A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy.

BACKGROUND: Post-surgical pyoderma gangrenosum (PSPG) presents as a rapidly expanding cutaneous ulcer at a site of surgery with potentially devastating consequences. We systematically reviewed the English and foreign language literature to identify risk factors for PSPG and propose a management strategy. METHODS: A systematic review was completed in PubMed, Medline, Embase, and Cochrane Database for all published reports of PSPG from January 1946 to June 2013. We manually examined bibliographies for relevant references and used Google Translate for articles in foreign languages, including Italian, Japanese, German, Dutch, Turkish, Spanish, Chinese, Dutch, Russian, Portuguese, and Czech. RESULTS: We identified 220 cases of PSPG (mean age 52.8 years, range 5-85 years). Thirty-seven patients (16.8%) had a history of pyoderma gangrenosum, nineteen (8.6%) had a hematologic disorder such as leukemia or lymphoma, thirteen (5.9%) had inflammatory bowel disease, and eight (3.6%) had rheumatoid arthritis. PSPG occurred most commonly after breast (25%), cardiothoracic (14%), abdominal (14%), and obstetric (13%) surgeries. The most common breast procedures were bilateral reduction mammoplasty (45%), breast reconstruction (25%), and lumpectomy or mastectomy (11%). Signs of wound complication occurred on average 7.0 days after surgery. Nineteen patients (8.6%) at risk for PSPG received perioperative corticosteroids during skin grafting or later surgeries with a favorable outcome. CONCLUSIONS: Patients with a history of pyoderma gangrenosum, rheumatoid arthritis, inflammatory bowel disease, or hematologic malignancy who are undergoing breast, cardiothoracic, or abdominal surgeries should be carefully observed for post-operative ulceration at incision sites. Debridement should not be performed before dermatologic consultation to assess for PSPG. Patients at risk of PSPG undergoing breast surgery may benefit from perioperative prednisone to prevent PSPG which can lead to destructive wound enlargement and significant scarring.

Efficacy of topical calcineurin inhibitors in vitiligo.

Topical tacrolimus and pimecrolimus are indicated for the treatment of atopic dermatitis, but they have been studied in many off-label uses. We reviewed the English language literature to define their roles in treatment of vitiligo. Double-blind studies show that tacrolimus 0.1% ointment combined with excimer laser is superior to placebo, especially for UV resistant areas, such as bony prominences of the extremities. When used alone, tacrolimus 0.1% ointment is almost as effective as clobetasol propionate 0.05% ointment. Other studies suggest it can also be effective for facial lesions. Double blind studies show that pimecrolimus 1% cream combined with narrow band UVB is superior to placebo, especially for facial lesions. Additional studies would further clarify the role of topical calcineurin inhibitors in vitiligo.

Efficacy of topical calcineurin inhibitors in lichen planus.

BACKGROUND: Topical calcineurin inhibitors have been studied in many skin disorders, including lichen planus. OBJECTIVE: To evaluate published reports of the use of topical calcineurin inhibitors in lichen planus. METHODS: We searched PubMed, Ovid/Cochrane, and Embase using the keywords "tacrolimus," "pimecrolimus," "topical calcineurin inhibitors," and "lichen planus. " RESULTS: We examined 5 double-blind studies, 1 investigator-blinded study, 10 open prospective studies, 6 retrospective studies, and 28 case reports evaluating tacrolimus or pimecrolimus for oral, vulvovaginal, and cutaneous lichen planus. CONCLUSIONS: Strong evidence (double-blind and open studies) supports the use of topical tacrolimus ointment in oral lichen planus, with efficacy at least equal to topical clobetasol propionate 0.05% ointment. Treatment of oral lichen planus with topical tacrolimus ointment can result in demonstrable blood tacrolimus levels, but without clinically significant adverse events. Strong evidence (double-blind and open studies) supports the use of topical pimecrolimus 1% cream in oral lichen planus, with efficacy equal to that of topical triamcinolone acetonide 0.1% paste. For vulvovaginal lichen planus, pimecrolimus was superior to placebo in one double-blind study, and tacrolimus was effective in open studies. Only case reports support the efficacy of topical calcineurin inhibitors in cutaneous lichen planus.

Pseudomonas skin infection: clinical features, epidemiology, and management.

Pseudomonas aeruginosa is a Gram-negative bacillus that is most frequently associated with opportunistic infection, but which can also present in the otherwise healthy patient. The range of P. aeruginosa infections varies from localized infections of the skin to life-threatening systemic disease. Many P. aeruginosa infections are marked by characteristic cutaneous manifestations. The aim of this article is to provide a comprehensive synthesis of the current knowledge of cutaneous manifestations of P. aeruginosa infection with specific emphasis on clinical features and management. The ability of P. aeruginosa to rapidly acquire antibacterial resistance is an increasingly well recognized phenomenon, and the correct application of antipseudomonal therapy is therefore of the utmost importance. A detailed discussion of currently available anti-pseudomonal agents is included, and the benefits of antimicrobial combination therapy versus monotherapy are explored. Rapid clinical recognition of P. aeruginosa infection aided by the identification of characteristic cutaneous manifestations can play a critical role in the successful management of potentially life-threatening disease.

Innovative use of topical calcineurin inhibitors.

Topical tacrolimus and pimecrolimus are indicated for treatment of atopic dermatitis, but they have been studied in many off-label uses. Double-blind and open studies have shown favorable results with topical tacrolimus and pimecrolimus in oral lichen planus. In 1 study of oral lichen planus, blood tacrolimus was detected in 54% of patients, but there were no signs of systemic toxicity. Double-blind and open studies of vitiligo have shown favorable results with tacrolimus in combination with excimer laser, especially for lesions over bony prominences and on extremities. Similarly, double-blind studies of vitiligo have shown favorable results when pimecrolimus is combined with narrow-band UVB, especially for facial lesions. Double-blind and open studies of psoriasis have shown favorable results for tacrolimus and pimecrolimus, especially for inverse psoriasis. Topical calcineurin inhibitors have been effective in many other cutaneous disorders, and further studies would help clarify their roles.

Use of pimecrolimus cream in disorders other than atopic dermatitis.

BACKGROUND: Pimecrolimus is indicated for treatment of atopic dermatitis and has been evaluated in many other disorders. OBJECTIVE: To review the efficacy of pimecrolimus in treatment of disorders other than atopic dermatitis. METHODS: We performed a PubMed search of the English-language literature using the key word "pimecrolimus." We reviewed articles reporting the use of pimecrolimus in disorders other than atopic dermatitis and classified them by the type of study used to evaluate efficacy. RESULTS: Randomized, double-blind studies have shown that pimecrolimus is superior to vehicle in treatment of seborrheic dermatitis, hand dermatitis, and asteatotic eczema but have yielded conflicting results regarding intertriginous psoriasis and vitiligo. Open-label studies involving four or more patients have shown favorable results in many disorders, including contact dermatitis, rosacea, lichen sclerosus, and oral and genital lichen planus. Case reports have shown that topical pimecrolimus may be useful in cutaneous graft-versus-host disease, lichen striatus, cutaneous lichen planus, and many other disorders. CONCLUSIONS: Topical pimecrolimus appears to be an effective treatment for many disorders other than atopic dermatitis, especially seborrheic dermatitis, hand dermatitis, and asteatoic eczema. It may be effective in many other disorders, but its role in these disorders remains to be clarified by additional studies.

Imipramine-induced facial pigmentation: case report and literature review.

BACKGROUND: Patients who present with facial pigmentation can be a diagnostic challenge. OBJECTIVE: The goal of this study was to discuss the diagnosis and management of imipramine-induced facial pigmentation. METHODS: We describe a patient with facial pigmentation of 26 years' duration that was associated with imipramine treatment for depression. We discuss light and election microscopic findings and review 11 previously reported cases of imipramine-induced skin pigmentation. RESULTS: Examination showed blue-gray facial pigmentation. Light microscopy showed perivascular pigment granule deposits in the upper dermis that stained positively with Fontana-Masson stain and negatively with Prussian blue stain. Electron microscopy showed electron-dense bodies within histiocytes without clearly identifiable melanin granules, consistent with drug-induced pigmentation. Six weeks after switching to sertraline the patient reported a slight improvement of her cutaneous pigmentation. CONCLUSION: Imipramine is a rare cause of gray-blue facial pigmentation. Light microscopy consistently shows granular dermal deposits that stain positively with Fontana-Masson stain but negatively with iron stain.

Squamous cell carcinoma in recessive dystrophic epidermolysis bullosa, presenting as an ulcer that appears to be filled with granulation tissue.

BACKGROUND: Cutaneous squamous cell carcinoma (SCCA) is an important cause of death in patients with the severe form of recessive dystrophic epidermolysis bullosa (RDEB). These cancers often present with features that are different from those of actinically induced SCCA. OBJECTIVE: To emphasize the unusual features with which SCCA can present in RDEB and discuss early recognition of such cancers. METHODS: We present the case of a patient with RDEB who developed a cutaneous ulcer that appeared to be filled with heaped-up granulation tissue. Biopsy, however, showed moderately differentiated squamous cell carcinoma. RESULTS: The patient underwent wide surgical excision of the cancer, with split-thickness skin graft. She has remained disease-free three years later. CONCLUSION: In patients with RDEB, any ulcer that appears to be filled with heaped-up granulation tissue should be biopsied to rule out SCCA.