Presentation on theme: "The Scar That Wouldn’t Heal Nancy Fuller, M.D. November 23, 2005."— Presentation transcript:
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
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
? Foreign body reaction? Split thickness skin graft done; continued episodes of dehiscence ?allergy to suture material? Labs done: CBC, ESR, CRP, immunoglobulins, RF, ANA
Patient developed 2 new small lesions- started as pustules, progressed to small ulcers Started on Prednisone and antibiotics Tacrolimus added Significant improvement!!
Dx: Pyoderma Gangrenosum
Objectives: Consider pyoderma gangrenosum in differential for ulcerative skin lesions Recognize potential problems in identification and diagnosis, treatment of PG No financial disclosures
1930 : “rapidly progressive painful supperative cutaneous ulcers with edematous, boggy, undermined and necrotic borders”-coined “ pyoderma gangrenosum”
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?
Treatment No well controlled studies For mild disease: local treatment such as topical steroids, topical tacrolimus ointment, colloidal membrane dressings
For severe disease or failure with topical treatments: -steroids: 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
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!