Post-surgical Pyoderma Gangrenosum: a Clinical Entity

Abstract

Post-surgical pyoderma gangrenosum (PSPG) represents a specific entity: it shares some clinical aspects of pyoderma gangrenosum (PG), but has a series of its own features. In this paper, two cases of PSPG associated with breast surgery are presented: their analysis, combined with a review of the few other cases reported in the literature, show the particular clinical presentation and evolution of this condition. Firstly, the onset of PSPG follows a sequence. After an apparently normal evolution of scar formation following a surgical procedure, the scar presents with many small dehiscences, which will progressively coalesce to some larger areas of wound ulceration, with no visible granulation tissue. Secondly, the delay between surgery and the beginning of symptoms is variable, from 4 days to sometimes 6 weeks. The process will evolve well beyond what would be expected for the initial wound that was created by surgery, with no self-limitation. The skin ulcerations become larger, despite any local treatment or antibiotics. Thirdly, PSPG can affect any anatomical location with the exception of the nipple-areolar complex. Fourthly, a dramatic response to immunomodulatory drugs will be observed. The pain is an inconstant symptom. Present in the first week after surgery, it can be severe and disproportionate regarding clinical presentation.

Postoperative pyoderma gangrenosum (PG): The Mayo Clinic experience of 20 years from 1994 through 2014

“…The microbiologic agents present in the mammary ducts, enhancing inflammatory and immunologic neutrophilic response to the skin, have been suggested as a possible explanation for the nipple-sparing. 5,46 However, the paraneoplastic phenomenon does not explain cases of postoperative PG in breasts after cosmetic breast augmentation. Additional studies may elucidate the unique pathophysiologic characteristics of postoperative PG and the breast environmental milieu contributing to this observation.…”

“…After erythema, the wound may dehisce or develop small punctate ulcerations that eventually coalesce. 5 A wound infection is often diagnosed, and antibiotics are initiated as disproportional pain and rapid wound breakdown is the typical presentation of necrotizing fasciitis. [6][7][8][9][10] Although antiinflammatory antibiotics such as minocycline or dapsone are used in conjunction with immunomodulators/immunosuppressors for treatment of PG and postoperative PG, treatment for a presumptive necrotizing fasciitis also includes debridement.…”

Pyoderma gangrenosum induced by episiotomy

“…Postoperative PG has been reported most commonly after abdominal surgery, breast surgery or venepuncture, but there is no reported case of PG after episiotomy 5. When resulting from operative wounds, PG usually begins as multiple small areas of dehiscence or ulceration several days to a few weeks later.…”

Postoperative Pyoderma Gangrenosum in Association with Renal Cell Carcinoma and Chronic Lymphocytic Leukemia

“…This entity is considered today as a variant of PG, similar to classical ulcerative form [13]. This form of PG begins as multiple small ulcerations several days to weeks after apparently normal healing [14]. It has been reported most often in association with abdominal and breast surgery, but it can complicate any invasive procedure [15].…”