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American Journal of Clinical Dermatology Sep 2022Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving... (Review)
Review
Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving cutaneous ulcers with undermined, irregular, erythematous-violaceous edges. Pyoderma gangrenosum pathogenesis is complex and involves a profound dysregulation of components of both innate and adaptive immunity in genetically predisposed individuals, with the follicular unit increasingly recognized as the putative initial target. T helper 17/T helper 1-skewed inflammation and exaggerated inflammasome activation lead to a dysregulated neutrophil-dominant milieu with high levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-1α, IL-8, IL-12, IL-15, IL-17, IL-23, and IL-36. Low-evidence studies and a lack of validated diagnostic and response criteria have hindered the discovery and validation of new effective treatments for pyoderma gangrenosum. We review established and emerging treatments for pyoderma gangrenosum. A therapeutic algorithm based on available evidence is also provided. For emerging treatments, we review target molecules and their role in the pathogenesis of pyoderma gangrenosum.
Topics: Dermatitis; Humans; Inflammation; Neutrophils; Pyoderma Gangrenosum
PubMed: 35606650
DOI: 10.1007/s40257-022-00699-8 -
Giornale Italiano Di Dermatologia E... Oct 2020Pyogenic arthritis, pyoderma gangrenosum (PG) and acne (PAPA) syndrome is an autosomal dominant autoinflammatory syndrome due to mutations in proline-serine-threonine... (Review)
Review
Pyogenic arthritis, pyoderma gangrenosum (PG) and acne (PAPA) syndrome is an autosomal dominant autoinflammatory syndrome due to mutations in proline-serine-threonine phosphatase interacting protein 1 (PSTPIP1) gene and presenting with cutaneous and articular manifestations. Other autoinflammatory syndromes caused by mutations in PSTPIP1 gene or characterized by clinical findings overlapping with those found in PAPA syndrome have been recently included in the group of PAPA spectrum disorders. These disorders are PASH (PG, acne and hidradenitis suppurativa [HS]), PAPASH (PASH associated with pyogenic sterile arthritis), PsAPASH (PASH combined with psoriatic arthritis [PsA], PASS (PG, acne, ankylosing spondylitis, with or without HS), PAC (PG, acne and ulcerative colitis [UC]) and PAMI syndrome (PSTPIP1-associated myeloid-related-proteinemia inflammatory syndrome). Except for PAPA and PAMI, no specific pathogenetic mutations have been identified in these syndromes. Dermatologists should be aware that PG, acne and HS may represent cutaneous signs hiding the presence of these rare entities. Systemic corticosteroids, a number of immunosuppressants and biologics, such as interleukin (IL)-1 antagonists and tumour necrosis factor (TNF) α inhibitors, are nowadays therapy for these diseases. A pathogenesis-driven treatment is the near future in the management of these conditions.
Topics: Acne Vulgaris; Arthritis, Infectious; Humans; Pyoderma Gangrenosum
PubMed: 32618443
DOI: 10.23736/S0392-0488.20.06629-8 -
Diagnostic Criteria of Ulcerative Pyoderma Gangrenosum: A Delphi Consensus of International Experts.JAMA Dermatology Apr 2018Pyoderma gangrenosum is a rare inflammatory skin condition that is difficult to diagnose. Currently, it is a "diagnosis of exclusion," a definition not compatible with...
IMPORTANCE
Pyoderma gangrenosum is a rare inflammatory skin condition that is difficult to diagnose. Currently, it is a "diagnosis of exclusion," a definition not compatible with clinical decision making or inclusion for clinical trials.
OBJECTIVE
To propose and validate diagnostic criteria for ulcerative pyoderma gangrenosum.
EVIDENCE REVIEW
Diagnostic criteria were created following a Delphi consensus exercise using the RAND/UCLA Appropriateness Method. The criteria were validated against peer-reviewed established cases of pyoderma gangrenosum and mimickers using k-fold cross-validation with methods of multiple imputation.
FINDINGS
Delphi exercise yielded 1 major criterion-biopsy of ulcer edge demonstrating neutrophilic infiltrate-and 8 minor criteria: (1) exclusion of infection; (2) pathergy; (3) history of inflammatory bowel disease or inflammatory arthritis; (4) history of papule, pustule, or vesicle ulcerating within 4 days of appearing; (5) peripheral erythema, undermining border, and tenderness at ulceration site; (6) multiple ulcerations, at least 1 on an anterior lower leg; (7) cribriform or "wrinkled paper" scar(s) at healed ulcer sites; and (8) decreased ulcer size within 1 month of initiating immunosuppressive medication(s). Receiver operating characteristic analysis revealed that 4 of 8 minor criteria maximized discrimination, yielding sensitivity and specificity of 86% and 90%, respectively.
