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The Scar That Wouldn’t Heal

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.

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The Scar That Wouldn’t Heal

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  1. The Scar That Wouldn’t Heal Nancy Fuller, M.D. November 23, 2005

  2. 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

  3. 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

  4. ? Foreign body reaction? • Split thickness skin graft done; continued episodes of dehiscence • ?allergy to suture material? • Labs done: CBC, ESR, CRP, immunoglobulins, RF, ANA

  5. Patient developed 2 new small lesions-started as pustules, progressed to small ulcers • Started on Prednisone and antibiotics • Tacrolimus added • Significant improvement!!

  6. Dx: Pyoderma Gangrenosum

  7. Objectives: • Consider pyoderma gangrenosum in differential for ulcerative skin lesions • Recognize potential problems in identification and diagnosis, treatment of PG • No financial disclosures

  8. 1930 : “rapidly progressive painful supperative cutaneous ulcers with edematous, boggy, undermined and necrotic borders”-coined “ pyoderma gangrenosum”

  9. 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?

  10. Pyoderma Gangrenosum • Sweet's Disease • Generalized Pustular Psoriasis • Reactive Arthritis (Reiter’s Syndrome)- Balanitis, keratoderma blennorrhagica

  11. Sweet’s Disease • Acute onset of fever/leukocytosis/erythematous plaques infiltrated by neutrophils • Uncommon • Female to male 4:1

  12. 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

  13. 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

  14. Pyoderma Gangrenosum • Ulcerative chronic inflammatory skin lesions • Single or multiple • Most common on legs, but can be anywhere • Pathergy • Painful

  15. 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

  16. Associated with underlying systemic diseases 50% of the time -Inflammatory bowel disease: 5% of ulcerative colitis, 2% Crohn’s -Inflammatory arthritis -lymphproliferative disorders

  17. Differential diagnosis • Deep mycotic infections • Bacterial infections, including mycobacteria, • Herpes simplex • Vasculitis • Insect reactions (eg, brown recluse spider) • Warfarin skin necrosis • Factitial ulcer • gumma

  18. 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

  19. Mistaken Identity? • Antiphospholipid syndrome • Wegeners granulomatosis • Chronic venous stasis ulcers • Vasculitis • Infection • Cancer (cutaneous lymphoma, etc)

  20. Treatment • No well controlled studies • For mild disease: local treatment such as topical steroids, topical tacrolimus ointment, colloidal membrane dressings

  21. 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

  22. 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!

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