Original Article
Skin Ulcers Misdiagnosed as Pyoderma Gangrenosum
N Engl J Med 2002; 347:1412-1418October 31, 2002
- Abstract
Background
Pyoderma gangrenosum is a diagnosis of exclusion, and the misdiagnosis of pyoderma gangrenosum can result in substantial complications in patients who have other causes of severe cutaneous ulceration.
Methods
We reviewed the charts of 240 patients with a diagnosis of pyoderma gangrenosum who were evaluated at our institution from 1975 through 2000, including 157 consecutive patients treated for presumed pyoderma gangrenosum from 1984 through 1992. We also reviewed the English-language literature.
Results
Ninety-five patients (49 from our institution and 46 described in the literature) had skin ulcers with a clinical resemblance to pyoderma gangrenosum. The final diagnoses were vascular occlusive or venous disease, vasculitis, cancer, primary infection, drug-induced or exogenous tissue injury, and other inflammatory disorders. Of the 95 patients studied, 64 had been treated for pyoderma gangrenosum for a median of 10 months (range, 3 to 180). These 64 included 15 of the 157 consecutive patients treated for pyoderma gangrenosum at our institution (10 percent). Of the ulcers in the 64 patients treated for pyoderma gangrenosum, it was clear that those in 23 patients (36 percent) did not respond to treatment directed at pyoderma gangrenosum, those in 8 (12 percent) were exacerbated by such treatment, and those in 15 (23 percent) improved with such treatment.
Conclusions
The misdiagnosis of pyoderma gangrenosum is not uncommon and exposes patients to risks associated with its treatment. A thorough evaluation is required in all patients suspected of having pyoderma gangrenosum in order to rule out alternative diagnoses.
Media in This Article
Figure 1
Ulceration Resembling Pyoderma Gangrenosum but Due to Antiphospholipid-Antibody Syndrome.Table 1
Ulcers Resembling Pyoderma Gangrenosum.Article Activity
- Article
The misdiagnosis of pyoderma gangrenosum can have serious consequences. Cutaneous ulcerations in patients with suspected pyoderma gangrenosum often prove, on further workup, to have a different cause. Moreover, treatment directed at pyoderma gangrenosum — high-dose prednisone or other immunosuppressive medications — may be contraindicated in patients with any of several diseases that may produce ulceration resembling that of pyoderma gangrenosum, such as infectious or malignant processes.
Numerous case reports describe diseases that “mimic” or “masquerade as” pyoderma gangrenosum, but no large studies evaluating this phenomenon have been conducted. This lack of data prompted us to review our experience and the literature to determine the frequency and consequences of misdiagnosis in patients with presumed pyoderma gangrenosum.
The objectives of our study were to determine the frequency of misdiagnosis of pyoderma gangrenosum at our tertiary referral center and to identify the causes of cutaneous ulceration and the usefulness of biopsy in patients who receive such misdiagnoses. For patients who had received treatment directed at pyoderma gangrenosum, we also attempted to ascertain the lag time between the initial diagnosis and the definitive diagnosis and the effect of treatment directed at pyoderma gangrenosum.
Methods
Ascertainment of Cases
Medical charts of 240 patients were reviewed, including those of 157 consecutive patients treated at the Mayo Clinic in Rochester, Minnesota, for pyoderma gangrenosum and evaluated from 1984 through 1992 and those of 83 patients identified in a 25-year extraction (for 1975 through 2000) from the master index of diagnoses at the Mayo Clinic. We searched the index for patients with concomitant diagnoses of pyoderma gangrenosum and other vascular, malignant, infectious, exogenous, or inflammatory conditions that may produce cutaneous ulceration. The charts of these patients were reviewed in order to identify patients who were initially mistakenly given a diagnosis of pyoderma gangrenosum.
In addition, a Medline search of the English-language literature using the key words “pyoderma gangrenosum” produced 767 references. We reviewed the abstracts of all these articles and further reviewed the full text of articles that suggested a possible alternative cause of pyoderma gangrenosum–like ulceration. The review was expedited by the targeting of phrases such as “presenting as,” “masquerading,” “induced by,” “mimicking,” “simulating,” “caused by,” and “associated with.”
Abstraction of Data
The charts and cases from the literature were reviewed by two of the investigators with the use of a formal abstraction tool. The information abstracted from the charts and cases included demographic information about the patients (age, sex, location of ulcer, and duration of ulcer), relevant medical history (inflammatory bowel disease, arthritis, monoclonal gammopathy, underlying cancer, coagulopathy, or connective-tissue disease), the initial diagnosis, the microscopical description and diagnoses rendered by a pathologist on the initial and subsequent biopsies of the ulcer, the final diagnosis, the interval between the initial clinical diagnosis and the final diagnosis, treatments prescribed before the final diagnosis, and the final treatment and outcome. If there was insufficient information concerning these variables, the patient was excluded from the analysis.
Case Definition
Cases that clinically resembled pyoderma gangrenosum but were found to be due to an alternative cause were included in the analysis. Cases in the subgroup of patients who received treatment directed at pyoderma gangrenosum before receiving an alternative final diagnosis were classified as “misdiagnosed.”