CONCLUSIONS AND RELEVANCE
This Delphi exercise produced 1 major criterion and 8 minor criteria for the diagnosis of ulcerative pyoderma gangrenosum. The criteria may serve as a guideline for clinicians, allowing for fewer misdiagnoses and improved patient selection for clinical trials.
Topics: Area Under Curve; Biopsy; Consensus; Delphi Technique; Humans; Neutrophils; Pyoderma Gangrenosum; ROC Curve; Skin; Skin Ulcer
PubMed: 29450466
DOI: 10.1001/jamadermatol.2017.5980 -
Drugs Sep 2023Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully... (Review)
Review
Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.
Topics: Humans; Pyoderma Gangrenosum; Skin; Pain Management; Biological Products; Cyclosporine
PubMed: 37610614
DOI: 10.1007/s40265-023-01931-3 -
Clinical Medicine (London, England) May 2019Pyoderma gangrenosum (PG) is a reactive non-infectious inflammatory dermatosis falling under the spectrum of the neutrophilic dermatoses. There are several subtypes,...
Pyoderma gangrenosum (PG) is a reactive non-infectious inflammatory dermatosis falling under the spectrum of the neutrophilic dermatoses. There are several subtypes, with 'classical PG' as the most common form in approximately 85% cases. This presents as an extremely painful erythematous lesion which rapidly progresses to a blistered or necrotic ulcer. There is often a ragged undermined edge with a violaceous/erythematous border. The lower legs are most frequently affected although PG can present at any body site. Other subtypes include bullous, vegetative, pustular, peristomal and superficial granulomatous variants. The differential diagnosis includes all other causes of cutaneous ulceration as there are no definitive laboratory or histopathological criteria for PG. Underlying systemic conditions are found in up to 50% of cases and thus clinicians should investigate thoroughly for such conditions once a diagnosis of PG has been made. Treatment of PG remains largely anecdotal, with no national or international guidelines, and is selected according to severity and rate of progression. Despite being a well-recognised condition, there is often a failure to make an early diagnosis of PG. This diagnosis should be actively considered when assessing ulcers, as prompt treatment may avoid the complications of prolonged systemic therapy, delayed wound healing and scarring.
Topics: Diagnosis, Differential; Early Diagnosis; Humans; Pyoderma Gangrenosum
PubMed: 31092515
DOI: 10.7861/clinmedicine.19-3-224 -
Wounds : a Compendium of Clinical... Jan 2016Pyoderma gangrenosum is an unusual cause of skin ulcerations that wound specialists must be prepared to recognize. There is no diagnostic test since it is a diagnosis of... (Review)
Review
Pyoderma gangrenosum is an unusual cause of skin ulcerations that wound specialists must be prepared to recognize. There is no diagnostic test since it is a diagnosis of exclusion, and if the disease is not recognized it can quickly become much worse. Pathergy, whereby a lesion begins or worsens due to trauma, such as a scrape, bite, debridement, surgery, or biopsy, is seen with pyoderma and requires special consideration. This case series and review will summarize the salient features of pyoderma and its treatment with an emphasis on the controversial role of surgery with pyoderma.
Topics: Anti-Infective Agents; Contraindications; Debridement; Diagnosis, Differential; Disease Progression; Early Diagnosis; Glucocorticoids; Humans; Methylprednisolone; Practice Guidelines as Topic; Prednisone; Pyoderma Gangrenosum; Wound Healing
PubMed: 26779805
DOI: No ID Found -
Ugeskrift For Laeger Jun 2021Pyoderma gangrenosum is a diagnostic and therapeutic challenge. A misdiagnosis or delayed diagnosis can lead to increased morbidity and death. A fast workup and... (Review)
Review
Pyoderma gangrenosum is a diagnostic and therapeutic challenge. A misdiagnosis or delayed diagnosis can lead to increased morbidity and death. A fast workup and initiation of treatment is essential. In this review, we present new diagnostic criteria, which can ease the diagnosis, and we summarise the evidence of different treatment modalities. The evidence points towards local immunosuppressive treatment in mild disease, supplemented by systemic glucorticosteroids, ciclosporin or tumour necrosis factor-alpha inhibitors in severe cases. Other biologics are emerging.
