treated
with antibiotics with no improvement
Over the next 8 months: progressive and persistent dehiscence
Resuturing Stapling Bx: supperative and granulomatous
dermatitis, dermal scar and chronic FB rx Cultures for fungus, mycobacteria, bacteria
? Foreign body reaction? Split thickness skin graft done; continued
episodes of dehiscence ?allergy to suture material? Labs done: CBC, ESR, CRP,
immunoglobulins, RF, ANA
Patient developed 2 new small lesions-started as pustules, progressed to small ulcers
Started on Prednisone and antibiotics Tacrolimus added Significant improvement!!
Dx: Pyoderma Gangrenosum
Objectives: Consider pyoderma gangrenosum in
differential for ulcerative skin lesions Recognize potential problems in
identification and diagnosis, treatment of PG
No financial disclosures
1930 : “rapidly progressive painful supperative cutaneous ulcers with edematous, boggy, undermined and necrotic borders”-coined “ pyoderma gangrenosum”
Neutrophilic Dermatoses Intense epidermal and/or dermal
inflammatory infiltrates Composed mainly of neutrophils No evidence of vasculitis or infection Pathogenesis: unknown; ?cytokine
disregulation? Altered immune reactivity?
Pyoderma Gangrenosum Sweet's Disease Generalized Pustular Psoriasis Reactive Arthritis (Reiter’s Syndrome)-
Balanitis, keratoderma blennorrhagica
Sweet’s Disease Acute onset of
fever/leukocytosis/erythematous plaques
infiltrated by neutrophils Uncommon Female to male 4:1
Associated with many underlying diseases: Malignancies(25%)-most hematopoetic Bacterial infections-strep, mycobacterium,
yersinia, typhus, salmonella Vaccinations Viral infections-CMV, CAH, HIV Drugs-lithium, furosemide, OCPs, TMP/SMZ Autoimmune and Collagen vascular diseases-RA,
SLE, MCTD, Behcet’s ,Hashimoto’s thyroiditis IBD-Crohns, Ulcerative colitis
Diagnostic Criteria:
MAJOR: abrupt onset of typical lesions Histopathology consistent MINOR: antecedent fever or infection Accompanying fever, arthralgias Leukocytosis Good response to systemic corticosteroids,
not to antibiotics
Pyoderma Gangrenosum Ulcerative chronic inflammatory skin lesions Single or multiple Most common on legs, but can be
anywhere Pathergy Painful
Rapid progression of ulceration Usually preceded by a papule, pustule, or
vesicle Histopathology depends on stage, but always
dense neutrophilic infiltrates No evidence of vasculitis on bx
Associated with underlying systemic diseases 50% of the time
-Inflammatory bowel disease: 5% of ulcerative colitis, 2% Crohn’s
-Inflammatory arthritis
-lymphproliferative disorders
Differential diagnosis Deep mycotic infections Bacterial infections, including mycobacteria, Herpes simplex Vasculitis Insect reactions (eg, brown recluse spider) Warfarin skin necrosis Factitial ulcer gumma
Diagnosis All patients with suspected PG: must rule
out other causes of ulcers prior to tx Skin biopsy Labs: CBC, ESR/CRP, LFTs, renal function
studies, SPEP, CXR, coag profile, ANCA, cryoglobulins
Mistaken Identity? Antiphospholipid syndrome Wegeners granulomatosis Chronic venous stasis ulcers Vasculitis Infection Cancer (cutaneous lymphoma, etc)
Treatment No well controlled studies
For mild disease: local treatment such as topical steroids, topical tacrolimus ointment, colloidal membrane dressings
For severe disease or failure with topical treatments:
-steroids: 60-120 mg prednisone per day
pulse methylprednisolone For refractory cases:
dapsone, thalidomide, mycophenolate, cyclosporine, azothioprine, IVIG
Surgery: split thickness skin grafts; also must use systemic immunosuppression
Conclusions PG-fortunately uncommon Diagnosis of exclusion because of the lack
of any specific diagnosis certainties Big mimicker Treatment often requires major
immunosuppression Keep it in your differential!