Results
Ulcers Resembling Pyoderma Gangrenosum
Ulceration resembling pyoderma gangrenosum had alternative causes in 95 patients (49 from our institution and 46 described in the literature). The cause of ulceration fell into one of six disease categories (Table 1Table 1
Ulcers Resembling Pyoderma Gangrenosum.): vascular occlusive or venous disease (in 28 patients) (Figure 1Figure 1Ulceration Resembling Pyoderma Gangrenosum but Due to Antiphospholipid-Antibody Syndrome.), vasculitis (in 21 patients), a malignant process involving the skin (in 16 patients), primary infection (in 14 patients), drug-induced or exogenous tissue injury (in 13 patients), and other inflammatory disorders (in 3 patients). Eighty-six patients had skin biopsies. The initial or repeated biopsy demonstrated diagnostic histologic findings of the alternative diagnosis in 46 of the cases in which biopsies were performed (53 percent) (Table 2Table 2
Frequency of Diagnostic Findings on Initial or Repeated Biopsy.).Ulcers Misdiagnosed as Pyoderma Gangrenosum
A total of 64 of the 95 patients (67 percent) had received treatment directed at pyoderma gangrenosum before the establishment of an alternative diagnosis. Included among the 64 were 15 of the 157 consecutive patients treated for pyoderma gangrenosum between 1984 and 1992 at our institution (10 percent), among whom the mean duration of follow-up was 42 months. The median lag time between the initial diagnosis of pyoderma gangrenosum and a final diagnosis among these 64 patients was 10 months overall and varied among the disease categories (vascular occlusive or venous disease, 12 months; vasculitis, 15 months; cancer, 12 months; infection, 5 months; and exogenous tissue injury, 5 months).
Disorders classically associated with pyoderma gangrenosum — seropositive or seronegative rheumatoid arthritis, inflammatory bowel disease, paraproteinemia, and myeloproliferative disorders — were present in 31 patients overall (33 percent) and in 25 of the 64 patients who received a misdiagnosis of pyoderma gangrenosum (39 percent).
Of the 64 patients who had received treatment for pyoderma gangrenosum, it was clear that 23 (36 percent) had ulcers that were refractory to standard treatment directed at pyoderma gangrenosum (high-dose prednisone [≥1 mg per kilogram of body weight], with or without a corticosteroid-sparing agent [e.g., azathioprine, cyclosporine, or cyclophosphamide]), 8 (12 percent) had an exacerbation of the condition simulating pyoderma gangrenosum (infection or lymphoma), and 15 (23 percent) had a further delay in diagnosis (because of temporary improvement of vasculitis, antiphospholipid-antibody syndrome, or lymphoma) while they were receiving treatment for presumed pyoderma gangrenosum.
Discussion
We identified six broad disease categories that may simulate pyoderma gangrenosum. Vascular occlusive or venous disease, vasculitis, cancer, infection, exogenous tissue injury, and other inflammatory disorders should be specifically ruled out before a diagnosis of pyoderma gangrenosum is made.
In 1930, Brunsting et al.42 of the Mayo Clinic described five patients with rapidly progressive, painful, suppurative cutaneous ulcers with edematous, boggy, blue, undermined, and necrotic borders, which they called “pyoderma gangrenosum.” This condition falls in the spectrum of the neutrophilic dermatoses, inflammatory disorders that have in common a tendency for pathergy (induction of the inflammatory process after skin trauma) and the presence of noninfectious neutrophilic infiltrates of the skin. Pyoderma gangrenosum is associated with a number of specific diseases, including inflammatory bowel disease, paraproteinemia, arthritis, and myeloproliferative diseases. The pathogenesis of pyoderma gangrenosum is poorly understood, but neutrophil dysfunction (defects in chemotaxis or hyperreactivity)43 and overexpression of interleukin-844 and interleukin-1645,46 have been reported. These observations suggest that pyoderma gangrenosum represents an overreactive inflammatory response to traumatic, inflammatory, or neoplastic processes in susceptible persons.
Biopsy of an early lesion of pyoderma gangrenosum often demonstrates a dermal neutrophilic abscess. Later-stage lesions show epidermal necrosis and ulceration, superficial dermal edema, and a dense, mixed dermal infiltrate that may extend to the panniculus. Histologic examination of the advancing, inflamed border reveals dense perivascular lymphocytic inflammation, which may at times be associated with vascular destruction. None of these histologic features is pathognomonic.
No laboratory finding is diagnostic of pyoderma gangrenosum, but patients often have a neutrophilic leukocytosis and an elevated erythrocyte sedimentation rate. Because of the protean nature of these findings, laboratory investigation should focus on identifying associated diseases and excluding diseases that may simulate pyoderma gangrenosum (Table 3Table 3
Approach to the Patient with Suspected Pyoderma Gangrenosum.).We found a frequency of misdiagnosis of pyoderma gangrenosum of approximately 10 percent. However, because of referral bias, this estimate most likely exceeds the actual frequency, because many patients with apparently refractory or difficult cases of ulceration resembling pyoderma gangrenosum are referred to academic centers such as ours, whereas those who have cases that are easily treated are unlikely to be referred.
More than half the patients from this study who had biopsies had histopathological evidence of an alternative diagnosis on the initial or repeated biopsy. Although the rate of pathergy in patients with pyoderma gangrenosum is unknown, we propose that the need to rule out an alternative disease should override the fear of exacerbating the condition by performing a biopsy.
