Pyoderma Gangrenosum presented by Jennifer Armstrong. UCI Emergency Medicine, August 24, 2011

1. UCI EMERGENCY MEDICINE
AUGUST 24, 2011
JENNIFER ARMSTRONG
Pyoderma Gangrenosum

2. Pyoderma gangrenosum
Uncommon noninfectious
ulcerative cutaneous
condition of uncertain
etiology.

3. What is Pyoderma Gangrenosum
 Often mistaken as an
infection
 Pustules form and give
way to ulcers with
necrotic, undermined
margin
 Primarily sterile
inflammatory neutrophilic
dermatosis.

4. Epidemiology
•Any age 20-50
•F>M
•All races equal
•Takes on a
number of
differing
clinical
presentations

5. Pyoderma Gangrenosum: 2 varients
2 primary variants are a classic ulcerative
form
1 – Lower extremities
2 – Hands
 More superficial
 Called atypical

6. The different clinical types of PG
Variants-Typical findings
Ulcerative PG
 Ulceration with rapidly evolving purulent wound ground
Pustular PG
 Discrete pustules, sometimes self-limited, commonly
associated with inflammatory bowel disease
Bullous PG
 Superficial bullae with development of ulcerations
Vegetative PG
 Erosions and superficial ulcers

7. Pathophysiology
• Poorly understood
• Dysregulation of the immune system, specifically altered
neutrophil chemotaxis, is believed to be involved

8. Associated Symptoms
……………………………………………………Fever, toxicity
…..…Pain
………………………Tissue Swelling

9. What to look for
Begin as extremely painful solitary
nodules
 Deep seated pustules
Rupture and form a shaggy ulcer
 Some pustules do not progress to ulcers
Boarders are deep violaceous or dusky
color
Bright erythema extend from the ulcer
 Can be lesions of oral mucosa, vulva, eyes
 Necrosis is common
 Purulent coating in the center common
 Can have oder

10. Who is at risk of pyoderma gangrenosum?
Pyoderma gangrenosum often affects a person
with an underlying internal disease such as
 Inflammatory bowel diseases (ulcerative colitis and Crohn
disease)
 Rheumatoid arthritis
 Myeloid blood dyscrasias
 Chronic active hepatitis
 Wegener granulomatosis

11. Key Clinical Findings
Starts quite suddenly, often
at the site of a minor injury.
 It may start as a small pustule,
red bump or blood-blister.
The skin then breaks down
resulting in an ulcer which
can deepen and widen
rapidly.
Any trauma worsens the
lesion

12. Treatment - Pyoderma Gangrenosum
Options
Mild
• Intralesional corticosteroids
Moderate/Severe
• Prednisone: 0.5-2mg/kg PO. Divided into 4x daily
• Usually weeks to months
• Cyclosporine-A: 0.5-1.0 mg /kg/day. Divide BID
• Rapid response and marked improvement of pain
Surgical
• NEVER!
• NO I/D, NO biopsy
Referral
• Dermatology for management is indicated for multiple
lesions

13. Wound Care
All Cases
 Saline soaked dressing
 Occlusive dressing
discouraged
 Until disease is controlled

14. Diagnosis
Often misdiagnosed
Diagnosed by its characteristic appearance.
There is no specific test.
 The wound should be swabbed and cultured for micro-
organisms, but these are not the cause of pyoderma
gangrenosum.
Mostly, blood tests are not particularly helpful. Some
patients may have a positive ANCA.
The pathergy test is usually positive (a skin prick test
causing a papule, pustule or ulcer).

15. Differential Diagnosis

16. References
• ON REQUEST
THANK YOU!!