Pyoderma gangrenosum--a review

Abstract

Pyoderma gangrenosum (PG) is a rare noninfectious neutrophilic dermatosis. Clinically it starts with sterile pustules that rapidly progress and turn into painful ulcers of variable depth and size with undermined violaceous borders. The legs are most commonly affected but other parts of the skin and mucous membranes may also be involved. Course can be mild or malignant, chronic or relapsing with remarkable morbidity. In many cases PG is associated with an underlying disease, most commonly inflammatory bowel disease, rheumatic or haematological disease and malignancy. Diagnosis of PG is based on history of an underlying disease, typical clinical presentation, histopathology, and exclusion of other diseases that would lead to a similar appearance. The peak of incidence occurs between the ages of 20 to 50 years with women being more often affected than men. Aetiology has not been clearly determined yet. The treatment of PG is a challenge. Randomized, double-blinded prospective multicenter trials for PG are not available. The best documented treatments are systemic corticosteroids and cyclosporin A. Combinations of steroids with cytotoxic drugs are used in resistant cases. The combination of steroids with sulfa drugs or immunosuppressants has been used as steroid-sparing modalities. Anti-tumor necrosis alpha therapy in Crohn's disease showed a rapid response of PG. Skin transplants and the application of bioengineered skin is useful in selected cases as a complement to the immunosuppressive treatment. Topical therapy with modern wound dressings is useful to minimize pain and the risk of secondary infections. Despite recent advances in therapy, the prognosis of PG remains unpredictable.

Figure 1

Acute rapid growing pyoderma gangraenosum with undermined violaceous borders.

Figure 2

Postsurgical pyoderma gangraenosusm [a] before treatment; [b] after immunosuppressive treatment with oral prednisolone and mesh-graft transplantation.

Figure 3

Ecthyma-like pyoderma gangraenosum.

Figure 4

Peristomal pyoderma gangraenosum in ulcerative colitis.

Figure 5

Deep purulent ulcerations due to pyoderma gangraenosum. In this patient later on a lower limb amputation was necessary, since he did not response to drug therapy.