A substantial number of the patients we analyzed who were treated for pyoderma gangrenosum had ulcers that were refractory to treatment. These cases emphasize the need to reconsider the diagnosis of pyoderma gangrenosum when the condition fails to respond to standard treatment. Some patients had progression of the condition simulating pyoderma gangrenosum or had temporary improvement in the condition while they were receiving treatment for presumed pyoderma gangrenosum. Five patients died from overwhelming infection, and four died from progression of disease. The contribution of treatment directed at pyoderma gangrenosum to exacerbated illness or death in these cases cannot be determined.
Treatment directed at pyoderma gangrenosum can itself produce substantial complications, or it may adversely affect other causes of ulceration — for example, by promoting the progression of infection or lymphoma. It may also result in temporary improvement of disorders such as vasculitis, antiphospholipid-antibody syndrome, and lymphoma and thereby delay the diagnosis of these disorders.
Venous stasis ulcers are the most common cause of ulceration of the legs, are classically located on the medial aspects of the legs, and are markedly less painful than pyoderma gangrenosum. It is usually not difficult to distinguish clinically between stasis ulcers and pyoderma gangrenosum unless there is a complicating factor such as secondary bacterial infection, arterial insufficiency, or irritant or allergic contact dermatitis.
Antiphospholipid-antibody syndrome can produce exquisitely tender vascular occlusive ulcers that may clinically resemble pyoderma gangrenosum. Our study revealed that this syndrome is a highly problematic simulator of pyoderma gangrenosum because of the low specificity of histologic findings in patients with the syndrome and its frequent response to systemic corticosteroids. Indeed, less than one third of cases showed histologic evidence of a coagulopathy. Moreover, approximately 60 percent of patients had improvement with systemic corticosteroids — which accounted for the greater lag time before a final diagnosis in patients with antiphospholipid-antibody syndrome as compared with those with other causes of ulceration. In the absence of a lupus anticoagulant, ulceration resembling pyoderma gangrenosum is very unusual in patients with systemic lupus erythematosus. In a prospective study involving patients with systemic lupus erythematosus, 3 of the 33 patients who were positive for lupus anticoagulant had ulceration resembling pyoderma gangrenosum during a mean follow-up of 13.8 years (range, 5 to 22). In contrast, none of the 37 patients with systemic lupus erythematosus who were negative for lupus anticoagulant had such ulceration during a mean follow-up of 15.7 years (range, 7 to 25).47
Livedoid vasculopathy is a rare segmental, thrombo-occlusive disorder of postcapillary venules that results in exquisitely tender, slow-healing, purpuric ulcers that principally affect the legs. It is characterized histologically by superficial, pauci-immune perivascular inflammation, thrombosis, and intramural hyaline deposition.48,49 Acute inflammation due to secondary infection of ulcers related to livedoid vasculopathy may cause the condition to be confused with pyoderma gangrenosum, even on histologic analysis, as it did in two of the four cases of livedoid vasculopathy in our study.
Cutaneous ulceration is a common manifestation of several vasculitides. We found that, in the vasculitis category, Wegener's granulomatosis was the most frequent cause of pyoderma gangrenosum–like ulceration. Lesions resembling pyoderma gangrenosum and involving the head and neck — called “malignant pyoderma” by Perry et al.50 — are characterized by a more aggressive clinical course than that of common, nonfacial pyoderma gangrenosum. Subsequently, Gibson et al.51 showed that many cases of malignant pyoderma are actually a manifestation of Wegener's granulomatosis.
Patients with systemic or cutaneous polyarteritis nodosa may present with cutaneous ulcers that can progress rapidly and simulate pyoderma gangrenosum. Patients with polyarteritis nodosa may also have livedo reticularis in association with cutaneous nodules. The histopathology of polyarteritis nodosa is distinctive (medium- and small-vessel arteritis), but because of the segmental nature of vascular involvement, multiple biopsies may be required in order to establish the diagnosis. Cryoglobulinemic vasculitis may occur in type II (monoclonal plus polyclonal) or type III (polyclonal) cryoglobulinemia, revealing leukocytoclastic vasculitis on histopathological analysis.
Lymphoma cutis, leukemia cutis, and Langerhans'-cell histiocytosis were the malignant diseases that simulated pyoderma gangrenosum in our series. On the basis of histopathological features alone, such malignant diseases would appear to be the easiest to rule out. However, in some cases, a biopsy was not performed during the initial workup, or the initial biopsy results were nonspecific or were interpreted as consistent with a diagnosis of pyoderma gangrenosum. Thus, it is often necessary to obtain repeated biopsies when following patients suspected of having pyoderma gangrenosum. Six of the nine patients with diseases in this category who had been treated for presumed pyoderma gangrenosum died of progression of their disease or overwhelming infection. A few patients had temporary improvement of their ulcers with treatment directed at pyoderma gangrenosum (prednisone), which may have delayed the diagnosis of lymphoma.
