Download Pyoderma Granulosum

Wound Management in the Patient with
Inflammatory Bowel Disease
Nancy Tomaselli, RN, MSN, CRNP, CWOCN, LNC
President & CEO
Premier Health Solutions, LLC
www.PremierHealthSolutions.com
Copyright 2009 Premier Health Solutions, LLC
Pyoderma Granulosum
• Chronic neutrophilic inflammatory disease
• Can cause painful ulcerative lesions
• Associated with systemic diseases such as
IBD (UC, regional enteritis, Crohn’s),
arthritis, hematologic and immunologic
abnormalities
• Pathophysiologic mechanism is unknown
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Pyoderma Granulosum
• Extremely painful lesions
• Begin as a nodule, pustule or bullae
• Develop significant induration and
erythema
• Progress to one or more chronic ulcers
• Course waxes and wanes
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Pyoderma Granulosum
• Common characteristics
• Irregular wound edges that are
elevated and violaceous
• Ulcers are deep, exudative and
extremely tender
• Wound base is often filled with yellow
slough and/or islands of necrosis
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Pyoderma Granulosum
• Common characteristics
• Wound edges are undermined
• Band of erythema may extend from
the wound edge, which defines the
direction the ulcer may extend
• Healing present along one edge with
enlargement along another edge
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Pyoderma Granulosum
• Common characteristics
• Ulcers heal slow and leave an atrophic,
irregular scar
• Common sites: lower legs, buttocks,
abdomen, face, hands
• Mechanism by which PG develops is
unknown
• Pathergy (development of lesions in
areas of trauma) plays a role
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Pyoderma Gangrenosum
• Distinguishing features
• Ragged and boggy borders
• Elevated
• Dusky red, purple
• Edema halo
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Pyoderma Gangrenosum
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Pyoderma Gangrenosum
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Pyoderma Gangrenosum
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Pyoderma Granulosum
• Difficult to diagnose
• Disease of exclusion
• Misdiagnosed as venous, arterial,
neuropathic, vasculitic, or neoplastic
wounds
• Dx based on clinical manifestations-no
diagnostic test to confirm
• H&P, skin biopsy to exclude other causes,
associated illness
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Pyoderma Granulosum
• Treatment : cure does not exist
• Systemic therapy with local wound
care
• Corticosteroids: Prednisone 60-120
mg daily until reduction of pain and
granulation tissue
• Dapsone used to control wound
bioburden
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Pyoderma Granulosum
• Treatment : cure does not exist
• Limited disease: topical or
intralesional steroids
• Antibiotics with anti-inflammatory
agents (cyclosporine)
• Infliximab
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Pyoderma Granulosum:
Topical Treatment
• Topical steroids (Orabase with Kenalog)
• Topical immunomodulators (tacrolimus
& pimecrolimus)
• Nicotine patch
• Intralesional steroids
• Methylprednisolone
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Pyoderma Granulosum:
Systemic Treatment
• Antineoplastics
• Chlorambucil
• Cyclophophamide
• Antibiotics
• Dapsone
• Minocycline
• Cyclosporine
• Clofazamine
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Pyoderma Granulosum:
Systemic Treatment
• Anti-inflammatories
• Mesalamine
• Antimetabolites
• Methotrexate
• Corticosteroids
• Prednisone
• Monoclonal antibodies
• Infliximab
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Pyoderma Granulosum:
Systemic Treatment
• Immunomodulatory agents
• Thalidonmide
• Immunosuppressents
• Azathioprine
• Mycophenolate mofetil
• IV immunoglobulin
• Plasmapheresis
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Pyoderma Granulosum
• Treatment
• Topical wound management
• Exudate management
• Protection from trauma
• Moist wound environment
• Pain control
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Pyoderma Granulosum
• Treatment
• Non-adhesive dressings d/t pain
• Debridement through autolysis and
regression of disease process itself
• Antibacterial topical dressings
warranted
• Use caution to prevent trauma
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Pyoderma Gangrenosum
• Case study
• 52 year old female diagnosed with
ulcerative colitis in 2005
• Colonoscopy revealed disease from
rectum to mid transverse colon
• Medically managed without surgery
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Pyoderma Gangrenosum
• Case study
• Medications
• Managed with Predisone until 2006
• Began Mesalamine in 2007
• Currently on Infliximab
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Pyoderma Gangrenosum
• Case study
• Hit leg on coffee table in October 2007
• Treated in ED with antibiotics and
wound did not heal
• Admitted to hospital 2 months later
• Diagnosed as venous ulcer
• Treated with Unna boot and
compression increased pathergy
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Pyoderma Gangrenosum
• PG
Venous Ulcer
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Pyoderma Gangrenosum
• Case study
• Admitted to University of Chicago in
February of 2008
• Biopsy of wound performed
• Started on Infliximab and lesions improved
• Treatment for wounds started in February
2008 and wounds were healed in March of
2008
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Pyoderma Gangrenosum
• Case study
• Topical treatment included
• Alginate
• Alginate with silver
• Hydrogel
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Pyoderma Gangrenosum
February 2008: Week 1
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Moist Wound Healing
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Pyoderma Gangrenosum
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Pyoderma Gangrenosum
February 2008: Week 1
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Pyoderma Gangrenosum
February 2008: Week 2
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Pyoderma Gangrenosum
February 2008: Week 3
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Pyoderma Gangrenosum
February 2008: Week 4
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Pyoderma Gangrenosum
March 2008: Week 1
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Pyoderma Gangrenosum
March 2008: Week 2
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Pyoderma Gangrenosum
March 2008: Week 2
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Hydrogel Dressing
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Pyoderma Gangrenosum
March 2008: Week 3
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Pyoderma Gangrenosum
Peristomal lesion
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References
• Baranoski, S., & Ayello, E.A. (2004).
Wound care essentials: Practice
principles. Philadelphia: Lippincott,
Williams & Wilkins.
• Bryant, R.A., & Nix, D.P. (2007). Acute
and chronic wounds: Current
management concepts (3rd ed). St.
Louis: Mosby, Inc.
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References
• Burch, J., Jones, M., & Fellows, J.
(2006). Pyoderma ganrenosum and leg
ulcers associated with vasculitis.
Journal of Wound, Ostomy and
Continence Nursing, 33, 77-82.
• Colwell, J.C., Goldberg, M.T., & Carmel,
J.E. (2004). Fecal & urinary diversions:
Management principles. St. Louis:
Mosby, Inc.
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