Case report 46 y caucasian male RE progressive cicatricial
ectropion 7 months
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Past history Antecedent small skin cyst upper cheek Treated at
Walk-in Centre Fit & well Chemical worker Smokes 1x pack/day,
drinks 1 bottle wine/day Hmm not sure what that is.. Lets try a
needle
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pyogenic reaction dramaticIntense
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Pathergy :Ulceration at site of minor trauma Violaceous
ulceration with undermined edges Swabs - negative Biopsy:
Non-specific inflammation Not malignant Not vasculitis
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Empirical treatment Topical Fucibet Oral minocycline Reduction
in inflammatory component
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4 Months post-puncture
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Progressive cribriform cicatrisation inducing further ectropion
Systemic cyclosporin with blood monitoring 5 months later
(September 09)
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Pyoderma Gangrenosum
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BMJ Review Article Brooklyn et al BMJ 2006;333:181-184 A rare
but serious neutrophilic dermatosis Commonly missed/ diagnosed late
Deep ulcer with a well defined border, usually violet or blue. edge
often undermined surrounding skin is erythematous and indurated
Most commonly on the legs. Patients are often systemically unwell
with fever & malaise. Lesions are usually painful and the pain
can be severe. When the lesions heal the scars are often
cribriform. Pathergy occurs in 25-50% of caseslesions develop at
the site of minor trauma, so surgery or debridement are
contraindicated. ??
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Subtypes
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Halogenoderma Sweets Syndrome
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Histopathology Findings: depend on: age of lesion site biopsied
Presence (or absence) of vasculitis: lymphocytic and/or
leukocytoclastic vasculitis at advancing erythematous edge in 73%
of cases) Earliest lesion: follicular and perifollicular
inflammation with intradermal abscess formation Later lesions:
necrosis of superficial dermis and epidermis: forms ulcer: may
extend into underlying subcutis sometimes giant cells: particularly
if associated Crohn's disease Advancing edge: lymphocytic
vasculitis: endothelial swelling disputed by some authors sometimes
leukocytoclastic vasculitis Acanthosis: prominent in perilesional
erythematous zone
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Who gets pyoderma gangrenosum? 50% are associated with
underlying systemic conditions 30% of cases occur in patients with
inflammatory bowel disease. 2% of patients with inflammatory bowel
disease will develop pyoderma PG not related to the activity of the
inflammatory bowel disease, often occurs in patients whose bowel
disease is in clinical remission. 25% of patients have arthritis,
most often seropositive rheumatoid arthritis Activity of the
arthritis is not related to pyoderma. Leukaemia is the most
frequently reported malignancy, usually AML
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PG and the eye Largest series I could find : 4 pts at
Moorfields Rose et al Ophthalmology 2003 slowly evolving, painful,
unilateral blue-grey swellings of the pretarsal tissues progressed
to frank tissue necrosis and loss of full-thickness eyelid, with
patchy sparing of the lid margin or lashes very distinctive
preservation of the pretarsal marginal artery across full-thickness
eyelid defects lid loss characteristically involved lateral one
third of the lower eyelid (3 of 4 lids) in one case, extending into
the postseptal tissues in the inferotemporal orbit. In 3 patients,
the pyoderma, responded well to systemic immunosuppression and
eyelid repair was undertaken during the quiescent phase. In a
single patient, relapsing disease led to loss of the eye as a
result of involvement of the globe and deep orbital tissues. Other
reports scleritis, PUK, orbital- coexistent with Sweets
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Medical Treatment Topical steroid Local injection of
triamcinolone under ulcer edge Topical tacrolimus Minocycline 100
mg twice daily Prednisolone is the drug of choice and is usually
started at (60-120 mg) (level B evidence) IV MePred 1g pulses x 3-5
Cyclosporine 3-5 mg/kg serious side effects, including
nephrotoxicity, hypertension, and increased risk of cancer have not
been reported for the low doses used to treat pyoderma Infliximab +
azathioprine
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Procianoy et al Arq Bras Oftalmol. 2009;72(3):384-6
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Surgical Management Essentially shortage of anterior lamella
Lateral tarsal strip procedure and scar tissue release with full-
thickness skin grafting Pretreated with corticosteroid for several
months Disease was considered quiescent for the previous 6 months
under treatment. Prednisolone dose increased from 40 mg/day to 60
mg/day 1 week before surgery. This dose was maintained during the
first month post-operatively and tapered.
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A) Preoperative B) 6-month post-operative C) Hypertrophic donor
site A B C
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Adjacent pustular ulcerated skin over zygoma
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Conclusion Pyoderma gangrenosum CAN be co-managed surgically
Excluding other diagnoses and investigation underlying associations
is essential Immunomodulation by experienced dermatologist is the
key to minimisinng surgical excitement
Slide 28
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gangrenosum: a review and update on new therapies. J Am Acad
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AG, et al. Pyoderma gangrenosum: an updated review. J Eur Acad
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Atypical pyoderma gangrenosum after breast reduction. Aesthetic
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Pyoderma gangrenosum after coronary artery bypass grafting. Ann
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P. Pyoderma gangrenosum after caesarean section: a case report.
Reprod Health 2006;3:9. 8. Akhras V, Sarkany R, Walsh S, et al.
Superficial granulomatous pyoderma treated preoperatively with
infliximab. Clin Exp Dermatol. 2009;34(5):e183-5. 9. Procianoy F,
Barbato MT, Osowski LE et al. Cicatricial ectropion correction in a
patient with pyoderma gangrenosum: case report. Arq Bras Oftalmol.
2009 72(3):384-6