In the category of primary cutaneous infection, deep fungal infection was the most frequent cause of pyoderma gangrenosum–like ulceration. In several of the cases, there was profound dermal neutrophilia, supporting a diagnosis of pyoderma gangrenosum. In a few of these cases, after tissue culture proved to be positive, special staining was performed retrospectively on the stored tissue and revealed the offending microorganism. In three of our cases, the perineum or perianal region was the site of involvement. Although pyoderma gangrenosum may rarely affect this region in adults, it appears to affect it more commonly in children.52-54
An important question regarding the patients given a final diagnosis of primary cutaneous infection is whether infection was indeed the primary cause of ulceration, because infection could occur as a complication of pyoderma gangrenosum, as a result of a compromised skin barrier and immunosuppression. However, after targeted antimicrobial therapy was started and treatment directed at pyoderma gangrenosum was discontinued, the ulcers healed in 8 of 11 patients with such infections who were being treated for pyoderma gangrenosum. The three other patients died from complications related to their illness.
Not surprisingly, biopsy was not helpful in ruling out exogenous causes of ulceration, because these tissue injuries are not characterized by specific histopathological findings. Self-induced ulceration (Munchausen's syndrome and factitial ulceration) was the most common diagnosis in this category.
In conclusion, our data indicate that the misdiagnosis of pyoderma gangrenosum is not uncommon (as high as 10 percent) and that it exposes patients to substantial risks associated with its treatment (exacerbation or delay in diagnosis of an alternative disease process in 36 percent of patients erroneously treated for pyoderma gangrenosum). A thorough workup (including biopsy) is required in all patients suspected of having pyoderma gangrenosum in order to rule out diagnoses that mimic pyoderma gangrenosum. Close long-term follow-up and reappraisal of the diagnosis (with repeated biopsy if indicated) are recommended for all patients with suspected pyoderma gangrenosum, even patients with a response to treatment or with coexisting conditions typically associated with pyoderma gangrenosum.
Presented in part at the 10th annual meeting of the European Academy of Dermatology and Venereology, Munich, Germany, October 10–14, 2001.
Source Information
From the Department of Dermatology, Mayo Clinic, 200 First St., SW, Rochester, MN 55905, where reprint requests should be addressed to Dr. Davis.
- References
References
1
Schlesinger IH ,Farber GA . Cutaneous ulceration resembling pyoderma gangrenosum in the primary antiphospholipid syndrome: a report of two additional cases and review of the literature. J La State Med Soc 1995;147:357-361
Medline2
Schmid MH ,Hary C ,Marstaller B ,Konz B ,Wendtner CM . Pyoderma gangrenosum associated with the secondary antiphospholipid syndrome. Eur J Dermatol 1998;8:45-47
Web of Science | Medline3
Babe KS Jr ,Gross AS ,Leyva WH ,King LE Jr . Pyoderma gangrenosum associated with antiphospholipid antibodies. Int J Dermatol 1992;31:588-590
CrossRef | Web of Science | Medline4
Freedman AM ,Phelps RG ,Lebwohl M . Pyoderma gangrenosum associated with anticardiolipin antibodies in a pregnant patient. Int J Dermatol 1997;36:205-207
CrossRef | Web of Science | Medline5
Chacek S ,MacGregor-Gooch J ,Halabe-Cherem J ,Nellen-Hummel H ,Quinones-Galvan A . Pyoderma gangrenosum and extensive caval thrombosis associated with the antiphospholipid syndrome -- a case report. Angiology 1998;49:157-160
CrossRef | Web of Science | Medline6
Grob JJ ,Bonerandi JJ . Cutaneous manifestations associated with the presence of the lupus anticoagulant: a report of two cases and a review of the literature. J Am Acad Dermatol 1986;15:211-219
CrossRef | Web of Science | Medline7
Selva A ,Ordi J ,Roca M ,Huguet P ,Castells-Rodellas A ,Vilardell M . Pyoderma-gangraenosum-like ulcers associated with lupus anticoagulant. Dermatology 1994;189:182-184
CrossRef | Web of Science | Medline8
White JC ,Adam BA ,Lau KS ,Horne RW ,Parkhouse RM . Cryoimmunoglobulin IgGκ with microtubular ultrastructure associated with pyoderma gangrenosum. J Pathol 1976;120:25-33
CrossRef | Web of Science | Medline9
Scheinman PL . Klippel-Trenaunay-Weber syndrome mimicking pyoderma gangrenosum. Int J Dermatol 1995;34:717-719
CrossRef | Web of Science | Medline10
