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Journal of Plastic, Reconstructive &... Mar 2015Post-surgical pyoderma gangrenosum (PSPG) presents as a rapidly expanding cutaneous ulcer at a site of surgery with potentially devastating consequences. We... (Review)
Review
BACKGROUND
Post-surgical pyoderma gangrenosum (PSPG) presents as a rapidly expanding cutaneous ulcer at a site of surgery with potentially devastating consequences. We systematically reviewed the English and foreign language literature to identify risk factors for PSPG and propose a management strategy.
METHODS
A systematic review was completed in PubMed, Medline, Embase, and Cochrane Database for all published reports of PSPG from January 1946 to June 2013. We manually examined bibliographies for relevant references and used Google Translate for articles in foreign languages, including Italian, Japanese, German, Dutch, Turkish, Spanish, Chinese, Dutch, Russian, Portuguese, and Czech.
RESULTS
We identified 220 cases of PSPG (mean age 52.8 years, range 5-85 years). Thirty-seven patients (16.8%) had a history of pyoderma gangrenosum, nineteen (8.6%) had a hematologic disorder such as leukemia or lymphoma, thirteen (5.9%) had inflammatory bowel disease, and eight (3.6%) had rheumatoid arthritis. PSPG occurred most commonly after breast (25%), cardiothoracic (14%), abdominal (14%), and obstetric (13%) surgeries. The most common breast procedures were bilateral reduction mammoplasty (45%), breast reconstruction (25%), and lumpectomy or mastectomy (11%). Signs of wound complication occurred on average 7.0 days after surgery. Nineteen patients (8.6%) at risk for PSPG received perioperative corticosteroids during skin grafting or later surgeries with a favorable outcome.
CONCLUSIONS
Patients with a history of pyoderma gangrenosum, rheumatoid arthritis, inflammatory bowel disease, or hematologic malignancy who are undergoing breast, cardiothoracic, or abdominal surgeries should be carefully observed for post-operative ulceration at incision sites. Debridement should not be performed before dermatologic consultation to assess for PSPG. Patients at risk of PSPG undergoing breast surgery may benefit from perioperative prednisone to prevent PSPG which can lead to destructive wound enlargement and significant scarring.
Topics: Humans; Postoperative Complications; Pyoderma Gangrenosum; Risk Factors; Surgical Wound Infection
PubMed: 25589459
DOI: 10.1016/j.bjps.2014.12.036 -
The British Journal of Dermatology Jun 2015Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful skin ulcerations for which treatment can be challenging. The genetic basis of PG may... (Review)
Review
Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful skin ulcerations for which treatment can be challenging. The genetic basis of PG may provide a better understanding of the disease and new targets for treatment. We systematically reviewed the published literature regarding the syndromes and genetic mutations associated with PG. A literature search was performed through the clinical queries PubMed (National Library of Medicine) database and the Cochrane database. The studies were assessed and then categorized as relating to syndromes or specific gene mutations. Two hundred and eight articles were identified, describing 823 cases of PG. A total of 537 (65·2%) cases were associated with inflammatory bowel disease, 133 (16·1%) with polyarthritis and 103 (12·5%) with haematological disorders. Thirty-one cases of pyogenic arthritis, pyoderma gangrenosum and acne, and its variants, were identified. Two patients had mutations in MTHFR and two had mutations in JAK2. Fourteen (1·7%) cases were familial. PG responded to different treatments depending on the setting. For example, treatment with B vitamins improved PG in cases of mutations in MTHFR, whereas patients with myelodysplastic syndrome improved with thalidomide treatment. PG can occur in isolation, associated with systemic disease or as part of various syndromes. Different genetic causes may be best treated with particular treatments. Understanding its genetic basis can help elucidate new potential targets for drug development.