Topics: Diagnostic Errors; Humans; Immunosuppressive Agents; Pyoderma Gangrenosum
PubMed: 34120685
DOI: No ID Found -
Ugeskrift For Laeger Apr 2022
Topics: Humans; Organic Chemicals; Pyoderma; Skin Diseases, Bacterial
PubMed: 35485797
DOI: No ID Found -
Dermatology (Basel, Switzerland) 2022Pyoderma gangrenosum (PG) is a rare ulcerating skin disease associated with multiple comorbidities and increased mortality. In recent decades, newer biologics such as... (Review)
Review
BACKGROUND
Pyoderma gangrenosum (PG) is a rare ulcerating skin disease associated with multiple comorbidities and increased mortality. In recent decades, newer biologics such as interleukin inhibitors have been used to treat PG; however, the literature is scarce, consisting predominantly of case reports and caseseries. The aim of our review was to evaluate the effectiveness and safety of interleukin inhibitors for the treatment of PG in adults.
SUMMARY
A literature search was conducted using search terms related to PG and interleukin inhibitors in databases such as PubMed, Embase, Scopus, Web of Science, and Cochrane Library. The study eligibility criteria included patients diagnosed with PG, over the age of 18, and treated with an interleukin inhibitor. Our study included 60 papers describing 81 patients fulfilling the eligibility criteria. The treatment with interleukin inhibitors resulted in 70% (95% CI 59-80%) response and 57% (95% CI 45-68%) complete response rates, and few (4%) mild adverse events, hence supporting the off-label use for the treatment of recalcitrant PG in adults. The response and complete response rates were 59% (17/29) and 38% (11/29) for anakinra, 64% (7/11) and 55% (6/11) for canakinumab, and 79% (27/34) and 71% (24/34) for ustekinumab, respectively. Limitations include publication bias that might have overestimated the efficacy as successful cases responding to treatment are more likely to be reported than nonresponding cases. Additionally, the heterogeneity of the treatment groups does not allow conclusions of superiority or inferiority of the different interleukin inhibitors to be drawn. Further studies are needed to investigate the efficacy of the different interleukin inhibitors and to investigate the importance of underlying disease for treatment response.
Topics: Adult; Biological Products; Humans; Interleukin Inhibitors; Middle Aged; Pyoderma Gangrenosum
PubMed: 34710873
DOI: 10.1159/000519320 -
The Pan African Medical Journal 2018Ecthyma gangrenosum (EG) is a severe potentially lethal cutaneous infection that progresses sequentially from maculopapular rash to haemorrhagic bulla and then to...
Ecthyma gangrenosum (EG) is a severe potentially lethal cutaneous infection that progresses sequentially from maculopapular rash to haemorrhagic bulla and then to necrotic ulceration with surrounding erythema. It usually occurs in immunocompromised patients (aplasia secondary to chemotherapy, HIV infection, neutropenia or functional deficit of neutrophils, agammaglobulinemia). It rarely affects healthy people. Differential diagnosis includes leishmaniasis, pyoderma gangrenosum, eschars and papulonecrotic tuberculides. Blood cultures and/or local sample allow the isolation of P. aeruginosa, which is the causative germ. Treatment is based on suitable parenteral antibiotic therapy according to results of susceptibility tests (third-generation cephalosporins, fluoroquinolones). We here report the case of a 2-year old child with no particular past medical history presenting with multiple necrotic ulcers on the back with erythematous border evolving in a febrile context. Blood culture was negative. Laboratory tests showed sedimentation rate 30 mm, CRP 80mg/l. Bacteriological sampling of pus revealed pseudomonas aeruginosa. The diagnosis of ecthyma gangrenosum was made. The patient underwent parenteral third-generation cephalosporins. Complete patient recovery with healing occurred after 4 weeks.
Topics: Anti-Bacterial Agents; Cephalosporins; Child, Preschool; Diagnosis, Differential; Ecthyma; Humans; Male; Pseudomonas Infections; Pseudomonas aeruginosa; Treatment Outcome
PubMed: 30344879
DOI: 10.11604/pamj.2018.30.95.6244