Micali G ,Cook B ,Ronan S ,Yadgir J ,Solomon LM . Cephalic pyoderma gangrenosum (PG)-like lesions as a presenting sign of Wegener's granulomatosis. Int J Dermatol 1994;33:477-480
CrossRef | Web of Science | Medline11
Handfield-Jones SE ,Parker SC ,Fenton DA ,Newton JA ,Greaves MW . Wegener's granulomatosis presenting as pyoderma gangrenosum. Clin Exp Dermatol 1992;17:197-200
CrossRef | Web of Science | Medline12
Thomas RH ,Payne CM ,Black MM . Wegener's granulomatosis presenting as pyoderma gangrenosum. Clin Exp Dermatol 1982;7:523-527
CrossRef | Web of Science | Medline13
Smith JB ,Shenefelt PD ,Soto O ,Valeriano J . Pyoderma gangrenosum in a patient with cryoglobulinemia and hepatitis C successfully treated with interferon alfa. J Am Acad Dermatol 1996;34:901-903
CrossRef | Web of Science | Medline14
Perniciaro CV ,Winkelmann RK ,Hunder GG . Cutaneous manifestations of Takayasu's arteritis: a clinicopathologic correlation. J Am Acad Dermatol 1987;17:998-1005
CrossRef | Web of Science | Medline15
Frances C ,Boisnic S ,Bletry O , et al. Cutaneous manifestations of Takayasu arteritis: a retrospective study of 80 cases. Dermatologica 1990;181:266-272
CrossRef | Medline16
Thomas R ,Vuitch F ,Lakhanpal S . Angiocentric T cell lymphoma masquerading as cutaneous vasculitis. J Rheumatol 1994;21:760-762
Web of Science | Medline17
Camisa C ,Helm TN ,Sexton C ,Tuthill R . Ki-1-positive anaplastic large-cell lymphoma can mimic benign dermatoses. J Am Acad Dermatol 1993;29:696-700
CrossRef | Web of Science | Medline18
Ho KK ,Browne A ,Fitzgibbons J ,Carney D ,Powell FC . Mycosis fungoides bullosa simulating pyoderma gangrenosum. Br J Dermatol 2000;142:124-127
CrossRef | Web of Science | Medline19
Kitahama A ,Roland PY ,Kerstein MD . Pyoderma gangrenosum with cutaneous T-cell lymphoma manifested as lower extremity ulcers -- case reports. Angiology 1991;42:498-503
CrossRef | Web of Science | Medline20
Vose JM ,Armitage JO ,Duggan M ,Braddock SW . Pyoderma gangrenosum or cutaneous lymphoma: a difficult clinical diagnosis. Cutis 1988;42:335-337
Web of Science | Medline21
Helm KF ,Peters MS ,Tefferi A ,Leiferman KM . Pyoderma gangrenosum-like ulcer in a patient with large granular lymphocytic leukemia. J Am Acad Dermatol 1992;27:868-871
CrossRef | Web of Science | Medline22
Torok L ,Kirschner A ,Gurzo M ,Krenacs L . Bullous pyoderma gangrenosum as a manifestation of leukemia cutis. Eur J Dermatol 2000;10:463-465
Web of Science | Medline23
Norris JF ,Marshall TL ,Byrne JP . Histiocytosis X in an adult mimicking pyoderma gangrenosum. Clin Exp Dermatol 1984;9:388-392
CrossRef | Web of Science | Medline24
Stroud JD . Sporotrichosis presenting as pyoderma gangrenosum. Arch Dermatol 1968;97:667-670
CrossRef | Web of Science | Medline25
Liao WQ ,Zang YL ,Shao JZ . Sporotrichosis presenting as pyoderma gangrenosum. Mycopathologia 1991;116:165-168
CrossRef | Web of Science | Medline26
Spiers EM ,Hendrick SJ ,Jorizzo JL ,Solomon AR . Sporotrichosis masquerading as pyoderma gangrenosum. Arch Dermatol 1986;122:691-694
CrossRef | Web of Science | Medline27
Lesher JL Jr ,Fitch MH ,Dunlap DB . Subclinical hypothyroidism during potassium iodide therapy for lymphocutaneous sporotrichosis. Cutis 1994;53:128-130
Web of Science | Medline28
Harmon CB ,Su WP ,Peters MS . Cutaneous aspergillosis complicating pyoderma gangrenosum. J Am Acad Dermatol 1993;29:656-658
CrossRef | Web of Science | Medline29
Massa MC ,Doyle JA . Cutaneous cryptococcosis simulating pyoderma gangrenosum. J Am Acad Dermatol 1981;5:32-36
CrossRef | Web of Science | Medline30
Liao WQ ,Yao ZR ,Li ZQ ,Xu H ,Zhao J . Pyoderma gangrenosum caused by Rhizopus arrhizus. Mycoses 1995;38:75-77
CrossRef | Web of Science | Medline31
Chiewchanvit S ,Mahanupab P ,Baosoung V ,Khamwan C . Uncommon manifestations of opportunistic infections in an HIV infected patient. J Med Assoc Thai 1998;81:923-926
Medline32
Brown TS ,Callen JP . Atypical presentation of herpes simplex virus in a patient with chronic lymphocytic leukemia. Cutis 1999;64:123-125
Web of Science | Medline33
Wahba A ,Cohen HA . Herpes simplex virus isolation from pyoderma gangrenosum lesions in a patient with chronic lymphatic leukemia. Dermatologica 1979;158:373-378
CrossRef | Medline34
Matsui M ,Ohtoshi E ,Yamaoka J , et al. Cutaneous tuberculosis and pyoderma gangrenosum. Int J Dermatol 2000;39:38-40
CrossRef | Web of Science | Medline35
Sunarwan I . A case of cutaneous amoebiasis. Dermatologica 1975;151:253-256
CrossRef | Medline36
Parent DJ ,Krafft T ,Noel JC , et al. Cutaneous Munchausen syndrome with presentation simulating pyoderma gangrenosum. J Am Acad Dermatol 1994;31:1072-1074
