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EditorPyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative skin disease. 1 Fewer than 50% of the patients achieve wound healing after 6 months of immunosuppressive therapy and relapses occur in 30% to 60% of the cases. 2,3 Progression of existing lesions or development of new lesions after surgery or minor trauma is reported in up to 30% of PG patients (pathergy phenomenon). 3,4 Therefore, the role of surgical interventions such as split thickness skin grafting (STSG) and negative pressure wound therapy (NPWT) is controversially discussed, as these procedures might pose a trigger and further aggravate the condition, especially if performed without immunosuppression. 5 A broad search of the PubMed, Medline, EBSCO Biomedical Reference Collection and Cochrane databases was performed and a total of 61 relevant articles describing 94 patients could be retrieved and complemented with our personal multicentre experience of 21 patients (see Table 1). A total of 115 patients with PG (69% females, median age 53) were identified. Ulcers were mainly situated on the lower extremities (n = 90; 78%), followed by breasts (n = 11; 10%), abdomen (n = 7; 6%) and other localizations (12; 10%). Surgical treatment consisted of split thickness skin grafts (STSG) alone (n = 53; 46%), STSG together with NPWT (n = 35; 30%), NPWT alone (12; 10%) or other forms of skin grafting (cultured cells, suction blisters, full thickness skin grafts, pinch grafts n = 15, 13%). Systemic immunosuppression consisted mainly of systemic corticosteroids (n = 107; 93%), supplemented with cyclosporine (21; 19%), dapsone (12; 9%), TNF-alpha antibodies (11; 9%), mycophenolate mofetil (9; 8%), azathioprine (7, 6%) and others used in less than five patients. Treatment was successful in 84 cases (73%), 18 patients healed but had a recurrence (16%), eight improved (7%), treatment failed in three patients and two patients died due to sepsis. The lower relapse rates observed in this review is probably due to the short follow-up in the many single patients reported. No case of pathergy was observed, neither at the side of PG nor at the skin graft donor sites.On the basis of the literature review and personal experience, we developed a surgical treatment algorithm with proposed immunosuppressive and adjuvant measures shown in Fig. 1. The basic immunosuppression consists of CS. As a second step, we prefer dapsone as anti-inflammatory steroid sparing agent over cyclosporine, as it does not affect renal function or blood pressure and for its well-known additional antimicrobial properties. 6 Indeed, mortality rates from 11% to 17% have been reported for PG and were mostly related to sepsis 3,7 and septical complications were the cause of death in the two deceased patients from the literature review. 3,8 As a third step, if necessary, the anti-TNF-alpha antibody infliximab is used as the sole biologic with a positive randomized, double-blinded, placebocontrolled trial for PG. We further suggest the use of pentoxyphylline as adjuvant treatment for its known rheolo...

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Despite transplacental HSV transmission remains a rare event, the potential devastating outcome justifies immediate adequate antiviral treatment in a pregnant woman affected by primary HSV infection.

STSGs are a valid option for closing large auricular skin defects. Even large cutaneous tumors of the external ear do not necessarily infiltrate the cartilage. Thus, cartilage-sparing tumor resection with subsequent defect closure using a STSG is an excellent and quick method associated with high patient satisfaction.

We confirm the histological difficulties in the diagnosis of this tumor entity and the large extension of MAC due to delay in diagnosis and treatment. Deep tumor removal including the periostium might be necessary to achieve tumor free margins. Fast granulation tissue above the frontal bone might be achieved by applying hyaluronic acid products. The combination an AT flap with transplantation of the adjacent Burow's triangles gives optimal skin texture and color matching and seems to be a good option to close even large defects of the front especially for supra brow defects.

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