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.
This patient has peristomal postinflammatory pigmentary changes in addition to multiple irregular ulcer. It is not clear if these ulcerative lesions are persisting since 12 months or there are recurrent in nature.
ReplyDeleteAccording to clinical picture provided, these ulcers seem to be due to mechanical effect with cumulated irritant dermatitis secondary to local pressure, multiple medicaments and maceration . But i would try to rule out eczema herpeticum in this case by tzanck smear, though biopsy do not show any evidence of the same, i would still have treated with a course of oral acyclovir. It is not suggestive of Pyoderma gangrenosum clinically.
There after, attemps should be to minimze local mecerations by using fluid protecting dressings like tigaderm in peristomal area, avoiding topical strong aniseptics and irritant, prefer to clean local area with saline, use topical mupirocin+metronidazole cream, try to keep area without occlusive dressings whenever possible, giving antibiotics like minocycline having antiinflammatory effects for few weeks.
Thank you. Comment # 1 is from Sunil Dogra, PGIMER, Chandigarh, India.
ReplyDeleteI recommend a biopsy of the ulcer edge with tissue sent for special stains to rule out infection as well as culture of the tissue. If the biopsy shows changes that could be consistent with pyoderma gangrenosum, I would recommend prednisone plus infliximab or etanercept. Peristomal PG is well described in the literature and treatment with TNF inhibitors has been successful.
ReplyDelete1. Hughes AP, Jackson MJ, Callen JP. Clinical features and treatment of peristomal pyoderma gangrenosum. JAMA. 2000; 284(12): 1546-1548.
2. Roy DB, Conte ET, Cohen DJ. The treatment of pyoderma gangrenosum using etanercept. JAAD. 2006; 54(3): S128-134.
3. Pastor N, Betlloch I, Pascual JC, Blanes M, Banuls J, Silvestre JF. Pyoderma gangrenosum treated with anti-TNF alpha therapy (etanercept). Clinical and Experimental Dermatology. 2005; 31: 152-153.
4. McGowan JW, Johnson CA, Lynn A. Treatment of pyoderma gangrenosum with etanercept. J Drugs Dermatol. 2004; 3(4): 441-444
5. Tan MH, Gordon M, Lebwohl O, George J, Lebwohl MG. Improvement of pyoderma gangrenosum and psoriasis associated with Crohn disease with anti-tumor necrosis factor alpha monoclonal antibody. Arch Dermatol. 2001; 137: 930-3.
I also have seen several patients with non-healing peristomal ulcerations whose diagnosis clarified as pyoderma gangrenosum after biopsy was done. I agree that prednisone and TNF blockers are a good option, however our patients did not respond to these. One did do well on cyclosporin, but had to be discontinued because of elevated creatinine - next we tried Cellcept 2g daily which was also helpful.
ReplyDeleteI would also send a punch biopsy for tissue culture (may be more sensitive than swab culture), and in addition it might be good to do a biopsy to rule out an atypical-appearing squamous cell carcinoma.
As far as therapeutic options, Ivy Block, a clay-based liquid that is used to prevent allergic contact dermatitis from poison oak or poison ivy, can be useful. I've been taught that it should be initiated after a course of high-potency topical steroids (our patients have had the most luck with Olux foam). It creates a physical barrier that can help minimize ICD/ACD.
Julianne Mann, MD
Resident physician, Dermatology
Oregon Health and Science University
Portland, OR USA
First of all, i have to say that i couldn't see the picture because it was blocked by our govt!
ReplyDeleteChronic periostomal irritation/erosion/ulceration is not a rare problem. In my hand biafine works good for this condition, but i have no idea about its mechanism. Also, sometimes a shot of kenalog makes the life easier for the patient.
Cheers
I had a recent patient with a long standing parastomal erosive process that looked similar. He did well, so I called him to see what he thought worked best. He felt that cold compresses with tap water x ~ 1/2 hour, followed by clobetasol 0.05% ointment was the most helped. He then wiped the clobetasol off and affixed the appliance. He also found that the adhesive he had been using caused immedidate symptoms so he switched to an alternative. After he was controlled, I switched him to the weaker fluocinalone 0.025% ointment. This is a simple approach, the so-called "K.I.S.S." t4echnique: Keep It Super Simple. He may well have had contact urticaria to the first adhesive and that may have played a role. The cause of these ulcerations is multifactorial, so the treatment for each case needs to be individualized. Please keep us posted as to how this patient does.
ReplyDeleteContact dematitis is the leading diagnosis but strange diagnoses should be thought about like parasitic infection by entamoeba histolytica or scc
ReplyDeletekhalifa sharquie baghdad
Thanks for your help. I will share these ideas with the patient and perhaps do another biopsy.
ReplyDeleteIf switching to hypoallergic adhesives does not work, I think that peristomal pyoderma gangrenosum is a good suggestion, especially that the histo showed nonspecific inflammation. I suggest you use topical steroid/antibiotic combination with dapsone.
ReplyDeletenidal obaidat
I know this is a dermatology blog, however I was curious what the preferred surgical management would be? Local site revision, debridement, ostomy relocation? Any articles on this? I have been having trouble locating any.
ReplyDeletethanks so much!