CrossRef | Web of Science | Medline37
Barrett AP ,Buckley DJ . Covert self-mutilation of oral tissues and skin by mechanical and chemical means. Oral Surg Oral Med Oral Pathol 1988;65:685-688
CrossRef | Medline38
David M ,Ingber A ,Sandbank M ,Feuerman J . Bromoderma caused by carbromalhydroxyzine hydrochloride. Biomed Pharmacother 1983;37:298-300
Web of Science | Medline39
Rees RS ,Fields JP ,King LE Jr . Do brown recluse spider bites induce pyoderma gangrenosum? South Med J 1985;78:283-287
CrossRef | Web of Science | Medline40
Hoover EL ,Williams W ,Koger L ,Murthy R ,Parsh S ,Weaver WL . Pseudoepitheliomatous hyperplasia and pyoderma gangrenosum after a brown recluse spider bite. South Med J 1990;83:243-246
CrossRef | Web of Science | Medline41
Peterson LL . Hydralazine-induced systemic lupus erythematosus presenting as pyoderma gangrenosum-like ulcers. J Am Acad Dermatol 1984;10:379-384
CrossRef | Web of Science | Medline42
Brunsting LA ,Goeckerman WH ,O'Leary PA . Pyoderma (echthyma) gangrenosum: clinical and experimental observations in 5 cases occurring in adults. Arch Dermatol Syph 1930;22:655-680
Web of Science43
Adachi Y ,Kindzelskii AL ,Cookingham G , et al. Aberrant neutrophil trafficking and metabolic oscillations in severe pyoderma gangrenosum. J Invest Dermatol 1998;111:259-268
CrossRef | Web of Science | Medline44
Oka M ,Berking C ,Nesbit M , et al. Interleukin-8 overexpression is present in pyoderma gangrenosum ulcers and leads to ulcer formation in human skin xenografts. Lab Invest 2000;80:595-604
Web of Science | Medline45
Lindor NM ,Arsenault TM ,Solomon H ,Seidman CE ,McEvoy MT . A new autosomal dominant disorder of pyogenic sterile arthritis, pyoderma gangrenosum, and acne: PAPA syndrome. Mayo Clin Proc 1997;72:611-615
CrossRef | Web of Science | Medline46
Yeon HB ,Lindor NM ,Seidman JG ,Seidman CE . Pyogenic arthritis, pyoderma gangrenosum, and acne syndrome maps to chromosome 15q. Am J Hum Genet 2000;66:1443-1448
CrossRef | Web of Science | Medline47
Stephansson EA ,Niemi KM ,Jouhikainen T ,Vaarala O ,Palosuo T . Lupus anticoagulant and the skin: a longterm follow-up study of SLE patients with special reference to histopathological findings. Acta Derm Venereol 1991;71:416-422
Web of Science | Medline48
Papi M ,Didona B ,De Pita O , et al. Livedo vasculopathy vs small vessel cutaneous vasculitis: cytokine and platelet P-selectin studies. Arch Dermatol 1998;134:447-452
CrossRef | Web of Science | Medline49
Maessen-Visch MB ,Koedam MI ,Hamulyak K ,Neumann HA . Atrophie blanche. Int J Dermatol 1999;38:161-172
CrossRef | Web of Science | Medline50
Perry HO ,Winkelmann RK ,Muller SA ,Kierland RR . Malignant pyodermas. Arch Dermatol 1968;98:561-576
CrossRef | Web of Science | Medline51
Gibson LE ,Daoud MS ,Muller SA ,Perry HO . Malignant pyodermas revisited. Mayo Clin Proc 1997;72:734-736
CrossRef | Web of Science | Medline52
Burgess NA ,Lari JL . Pyoderma gangrenosum with large circumferential perianal skin loss in a child. Br J Clin Pract 1991;45:223-224
Medline53
al-Rimawi HS ,Abuekteish FM ,Daoud AS ,Oboosi MM . Familial pyoderma gangrenosum presenting in infancy. Eur J Pediatr 1996;155:759-762
CrossRef | Web of Science | Medline54
Graham JA ,Hansen KK ,Rabinowitz LG ,Esterly NB . Pyoderma gangrenosum in infants and children. Pediatr Dermatol 1994;11:10-17
CrossRef | Web of Science | Medline
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Jaymie Panuncialman, Vincent Falanga. (2010) Unusual Causes of Cutaneous Ulceration. Surgical Clinics of North America 90:6, 1161-1180
CrossRef12
Claas H. Hinze, Anne W. Lucky, Kevin E. Bove, Rebecca A. Marsh, Jack H. Bleesing, Murray H. Passo. (2010) Leukocyte Adhesion Deficiency Type 1 Presenting with Recurrent Pyoderma Gangrenosum and Flaccid Scarring. Pediatric Dermatology 27:5, 500-503
CrossRef13
Michael V. Schintler, Martin Grohmann, Claudio Donia, Elisabeth Aberer, Erwin Scharnagl. (2010) Management of an unfortunate triad after breast reconstruction: Pyoderma gangrenosum, full-thickness chest wall defect and Acinetobacter Baumannii Infection. Journal of Plastic, Reconstructive & Aesthetic Surgery 63:7, e564-e567
CrossRef14
Benjamin D. Ehst, Karen Minzer-Conzetti, Amy Swerdlin, Theresa Schroeder Devere. (2010) Cutaneous Manifestations of Internal Malignancy. Current Problems in Surgery 47:5, 384-445
CrossRef15
Neil Cox, J. L. Jorizzo, J. F. Bourke, C. O. S. Savage. 2010. Vasculitis, Neutrophilic Dermatoses and Related Disorders. , 1-95.
