Systematic review of surgical treatment of pyoderma gangrenosum with negative pressure wound therapy or skin grafting

Abstract

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...

Successful treatment with ustekinumab and vacuum-assisted closure therapy in recalcitrant myelodysplastic syndrome-associated pyoderma gangrenosum: case report and literature review

“…It has proved to be useful alone or in combination with skin grafting, and is a safe option when used under adequate immunosuppressive therapy, shortening the time to improvement and healing. 6 In summary, we present what to our knowledge is the first reported case of the use of ustekinumab plus VAC therapy in recalcitrant MDS-associated PG. This case supports the use of surgical treatment as a…”

“…As in our case, it promotes closure of the ulcers; removes exudates, infectious material and cellular debris; enhances perfusion by stimulating neoangiogenesis and diminishing tissue oedema; and increases cellular migration and proliferation. It has proved to be useful alone or in combination with skin grafting, and is a safe option when used under adequate immunosuppressive therapy, shortening the time to improvement and healing …”

Pyoderma Gangrenosum after Deep Inferior Epigastric Perforator Breast Reconstruction: Systematic Review and Case Report

“…The use of VAC is debatable as it can traumatize the wound bed but has been shown to be safe and useful if performed under immunosuppressive therapy. 22,24 The use of skin grafts or skin substitutes has shown to accelerate wound healing, but this should be performed in patients with large wounds in the setting of medical therapy. 13,14,24 …”

Clinically inactive pyoderma gangrenosum successfully treated with negative pressure therapy and punch grafting

“…However, once inflammation is controlled by systemic immunosuppresion, these wounds may benefit from invasive treatments. [3][4][5] We present a case of pyoderma gangrenosum under immunosuppression, with no clinical signs of inflammation that responded successfully to negative pressure therapy and punch grafting.…”

“…Complete healing rates with classical immunosuppressive treatments (predominantly oral corticosteroids and cyclosporine) do not reach 50% at 6 months. 3,4 Although different biologic agents may be an effective alternative in nonresponders, the problem is not only controlling pyoderma activity but also repairing all lost tissue.…”