Pyoderma gangrenosum (PG) is associated with a number of systemic diseases. PG in association with hidradenitis suppurativa (HS) has been rarely reported. We describe six patients (three men, three women; aged 35--51 years), who developed PG on a background of HS. The onset of PG occurred only after HS had been present for at least two decades. No relationship in disease activity between the two conditions was observed. Three patients described previous severe adolescent acne vulgaris, one had concurrent systemic lupus erythematosus and another had chronic iron-deficiency anaemia. The course of PG was severe and refractory in four patients, who required treatment including high-dose oral corticosteroids, ciclosporin, intravenous immunoglobulin and intravenous cyclophosphamide.
Summary
Secukinumab is an interleukin (IL)‐17 monoclonal antibody inhibiting T‐helper (Th)1‐mediated immune response. It has proven high efficacy for moderate to severe psoriasis but data on its long‐term toxicities are limited. We describe two patients who received secukinumab for clinically presumed psoriasis, but were subsequently diagnosed with mycosis fungoides (MF) following skin biopsies triggered by skin deterioration while on secukinumab. Previous studies suggested decreased numbers of regulatory T cells (Tregs) with increasing stage of MF, which may lead to the shift in the Treg/Th17 balance towards the Th17 pathway. Theoretically, the use of IL‐17 monoclonal antibodies to inhibit Th17 pathway may lead to further immunosuppression and disease progression in cutaneous T‐cell lymphoma (CTCL) by shifting the balance towards Tregs, although this hypothesis has not been proven. With uncertainty over the role of IL‐17 and Treg/Th17 as well as diagnostic challenges in CTCL, we recommend that patients should have a confirmatory skin biopsy prior to the commencement of biologic therapy.
Our experience supports the continued and safe use of warfarin for a wide variety of cutaneous surgical procedures with a preoperative INR of < 3.5. We recommend a routine INR before the procedure, preferably within 24 h.
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