CrossRef16
Gert Van Assche, Axel Dignass, Walter Reinisch, C. Janneke van der Woude, Andreas Sturm, Martine De Vos, Mario Guslandi, Bas Oldenburg, Iris Dotan, Philippe Marteau, Alessandro Ardizzone, Daniel C. Baumgart, Geert D'Haens, Paolo Gionchetti, Francisco Portela, Boris Vucelic, Johan Söderholm, Johanna Escher, Sibylle Koletzko, Kaija-Leena Kolho, Milan Lukas, Christian Mottet, Herbert Tilg, Séverine Vermeire, Frank Carbonnel, Andrew Cole, Gottfried Novacek, Max Reinshagen, Epameinondas Tsianos, Klaus Herrlinger, Bas Oldenburg, Yoram Bouhnik, Ralf Kiesslich, Eduard Stange, Simon Travis, James Lindsay. (2010) The second European evidence-based Consensus on the diagnosis and management of Crohn's disease: Special situations. Journal of Crohn's and Colitis 4:1, 63-101
CrossRef17
N. H. Cox, I. H. Coulson. 2010. , 1.
CrossRef18
Magdolna Lőrincz, Miklós Kleszky, Tibor Szalóki ., Tibor Szalóki. (2010) Refrakter pyoderma gangraenosum sikeres visilizumabkezelése colitis ulcerosás betegben. Orvosi Hetilap 151:4, 144-147
CrossRef19
Ioannis Protopsaltis, Angeliki Angelidi, Haralampos Milionis, Ioannis Katsantonis, Paraskevi Gavra, Adamantia Zizi-Sermpetzoglou, Despina Perimeni, Nikolaos Paschalidis. (2009) More Than Skin Deep. The American Journal of Medicine 122:9, 830-832
CrossRef20
C. Ferrandiz-Pulido, R. Bartralot, M. J. Fuente, C. Heras, P. Bassas, G. Aparicio, D. Bodet, J. Mollet, M. T. Tortola, V. Garcia-Patos. (2009) Postoperative pyoderma gangrenosum: diagnostic value of 16s ribosomal RNA sequencing and review of the literature. Clinical and Experimental Dermatology 34:5, 598-602
CrossRef21
Keira L. Barr, Hardeep K. Chhatwal, Stanton K. Wesson, Indraneel Bhattacharyya, Vladimir Vincek. (2009) Pyoderma gangrenosum masquerading as necrotizing fasciitis. American Journal of Otolaryngology 30:4, 273-276
CrossRef22
Giovanni Mariscalco, Gabriele Piffaretti, Sandro Ferrarese, Matteo Tozzi, Paolo Cattaneo, Andrea Sala. (2009) Rare Complication after Cardiac Surgery: A Case Report of Pyoderma Gangrenosum. Journal of Cardiac Surgery 24:1, 93-97
CrossRef23
JiHun Kim, Sung-Hoon Park, Seong-Kyu Kim, Jung-Yoon Choe. (2009) Infected Pyoderma Gangrenosum in Behçet's Disease. The Journal of the Korean Rheumatism Association 16:1, 64
CrossRef24
Roger H. Weenig, Khosrow Mehrany. (2008) Dermal and Pannicular Manifestations of Internal Malignancy. Dermatologic Clinics 26:1, 31-43
CrossRef25
D.L. Cummins, G.J. Anhalt, T. Monahan, J.H. Meyerle. (2007) Treatment of pyoderma gangrenosum with intravenous immunoglobulin. British Journal of Dermatology 157:6, 1235-1239
CrossRef26
M. Oka. (2007) Pyoderma gangrenosum and interleukin 8. British Journal of Dermatology 157:6, 1279-1281
CrossRef27
Jeffrey P. Callen, J. Mark Jackson. (2007) Pyoderma Gangrenosum: An Update. Rheumatic Disease Clinics of North America 33:4, 787-802
CrossRef28
Philip Seo. (2007) Pregnancy and Vasculitis. Rheumatic Disease Clinics of North America 33:2, 299-317
CrossRef29
Walid Hadid, Pritesh Patel, Warren W. Piette. (2007) After the Injury. The American Journal of Medicine 120:2, 140-142
CrossRef30
Peter U. Kalu, Greg Williams. (2007) Scalding as an unusual cause of pyoderma gangrenosum. Burns 33:1, 105-108
CrossRef31
A. P. Ruhl, J. E. Ganz, S. J. Bickston. (2007) Neutrophilic Folliculitis and the Spectrum of Pyoderma Gangrenosum in Inflammatory Bowel Disease. Digestive Diseases and Sciences 52:1, 18-24
CrossRef32
Mark D. Hoffman. (2007) Inflammatory ulcers. Clinics in Dermatology 25:1, 131-138
CrossRef33
Jaymie Panuncialman, Vincent Falanga. (2006) Basic approach to inflammatory ulcers. Dermatologic Therapy 19:6, 365-376
CrossRef34
J Mark Jackson, Jeffrey P Callen. (2006) Pyoderma gangrenosum: an expert commentary. Expert Review of Dermatology 1:3, 391-400
CrossRef35
PEDRO LLORET, PEDRO REDONDO, ALEJANDRO SIERRA, JUAN CABRERA. (2006) Mixed Skin Ulcers Misdiagnosed as Pyoderma Gangrenosum and Rheumatoid Ulcer: Successful Treatment With Ultrasound-Guided Injection of Polidocanol Microfoam. Dermatologic Surgery 32:5, 749-752
CrossRef36
AE Costa Franca, LK Braga Salvino, SH Rodrigues Leite, JG Paraiso Ferraz, TD Santos Rocha, ML Cintra, PE Neves Velho, EM Souza. (2006) Pyoderma gangrenosum as first clinical manifestation of gastric adenocarcinoma. Journal of the European Academy of Dermatology and Venereology 20:4, 440-441
CrossRef37
Jeffrey A. Niezgoda, E Bernadette Cabigas, Heidi K. Allen, John P. Simanonok, Eric P. Kindwall, James Krumenauer. (2006) Managing Pyoderma Gangrenosum: A Synergistic Approach Combining Surgical D??bridement, Vacuum-Assisted Closure, and Hyperbaric Oxygen Therapy. Plastic and Reconstructive Surgery 117:2, 24e-28e
