Peristomal Pyoderma Gangrenosum and Inflammatory Bowel Disease

Abstract

Pyoderma gangrenosum (PG) is a debilitating skin disease most often associated with inflammatory bowel disease and is a reportedly rare cause of peristomal ulceration. The lesions of PG rapidly evolve from small, erythematous pustules to deep, painful, pyogenic ulcers within hours to days of onset. Although the behavior and the appearance of the lesions of peristomal PG are diagnostic, a lack of familiarity with PG often leads to misdiagnosis and inappropriate therapy. This study reports four cases of peristomal PG and discusses the 20 previously reported cases in patients with inflammatory bowel disease. Seventy-five percent of patients were female and 67% had Crohn's disease. All patients had colitis, including all of the patients with Crohn's disease, 82% of whom had additional perineal complications. The diagnosis of peristomal PG was based on clinical appearance alone in 83% of cases. The onset of peristomal PG ranged from 2 weeks to 3 years following ostomy. The response to medical therapy was variable. All cases (17 of 17) treated with high-dose corticosteroids and local wound care responded, but five cases required additional therapy. No patient was successfully treated with stoma revision. Risk factors for the development of peristomal PG include Crohn's colitis, female gender, and perineal disease. While most patients respond well to systemic steroids and local wound care, up to one third of patients require long-term medical management.

Bilateral Pyoderma Gangrenosum Following Bilateral Reduction Mammoplasty: Case Report

“…Hepatitis C or other viral infections, Wegener's granulomatosis, systemic lupus erythematosus and other autoimmune diseases are other likely causes. [9][10][11][12][13] Twenty-three percent of cases are induced and aggravated by minor trauma or surgery and this, points out the pathergy phenomenon in the PG. It was also reported as a complication of various surgical interventions, such as hernioplasty, cardiac surgery, cesarean section and breast surgery.…”

“…The most common diseases associated with PG are ulcerative colitis, Crohn's disease and rheumatoid arthritis. [9][10][11][12][13] Management of PG involves medical control of the inflammatory phase of PG and local wound care.…”

A case of parastomal pyoderma gangrenosum

“…This can be mistaken for other causes such as infection, stitch abscess, contact dermatitis and irritation from fecal material [1]. Missed diagnosis occur also due to lack of knowledge and familiarity of clinicians to parastomal pyoderma gangrenosum [5]. It is often a diagnosis of exclusion and is particularly difficult to manage owing to its constant pain resulting in poor application of stoma appliance.…”

“…While histology from skin biopsy typically show edema and massive neutrophil infiltration confined to the dermis, diagnosis of parastomal pyoderma gangrenosum is mainly via its clinical appearance, a high degree of pain and its rapid progression. The ulcers are very destructive and can expand by 1 to 2 cm from hours to a day [1,5]. Biopsies are done often to rule out other causes of ulceration rather than to diagnose pyoderma gangrenosum histologically [3].…”

“…Medical rather than surgical management is preferred as debridement is not recommended and relocation of stoma is contraindicated unless it is done for other reasons [3]. Given the nature of pathergy, debridement will only exacerbate the problem and relocation often result in recurrence of the disease at the new stoma site [1,5]. Treatment regimen depends on the severity of the disease and whether there is active systemic disease (i.e., IBD).…”