Topics: Acne Vulgaris; Arthritis; Child; Child, Preschool; Forecasting; Hematologic Diseases; Humans; Irritable Bowel Syndrome; Janus Kinase 2; Methylenetetrahydrofolate Reductase (NADPH2); Mutation; Pyoderma Gangrenosum
PubMed: 25350484
DOI: 10.1111/bjd.13493 -
Giornale Italiano Di Dermatologia E... Oct 2014Pyoderma gangrenosum (PG) is a rare, chronic neutrophilic dermatosis of unknown etiology. The world wide incidence is estimated to be around 3-10 cases per million... (Review)
Review
Pyoderma gangrenosum (PG) is a rare, chronic neutrophilic dermatosis of unknown etiology. The world wide incidence is estimated to be around 3-10 cases per million population per year. In 50-70% of cases inflammatory bowel diseases, hematological malignancies or rheumatologic disorders are associated to PG. Although the etiology is uncertain, the dysregulation of the immune system appears to be implied. Pathergy is the most important triggering factor of PG. Indeed, 20-30% of patients report the onset of PG following trivial trauma. Four main variants of PG have been described, namely classic, pustular, bullous, and vegetative forms. The classic form of PG is characterized by ulcers with a raised, undermined, inflammatory border. Intense pain is generally associated to PG. The diagnosis is mainly clinical and of exclusion. The differential diagnosis should take into account infections, vascular disorders and malignancies. The clinical course can be explosive and rapidly progressive or indolent and gradually progressive. Often patients develop only one episode and the overall prognosis is good but extremely influenced by the underlying disorders. Local therapy, mainly with topic steroids is used for mild to moderate lesions. For severe forms of PG a systemic therapy with glucocorticoids and/or other drugs such as tacrolimus, cyclosporine, etc. is needed. This paper is a systematic review of literature on PG.
Topics: Anti-Inflammatory Agents; Arthritis; Dermatologic Agents; Diagnosis, Differential; Disease Progression; Disease Susceptibility; Female; Humans; Immunologic Factors; Immunosuppressive Agents; Inflammatory Bowel Diseases; Leukapheresis; Lymphoproliferative Disorders; Male; Pregnancy; Pregnancy Complications; Prognosis; Pyoderma Gangrenosum; Skin Ulcer; Thalidomide
PubMed: 25213386
DOI: No ID Found -
Annals of Plastic Surgery Aug 2016Pyoderma gangrenosum (PG) is a rare cutaneous disorder that poses a diagnostic challenge in the postoperative period. A systematic literature review was performed to... (Review)
Review
BACKGROUND
Pyoderma gangrenosum (PG) is a rare cutaneous disorder that poses a diagnostic challenge in the postoperative period. A systematic literature review was performed to determine distinguishing characteristics of PG in the setting of breast surgery that can facilitate timely diagnosis and appropriate treatment.
METHODS
PubMed, EMBASE, Scopus, and Web of Science databases were systematically searched for articles with cases of PG occurring after breast surgery. Forty-three relevant articles, including 49 case reports, were identified.
RESULTS
PG manifested bilaterally in 30 of 34 cases (88%) in which bilateral surgery was performed. Abdominal wounds were present in 6 of 7 cases in which an abdominal donor site was used for breast reconstruction. Nipples were spared from wound involvement in 33 of 37 cases (89%) in which nipples were present after surgery. Presence of fever was noted in 27 cases (55%) and leukocytosis in 21 cases (43%). A total of 33 patients (67%) underwent wound debridement. Successful medical treatment most commonly involved steroids (41 cases, 84%) and cyclosporine (10 cases, 20%).
CONCLUSIONS
Pertinent clinical features were identified that may aid in timely diagnosis and treatment of PG after breast surgery. Appearance of discrete wounds involving multiple surgical sites that surround but spare the nipples should raise suspicion for PG rather than infection or ischemia, even with concomitant fever and leukocytosis. Wound debridement should be minimized and skin grafting considered only after medical therapy is initiated. Cognizance of these features may enable prompt therapeutic intervention that minimizes morbidity and improves outcomes.