CrossRef38
2006. Necrotic Skin Lesion. , 102-103.
CrossRef39
Sinead M. Langan, Frank C. Powell. (2005) Vegetative pyoderma gangrenosum: a report of two new cases and a review of the literature. International Journal of Dermatology 44:8, 623-629
CrossRef40
R. P. Kiran, B. O'Brien-Ermlich, J. P. Achkar, V. W. Fazio, C. P. Delaney. (2005) Management of Peristomal Pyoderma Gangrenosum. Diseases of the Colon & Rectum 48:7, 1397-1403
CrossRef41
Curdin Conrad, Ralph M. Trueb. (2005) Pyoderma gangrenosum. Pyoderma gangraenosum. Journal der Deutschen Dermatologischen Gesellschaft 3:5, 334-342
CrossRef42
C. C. Y. Oh, D. B. McKenna, K. M. McLaren, M. J. Tidman. (2005) Factitious panniculitis masquerading as pyoderma gangrenosum. Clinical and Experimental Dermatology 30:3, 253-255
CrossRef43
JE Herrero, JM Mascaro, A Llambrich, C Herrero. (2005) Sarcoidosis and pyoderma gangrenosum: an exceptional association. The role of trauma and immunosuppressive agents. Journal of the European Academy of Dermatology and Venereology 19:1, 97-99
CrossRef44
W. P. Daniel Su, Mark D. P. Davis, Roger H. Weenig, Frank C. Powell, Harold O. Perry. (2004) Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria. International Journal of Dermatology 43:11, 790-800
CrossRef45
Angela Ehling, Sigrid Karrer, Frank Klebl, Andreas Sch
ffler, Ulf M
CrossRef46
Cathy Thomas Hess, Jennifer T. Trent. (2004) Incorporating Laboratory Values in Chronic Wound Management. Advances in Skin & Wound Care 17:7, 378-386
CrossRef47
Bill Newman, David Cescon, Adam Domenchini, Katherine A. Siminovitch. (2004) CD2BP1 and CARD15 Mutations Are Not Associated with Pyoderma Gangrenosum in Patients with Inflammatory Bowel Disease. Journal of Investigative Dermatology 122:4, 1054-1056
CrossRef48
J. Margaret Moresi. (2004) Neutrophilic Dermatoses. Pathology Case Reviews 9:2, 46-54
CrossRef49
Eddys Disla, Bhasit Quayum, Girolamo G. Cuppari, Roberto Pancorbo. (2004) Successful Use of Etanercept in a Patient With Pyoderma Gangrenosum Complicating Rheumatoid Arthritis. JCR: Journal of Clinical Rheumatology 10:1, 50-52
CrossRef50
G. K. Isbister, I. M. Whyte. (2004) Suspected white-tail spider bite and necrotic ulcers. Internal Medicine Journal 34:1-2, 38-44
CrossRef51
Carolyn V. Gould, Victoria P. Werth, Stephen J. Gluckman. (2004) Fatal Disseminated Mycobacterium marinum Infection With Bacteremia in a Patient Misdiagnosed as Pyoderma Gangrenosum. Infectious Diseases in Clinical Practice 12:1, 26-29
CrossRef52
Richard S Vetter, Paula E Cushing, Rodney L Crawford, Lynn A Royce. (2003) Diagnoses of brown recluse spider bites (loxoscelism) greatly outnumber actual verifications of the spider in four western American states. Toxicon 42:4, 413-418
CrossRef53
Richard S. Vetter. (2003) Brown Recluse Spider Bite Diagnoses and Lawsuits. Pediatric Emergency Care 19:4, 291-292
CrossRef54
J. Arnout, J. Vermylen. (2003) Current status and implications of autoimmune antiphospholipid antibodies in relation to thrombotic disease. Journal of Thrombosis and Haemostasis 1:5, 931-942
CrossRef55
Irwin M. Braverman. (2003) Skin signs of gastrointestinal disease1 1Abbreviations used in this paper: AVM, arteriovenous fistulae and malformations; HHT, hereditary hemorrhagic telangiectasia.. Gastroenterology 124:6, 1595-1614
CrossRef56
(2003) Skin Ulcers Misdiagnosed as Pyoderma Gangrenosum. New England Journal of Medicine 348:11, 1064-1066
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