Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI).
We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF).
Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis.
There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
1. Cozzani E, Gasparini G, Parodi A. Pyoderma gangrenosum: a systemic review. G Ital Dermatol Venereol 2014;149:587–600.Search in Google Scholar
2. Alavi A, French LE, Davis MD, Brassard A, Kirsner RS. Pyoderma gangrenosum: an update on pathophysiology, diagnosis and treatment. Am J Clin Dermatol 2017;18:355–72.10.1007/s40257-017-0251-7Search in Google Scholar PubMed
3. Haag CK, Nutan F, Cyrus JW, Satpathy J, Shinkai K, Ortega-Loayza AG. Pyoderma gangrenosum misdiagnosis resulting in amputation: a review. J Trauma Acute Care Surg 2019;86:307–13.10.1097/TA.0000000000002096Search in Google Scholar PubMed
4. Erhl DC, Heidekrueger PI, Broer PN. Pyoderma gangrenosum after breast surgery: a systematic review. J Plast Reconstr Aesthet Surg 2018;71:1023–32.10.1016/j.bjps.2018.03.013Search in Google Scholar PubMed
5. Sanchez IM, Lowenstein S, Johnson KA, Babik J, Haag CK, Keller JJ, et al. Clinical features of neutrophilic dermatosis variants resembling necrotizing fasciitis. J Am Med Assoc Dermatol 2019;155:79–84.10.1001/jamadermatol.2018.3890Search in Google Scholar PubMed PubMed Central
6. Bisarya K, Azzopardi S, Lye G, Drew PG. Necrotizing fasciitis vs pyoderma gangrenosum: securing the correct diagnosis! A case report and literature review. Eplasty 2011;11:e24.Search in Google Scholar
11. Cheung J, Fung B, Tang W, Ip W. A review of necrotising fasciitis in the extremities. Hong Kong Med J 2009;15:9.Search in Google Scholar
13. Edlich RF, Cross CL, Dahlstrom JJ, Long WB. Modern concepts of the diagnosis and treatment of necrotizing fasciitis. J Emerg Med 2010;39:261–5.10.1016/j.jemermed.2008.06.024Search in Google Scholar PubMed
17. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg 2014;51:344–62.10.1067/j.cpsurg.2014.06.001Search in Google Scholar PubMed PubMed Central
18. Headley AJ. Necrotizing soft tissue infections: a primary care review. Am Fam Physician 2003;68:323–8.Search in Google Scholar
28. Saeed K, Esposito S, Gould I, Ascione T, Bassetti M, Bonnet E, et al. Hot topics in necrotising skin and soft tissue infections. Int J Antimicrob Agents 2018;52:1–10.10.1016/j.ijantimicag.2018.02.012Search in Google Scholar PubMed
36. Necrotizing Fasciitis. Wallace HA, Waheed A, Perera TB. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. http://www.ncbi.nlm.nih.gov/books/NBK430756/. Accessed September 5, 2019.Search in Google Scholar
40. Sarkar B, Napolitano LM. Necrotizing soft tissue infections. Minerva Chir 2010;65:347–62.Search in Google Scholar
41. Carbonetti F, Carusi V, Guidi M, David V. Necrotizing fasciitis: a comprehensive review. Clin Ter 2015;166:e132–9.Search in Google Scholar
42. Ruocco E, Sanguiliano S, Gravina AG, Miranda A, Nicoletti G. Pyoderma gangrenosum: an updated review. J Eur Acad Dermatol Venereol 2009;23:1008–17.10.1111/j.1468-3083.2009.03199.xSearch in Google Scholar PubMed
43. Xu A, Balgobind A, Strunk A, Garg A, Alloo A. Prevalence estimates for pyoderma gangrenosum in the United States: an age- and sex- adjusted population analysis. J Am Acad Dermatol 2019;S0190-9622(19)32494–6. [Epub ahead of print].10.1016/j.jaad.2019.08.001Search in Google Scholar PubMed
44. Hammer P, Latour E, Bohnett MC, McKenzie F, Korcheva VB, Mengden S, et al. The utility and challenges in the diagnosis of nonmalignant skin ulcers. Wound Rep Reg 2019; doi: 10.1111/wrr.12780. [Epub ahead of print].Search in Google Scholar PubMed
45. Haynes D, Hammer P, Malachowski SJ, Kaffenberger B, Yi JS, Vera N, et al. Characterisation and diagnosis of ulcers in inpatient dermatology consultation services: a multi-centre study. Int Wound J 2019;16:1440–4.10.1111/iwj.13211Search in Google Scholar PubMed PubMed Central
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