Post-traumatic Pyoderma Gangrenosum
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Abstract: Chronically nonhealing wounds caused by pyoderma gangrenosum (PG) are rare and often misdiagnosed. Since PG has no pathognomonic features, the diagnosis is based on clinical grounds. It is a diagnosis of exclusion and presents a considerable challenge, particularly in the absence of systemic diseases commonly associated with PG. Mistreatment or delayed proper treatment can be harmful to patients. The need to recognize trauma (pathergy) as a potential trigger of PG is important for the optimal management of these wounds. The authors present 5 patients who had PG following different forms of trauma at or near the wound site.
Address correspondence to:
Philip W. Paparone, DO
Stockton Medical Complex
72 West Jimmie Leeds Road
Absecon, NJ 08205-9407
Pyoderma gangrenosum (PG) is a rare gangrene of the skin, characterized by rapidly progressive, painful ulceration with violaceous, undermined borders.1–3 Lesions often begin with a discrete pustule with surrounding erythema that quickly breaks down to form the characteristic ulceration. The legs are most commonly affected, but other parts of the skin and mucous membranes might also be involved.1 In many cases, PG is associated with systemic disease—most commonly inflammatory bowel disease, arthritis, hepatitis, and myeloproliferative disorders.4,5 Additionally, PG is often associated with trauma in patients who may or may not have systemic disease as a consequence of pathergy—the process in which the induction of a lesion at a site of minor trauma occurs.4 While the diagnosis of PG is based on exclusion, the etiology of PG remains unknown. Histopathologic features are not diagnostic; however, biopsy is useful for the exclusion of other diseases. As a neutrophilic dermatosis, PG often is characterized by the presence of marked neutrophilic infiltrates in the dermis. Misdiagnosis is not uncommon (as high as 10%),6 and can result in inappropriate and potentially detrimental treatment. The proper treatment of PG, often as much of a challenge as its diagnosis, usually requires systemic corticosteroids or other immunosuppressive medications.5
The present report describes 5 cases of post-traumatic PG, and demonstrates the need for appreciating the significance of trauma (pathergy) in the evaluation of chronically nonhealing wounds. It is proposed that increased recognition of associated trauma in PG, as well as suspected trauma, may decrease the incidence of costly misdiagnosis.
Patient 1. A 58-year-old man presented with a wound on the right lower leg. It was associated with a traumatic injury that had occurred on a boat. The wound improved slowly with local wound care. Vascular problems were suspected and later confirmed. Cultures grew a Hormonema fungus that was treated, but this treatment did not produce significant wound improvement. Pyoderma gangrenosum was suspected and a biopsy was performed. Results of the biopsy were consistent with PG. The patient was placed on thalidomide (100 mg twice daily) and prednisone (60 mg once daily). Consequently, the wound healed over the course of several months. The patient responded well and the wound remained healed until he accidentally dropped a stapler on his right leg, which caused a new wound (Figure 1). Treatment with thalidomide (100 mg once daily) and prednisone (60 mg once daily) was effective. When the wound showed signs of improvement, the prednisone was tapered off gradually over 2 months. The wound finally healed and the thalidomide treatment was stopped.
1. Callen JP, Jackson JM. Pyoderma gangrenosum: an update. Rheum Dis Clin North Am. 2007;33(4):787–802.
2. Reichrath J, Bens G, Bonowitz A, Tilgen W. Treatment recommendations for pyoderma gangrenosum: an evidence-based review of the literature based on more than 350 patients. J Am Acad Dermatol. 2005;53(2):273–283.
3. Su WP, Davis MD, Weenig RH, Powell FC, Perry HO. Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. Int J Dermatol. 2004;43(11):790–800.
4. Blitz NM, Rudikoff D. Pyoderma gangrenosum. Mt Sinai J Med. 2001;68(4-5):287–297.
5. Wolff K, Stingl G. Pyoderma gangrenosum. In: Freedberg I, Eisen A, Wolff K, et al, eds. Dermatology in General Medicine. 5th ed. New York, NY: McGraw-Hill; 1999:1140–1148.
6. Weenig RH, Davis MD, Dahl PR, Su WP. Skin ulcers misdiagnosed as pyoderma gangrenosum. N Engl J Med. 2002;347(18):1412–1418.
7. Lorentzen HF, Gottrup F. Clinical assessment of infection in nonhealing ulcers analyzed by latent class analysis. Wound Repair Regen. 2006;14(3):350–353.
8. Brunsting LA, Goeckerman WH, O’Leary PA. Pyoderma (echthyma) gangrenosum: clinical and experimental observations in five cases occurring in adults. Arch Derm Syphilol. 1930;22(4):655–680.
9. Prystowsky JH, Kahn SN, Lazarus GS. Present status of pyoderma gangrenosum. Arch Dermatol. 1989;125(1):57–64.
10. von den Driesch P. Pyoderma gangrenosum: a report of 44 cases with follow-up. Br J Dermatol. 1997;137(6):1000–1005.
11. Walusimbi M, Mannari RJ, Payne WG, Ochs D, Blue ML, Robson MC. Pyoderma gangrenosum: case report of novel treatment with topical steroid and silver sulfadiazine. WOUNDS. 2002;14(6):227–229.
12. Habif TP. Hypersensitivity syndromes and vasculitis. In: Clinical Dermatology. 4th ed. New York, NY: Mosby; 2004:626–634.
13. Wollina U. Pyoderma gangrenosum—a review. Orphanet J Rare Dis. 2007;2:19.
14. Holbrook MR, Doherty M, Powell RJ. Post-traumatic leg ulcer. Ann Rheum Dis. 1996;55(4):214–215.
15. Finkel SI, Janowitz HD. Trauma and the pyoderma gangrenosum of inflammatory bowel disease. Gut. 1981;22(5):410–412.
16. Gleichmann US, Otte HG, Körfer R, Stadler R. Post-traumatic pyoderma gangrenosum: combination therapy with intravenous immunoglobulins and systemic corticosteroids. [Article in German]. Hautarzt. 1999;50(12):879–883.
17. Born S, Marsch WC. Postoperative pyoderma gangrenosum. [Article in German]. Chirurg. 2001;72(9):1043–1047.
18. Keskin M, Tosun Z, Ucar C, Savaci N. Pyoderma gangrenosum in a battered child. Ann Plast Surg. 2006;57(2):228–230.
19. Gül A, Esin S, Dilsen N, Koniçe M, Wigzell H, Biberfeld P. Immunohistology of skin pathergy reaction in Behçet’s disease. Br J Dermatol. 1995;132(6):901–907.
20. Chakrabarty A, Phillips TJ. Diagnostic dilemmas: pyoderma gangrenosum. WOUNDS. 2002;14(8):302–305.
21. Koo K, Brem H, Lebwohl M. Pyoderma gangrenosum versus chronic venous ulceration: comparison of diagnostic features. J Cutan Med Surg. 2006;10(1):26–30.
22. Rosina P, Cunego S, Franz CZ, D’Onghia FS, Chieregato G. Pathergic pyoderma gangrenosum in a venous ulcer. Int J Dermatol. 2002;41(3):166–167.
23. Wollina U. Clinical management of pyoderma gangrenosum. Am J Clin Dermatol. 2002;3(3):149–158.