Topics: Female; Humans; Mammaplasty; Mastectomy; Postoperative Complications; Pyoderma Gangrenosum
PubMed: 25003456
DOI: 10.1097/SAP.0000000000000248 -
Journal of the American Academy of... Oct 2013
Review
Topics: Acquired Hyperostosis Syndrome; Antibodies, Monoclonal; Colitis, Ulcerative; Comorbidity; Crohn Disease; Drug-Related Side Effects and Adverse Reactions; Female; Follow-Up Studies; Hidradenitis Suppurativa; Humans; Inflammation; Infliximab; Male; Psoriasis; Pyoderma Gangrenosum; Risk Assessment; Spondylitis, Ankylosing; Treatment Outcome
PubMed: 24034373
DOI: 10.1016/j.jaad.2013.04.032 -
Systematic review: IBD-associated pyoderma gangrenosum in the biologic era, the response to therapy.Alimentary Pharmacology & Therapeutics Sep 2013Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is uncommon and therapeutically challenging. Its treatment remains poorly characterised due to limited... (Review)
Review
BACKGROUND
Pyoderma gangrenosum (PG) in inflammatory bowel disease (IBD) is uncommon and therapeutically challenging. Its treatment remains poorly characterised due to limited individual centre or practitioner experience. No large series are reported since 2003, yet IBD treatment has changed substantially.
AIM
To provide an up-to-date review of the published treatment efficacy of currently available therapies for IBD-related PG in the biologic era.
METHODS
Systematic review of cases published post-2003 since the broad availability of anti-tumour necrosis factor-alpha (TNFα) therapy. Cases which did not have coexistent IBD, were non-English language, of paediatric age or without data on response to therapy were excluded.
RESULTS
Sixty cases were identified; 55% female, 50% UC, 45% CD, 5% IBD-U. At PG diagnosis, 58% had active and only 15% inactive IBD, with 27% with IBD activity unspecified. Predominant sites were lower limb (48%) and peristomally (25%); 42% had multiple lesions. In 12%, trauma preceded PG. In 42%, new PG appeared whilst on IBD-specific therapy, whilst 28% were on no therapy and in 30%, IBD therapy was unspecified. Of patients on no therapy at PG onset (n = 17), 16 healed; seven with first- and eight with second-line therapy. In total, 34/60 patients received infliximab, four received adalimumab, two had both; with 33 (92%) responding to one or the other. There was no correlation of PG duration or size with healing times.
CONCLUSIONS
Pyoderma gangrenosum appears predominantly during active IBD and is seen equally in CD and UC. New PG may be a manifestation of recrudescent IBD or it follow trauma. Anti-TNFα therapy as a first-line agent for PG should be considered, as it appears to be highly effective.
Topics: Adalimumab; Antibodies, Monoclonal; Antibodies, Monoclonal, Humanized; Dermatologic Agents; Humans; Inflammatory Bowel Diseases; Infliximab; Pyoderma Gangrenosum; Treatment Outcome; Tumor Necrosis Factor-alpha
PubMed: 23914999
DOI: 10.1111/apt.12431 -
Veterinary Dermatology Aug 2012To identify and evaluate existing evidence for the effectiveness of systemic antimicrobial treatments for naturally occurring superficial and deep canine pyoderma. (Review)
Review
AIM
To identify and evaluate existing evidence for the effectiveness of systemic antimicrobial treatments for naturally occurring superficial and deep canine pyoderma.
METHOD
Electronic searches of PubMed, MEDLINE and CAB Direct were carried out (25 May 2011) without date or language restrictions. Proceedings of ESVD/ECVD, AAVD/ACVD, NAVDF and WCVD annual congresses were searched. Unpublished studies were sought via the Veterinary Dermatology discussion list and Veterinary Information Network.
RESULTS
Seventeen full-length, peer-reviewed controlled trials reporting clinical outcomes of systemic antimicrobial treatment for canine pyoderma were identified. Outcomes specific to superficial or deep pyoderma were reported in nine and five studies, respectively. Five studies reported outcomes only for nondifferentiated pyoderma depth. Heterogeneity of study designs and outcome measures made meta-analysis inappropriate. A good level of evidence was identified supporting the high efficacy of subcutaneously injected cefovecin in superficial pyoderma and for oral amoxicillin-clavulanic acid in deep pyoderma. A fair level of evidence was identified for moderate to high efficacy of oral amoxicillin-clavulanic acid, clindamycin, cefadroxil, trimethoprim-sulphamethoxazole and sulfadimethoxine-ormetoprim in superficial pyoderma and oral pradofloxacin, oral cefadroxil and subcutaneously injected cefovecin in deep pyoderma. Eleven trials reported observations of adverse effects in treated pyoderma cases by intervention group; four dogs were withdrawn owing to the severity of adverse effects.
