Parastomal Ulceration

Presented by Amanda Oakley, Hamilton, NZ

The patient is a 44 year old man with parastomal ulceration over the last 12 months.
He had a stable stoma for 12 years, following colostomy to remove rectal tumour (carcinoid) and is healthy otherwise with no bowel problems and no skin disease elsewhere.

Last year he received IV antibiotics for peristomal cellulitis, with complete recovery. A month or so later the peristomal skin began ulcerating. Partial healing is followed by skin lifting off at bag changes alternate days, leaving painful ulceration. Meticulous hygiene resulted in no improvement with different devices or topical steroid for one month, applied as beclomethasone nasal spray. Now trying clobetasol solution on appliance, allowed to dry before fitting to skin. He is on no medications.

Swab: group G streptococcus on two swabs - no deep fungi or mycobacteria.
Blood screen: all normal - no sign carcinoid or other disease

Clinical Photos (July '09 (top) and February '09 bottom):


Histology: paucicellular; subepidermal clefting. Not diagnostic.

Dr. Oakley's Comments: Most stomal rashes are dealt with by stoma nurses and a dermatologist's opinion is rarely sought; so we don't see many of them. I see irritant dermatitis from time to time and it responds to topical steroids. He has no risk factors for pyoderma gangrenosum, and the histology is not typical of that.

Questions: Could group G streptococcus do this? There is no cellulitis or abscess formation and I have prescribed antibiotics without improvement.
Any suggestions re: diagnosis and treatment will be gratefully received! I am hoping some dermatologists have greater exposure to stomal disease and I can benefit from their experience.

Reference:
Yeo H, Abir F, Longo WE. Management of parastomal ulcers.
World J Gastroenterol. 2006 28;12(20):3133-7.
Management of surgically placed ostomies is an important aspect of any general surgical or colon and rectal surgery practice. Complications with surgically placed ostomies are common and their causes are multifactorial. Parastomal ulceration, although rare, is a particularly difficult management problem. We conducted a literature search using MD Consult, Science Direct, OVID, Medline, and Cochrane Databases to review the causes and management options of parastomal ulceration. Both the etiology and treatments are varied. Different physicians and ostomy specialists have used a large array of methods to manage parastomal ulcers; these including local wound care; steroid creams; systemic steroids; and, when conservative measures fail, surgery. Most patients with parastomal ulcers who do not have associated IBD or peristomal pyoderma gangrenosum (PPG) often respond quickly to local wound care and conservative management. Patients with PPG, IBD, or other systemic causes of their ulceration need both systemic and local care and are more likely to need long term treatment and possibly surgical revision of the ostomy. The treatment is complicated, but improved with the help of ostomy specialists. Note: This reference is available as free full text from the publisher.

Localized Bullae

This healthy 83 year-old man has had a one year history of bullae and vesicles on the medial aspect of the left knee. They come and go. He is on no new medications and does not take any drugss on an as necessary or intermittent basis. His medications consist of valsartan (Diovan), simvastatin and omeprazole (Prilosec).

O/E: A collection of vesicles and bullae left knee.

Clinical Photo:


Lab and Path:
Bacterial Culture 8/14/o9 Negative
Biopsies were done by two other dermatologists (will try to get results). Apparently, no firm diagnosis was made.

Path Report: 9/30/08 Perivascular and interstitial dermatitis with mixed cell infiltrate including eosiniphils. Dermal hypersensitivity reaction. "These findings may be seen in the prebullous lesions of pemphigoid." DIF was negative.

Diagnosis:
Consider localized bullous pemphigoid.

Discussion: This is an 82 yo man with a one year history of a localized bullous disorder. The initial pathology showed an inflammatory process with eosinophils. The bullous process has stayed localized to the left knee. It seems likely that this is localized bullous pemphigoid. There is a "pretibial variant" and this may be related. Apparently, many of these patients have negative direct immunofluorescence (See ref. below)
Plan to treat initially with clobetasol ointment and if does well follow with tactolimus ointment 0.1%.

Questions: What do you think? What else is in your differential diagnosis? Therapeutic options?

Reference:

Kurzhals G, et. al. [Localized cicatricial bullous
pemphigoid of the Brunsting-Perry type] Hautartz.
1993 Feb;44(2):110-3 [Article in German]
Localized cicatricial pemphigoid of the Brunsting-
Perry type is a very rare bullous condition, which
has so far been reported in 51 cases. It is
characterized by scarring blisters confined to the
head, scalp and neck.  Diagnosis can be difficult
because of the discrete skin lesions, often repeatedly
false-negative direct immunofluorescence, and the
absence of circulating antibodies. We report on a
87-year-old male patient with the typical clinical
feature of a cicatricial pemphigoid of the Brunsting-
Perry type and give a reviewof the 51 cases published
in the world literature.

Follow-up Photo (08/21/09):  The patient was seen after a week for a second visit.  No
treatment had been rendered and the bullae had resolved.  One wonders
what triggers the bullae?  He's a tennis player, so could it be minor
trauma, UVL?

Tan Papules in a Child

Abstract: Eight year old boy with six month hx of tan macules

HPI: This otherwise healthy boy has had a six-month history of asymptomatic tan macules on his torso. Takes no meds by mouth and is asymptomatic.

O/E: Six - eight smooth surfaced tan macules measuring from 5 mm to 15 mm in diameter on torso. After lesions are rubbed they urticate mildly and are faint pink. Dermographia is negative.

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Pathology:

Diagnosis: