Issn Print: 0148-7043

Publication Date: 2002/05/01


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Invited Discussion

Mark S. Granick; Takkin Lo

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Excerpt

Plastic surgeons have long been interested in the surgical management of wounds. It has only been during the past few years that the medical community’s awareness of wounds has been heightened. This may be the result of the influx of marketing money along with the advent of biologically active wound treatments. Regardless, wound-healing centers have sprouted up all over the country. At all of these sites, pyoderma gangrenosum (PG) has been one of the most perplexing problems. The article entitled “Pyoderma Gangrenosum: A Great Marauder” (Ann Plast Surg 2002;48:546–552) by Drs Ma and colleagues is an interesting example of an unusual presentation of PG. Their review of the subject is quite thorough. It is important that the reader comes away with a feeling of the obscure and variable nature of PG. Another name for this article could have been “PG: The Great Masquerader.”
A high index of suspicion is the key to diagnosis. The wounds typically are painful, angry-looking lesions that present most commonly on the legs (Fig). The ulcers can also present on the trunk, as in the article by Ma and colleagues, or even on the face. Biopsies demonstrate inflammation but have no pathognomonic signs. Approximately half the patients have an associated systemic disease, most commonly ulcerative colitis. The ulcers can be confused easily with necrotizing infections, granulomatous disease, vasculitis, primary or metastatic tumor, factitious ulceration, and so forth. When in doubt, think PG.
Patients often have a long course of random and ineffectual treatment before presentation. There needs to be a multiprong approach to the successful treatment of PG. Treatment options should be aimed at curbing the uncontrolled proliferative activity of the leukocytes, such as the rolling and adhesive effect of neutrophils when activated, reducing the inflammatory insult to the local tissue, and stimulating adequate angiogenesis for proper healing. Surgery is of limited value alone. It is difficult to obtain a stable, surgically healed wound without long-term control of the associated medical problems. 1 Optimal management consists of stabilization of any underlying systemic disease, topical and parenteral steroids, and hyperbaric oxygen treatment. Hyperbaric oxygen therapy can reverse the local hypoxic wound environment via its hyperoxygenation effect. In addition, it can enhance the oxidative “burst killing” of bacteria by the neutrophils, as well as the fibroblastic proliferation and ultimate granulation deposition to the wound. Refractory patients can respond to immunosuppressive agents.
Certainly, in our experience dealing as consultants to numerous wound centers, PG has been the most consistently overlooked diagnosis in the most perplexing patients. Although it is important to rule out other more readily treatable disease entities, do not forget about PG.
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