CONCLUSIONS
There is a need for greater numbers of adequately sized, blinded, randomized controlled trials evaluating systemic antimicrobial interventions for canine pyoderma. Improved differentiation between superficial and deep pyoderma in outcome reporting, outcome measure standardization and association of outcomes with causative bacterial species and their resistance patterns are required.
Topics: Animals; Anti-Bacterial Agents; Dog Diseases; Dogs; Pyoderma
PubMed: 22734856
DOI: 10.1111/j.1365-3164.2012.01050.x -
Ostomy/wound Management Jan 2010An ileal conduit is the most common urinary diversion following radical cystectomy for invasive bladder cancer. Unlike internal complications commonly described in... (Review)
Review
An ileal conduit is the most common urinary diversion following radical cystectomy for invasive bladder cancer. Unlike internal complications commonly described in urological literature, reports about the incidence of external complications are sparse. A Medline database review (1996-2008) of English-language literature was conducted to: 1) describe and compare external stoma and peristomal complications and complication rates among outpatients with ileal conduit diversion following radical cystectomy, and 2) summarize commonly used prevention and management strategies. Fourteen publications (mostly retrospective, single-center studies) met inclusion criteria. The reported incidence of complications ranged from 15% to 65%. Divided according to pathogenesis, the most commonly reported complications are 1) stoma or abdominal wall-related changes--parastomal hernia, stoma prolapse, stenosis, and retraction; and 2) peristomal skin changes--chemical injury: irritant contact dermatitis, pseudoverrucous lesions, and alkaline crustations; mechanical injury: pressure ulcers, skin stripping injuries, mucocutaneous separation; infection: candidiasis, folliculitis; immunologic disorders: allergic contact dermatitis; and disease-related lesions: varices, pyoderma gangrenosum, malignancy. Peristomal complications also appear to be under-recognized and under-reported. Research to establish the validity and reliability of assessment tools and long-term follow-up studies are needed to improve the evidence-base of prevention and care.
Topics: Cystectomy; Humans; Ileum; Surgical Stomas
PubMed: 20093715
DOI: No ID Found -
Journal of Crohn's & Colitis Dec 2008Ocular episcleritis and uveitis are well-recognised extra-intestinal manifestations of Crohn's disease. Orbital myositis is rare: to our knowledge it has been associated...
BACKGROUND
Ocular episcleritis and uveitis are well-recognised extra-intestinal manifestations of Crohn's disease. Orbital myositis is rare: to our knowledge it has been associated with Crohn's disease in thirteen cases. Posterior scleritis, orbital myositis and Crohn's disease have been reported as coexisting in only two cases.
METHODS AND RESULTS
We describe a third case, that of a 31-year old female with Crohn's colitis for 8 years, complicated by enteropathic arthritis and pyoderma gangrenosum. She presented with intense and intractable periorbital pain, particularly at night and worse on eye movements. B-scan ultrasonography confirmed posterior scleritis and treatment with high dose oral steroids (up to 60 mg prednisolone) was initially effective, but subsequently failed to control the inflammation. There was only a partial response to infliximab. Five months after presentation, diplopia developed, with failure of abduction of the left eye. MRI scan of the orbits confirmed orbital myositis involving the left lateral and medial rectus muscles. Pulsed intravenous methylprednisolone and six cycles of intravenous cyclophosphamide over a three month period resulted in complete resolution of inflammatory symptoms.
CONCLUSIONS
This case highlights a rare combination of ocular abnormality secondary to Crohn's disease and reports successful resolution with aggressive immunosuppressive therapy.
PubMed: 21172235
DOI: 10.1016/j.crohns.2008.06.002