Trauma, sometimes from surgery for Crohn's, brings a skin condition known as parastomal pyoderma gangrenosum. The Merriam–Webster dictionary describes the general condition of pyoderma gangrenosum (GP) as "a chronic noninfectious condition that is marked by the formation of purplish nodules and pustules which tend to coalesce and form ulcers and that it is associated with various underlying systemic or malignant diseases."
Typical Procedure For Diagnosis
In my wife's case, an apparent impact wound from an ostomy belt buckle was, at first, treated as a cut and managed using antibiotics. However, after several months of treatment under the watchful eye of a wound nurse, there were no signs of healing. This is typical: other processes are excluded in order to confirm a diagnosis of PPG. They can include:
- stitch absesses
- contact dermatitis
- irritation from leaked feces
- extension of underlying Crohn's
- wound infection.
What is PPG?
Jackson and Callen define the general condition of PG as an ulcerated skin condition with uncertain causes. Yeo, Abir, and Longo further define ulcers on the skin close to or around a stoma as parastomal pyoderma gangrenosum or PPG.
Effective Therapies
While a clinical study by Hughes, Jackson and Callen found no single effective therapy, the following were suggested:
- Topical superpotent corticosteroids e.g. Vanos Cream.
- Intralesional injection of triamcinolone acetonide at the ulcer margin
- Topical cromolyn sodium prevents the release of inflammatory chemicals such as histamine from mast cells (e.g. used in asthma inhalers)
- Oral dapsone – an immunosuppressant drug (e.g. used in organ transplants to prevent rejection)
- Prednisone
- Cyclosporine – an immunosuppressant drug (e.g. used in organ transplants to prevent rejection)
- Mycophenolate mofetil – an immunosuppressant drug
- lntravenous infliximab (e.g Remicade).
Conclusions
A review by twenty cases of PPG by D.G. Sheldon et al. produced the following conclusions:
- PPG complicating inflammatory bowel disease is uncommon and often misdiagnosed by clinicians;
- Local wound care measures have little role in the healing of PPG;
- PPG usually heralds active Crohn's disease
- In patients with prior history of UC, PPG indicates CD until proven otherwise;
- Prolonged medical therapy (11 months), usually with immunosupression, is required for healing of PPG; and
- If feasible, surgical resection of all active Crohn's leads to the healing of PPG ulcers.
Disclaimer: The information contained in this article is for educational purposes only and should not be used for diagnosis or to guide treatment without the opinion of a health professional. Any reader who is concerned about his or her health should contact a doctor for advice.
Sources
- Amy Hughes, J. Mark Jackson and Jeffrey P. Callen. Clinical Features and Treatment of Peristomal Pyoderma Gangrenosum. JAMA
- D.G. Sheldon et al. Twenty Cases of Peristomal Gangrenosum: Implications and Management. NCBI. May 2000 (accessed Feb. 10, 2012)
- Gary Williams and Murray Kutcher. Primary Care Dermatology Module Nomenclature of Skin Lesions. University of Wisconsin.
- Heather Yeo, Farshad Abi and Walter E. Longo. Management of Parastomal Ulcers. The WJG Press. May 28, 2006) accessed Feb. 9, 2012)
- J. Mark Jackson and Jeffrey P. Callen. Pyoderma Gangrenosum. Medscape Reference. Mar. 23, 2010. (accessed Feb. 09, 2012)
- Pyonderma Gengrenosum. Merriam-Webster Dictionary. (accessed Feb. 9, 2012)
James Gibson - James Gibson is a retired teacher and small business owner. He is a published writer and has a wide spectrum of interests.
