Aims:
Pyoderma Gangrenosum (PG) is believed to be an inflammatory neutrophilic dermatosis typically characterized by necrotizing ulceration. PG can be exacerbated by minor trauma leading to exaggerated skin injury, a concept known as pathergy. The failure of postoperative surgical site infection to resolve after appropriate antibiotic therapy, or worsening following surgical debridement should alert the clinician to other diagnoses. We aim to remind surgeons of this condition, highlight early signs to assist diagnosis and provide an algorithm for management.
Methods:
Case series of pyoderma gangrenosum arising after immediate reconstruction for breast oncological surgery from 1st January 2006 – 1st September 2014.
Observations and results:
395 immediate breast reconstructions were performed in 335 patients. 3 cases of post-surgical PG were identified (0.76%), all in the setting of mastectomy for breast cancer. Two cases had immediate reconstruction with pedicled transverse rectus abdominus myocutaneous (TRAM) flaps and one had submuscular expander insertion. There was a mean delay of 6.3 days from first symptoms to diagnosis of PG. Each patient underwent multiple debridements in the operating room of a presumably infected wound. Diagnosis was made on the basis of clinical examination in conjunction with histopathology results. Treatment commonly included methylprednisolone, prednisone and ciclosporin with good success at halting disease progress. Significant scarring impacted all three women. Intravenous immunoglobulin (IVIG) was utilized preventatively for further surgical procedures in one patient. A diagnostic and treatment algorithm is presented as a guide for surgeons when considering this disease.
Discussion and conclusion:
Surgeons awareness of the potential diagnosis of PG in the setting of a necrotic, ulcerating surgical wound with a vialoceous border not responding to antibiotics and debridements will allow early diagnosis. Early liaison with dermatology and commencement of immunosuppressive medication while avoiding further surgery can minimize poor cosmetic outcomes and halt disease progression.