Kolios L, Hirche C, Ryssel H, Lehnhardt M, Daigeler A
BG Unfallklinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie an der Universität Heidelberg, Ludwigshafen.
Handchir Mikrochir Plast Chir. 2012 Apr;44(2):89-92. doi: 10.1055/s-0031-1298008. Epub 2012 Apr 11.
Pyoderma gangraenosum (PG) as an idiopathic, ulcerative inflammatory skin disease with varying clinical pictures has an estimated incidence of 0.3/100,000 and is due to the non-specific histology primarily a clinical exclusion diagnosis. The rapid progression, as well as the often fatal course of the pathergy phenomenon after surgical intervention is a therapeutic challenge. With the example of the complicated course of a 47-year-old patient with free DIEP flap for bilateral breast reconstruction due to PG, we want to direct attention to this often underrated disease.
For bilateral breast reconstruction, a 47-year-old patient received a double free DIEP flap, which had to be resected on the right due to multiple arterial thromboses. The clinical presumptive diagnosis of a PG arose and an IV steroid therapy was started immediately. After 13 days a further debridement and mesh graft transplantation were performed. Now, the histological examination was for the first time compatible with PG. Under the initiated steroid treatment the wounds could be stabilised and the remaining defects could be covered. After 6-week stay, the patient was finally discharged with healed wound conditions, but an unsatisfactory aesthetic result.
If unclear, rapidly progressive ulcers occur in surgical interventions one should always think of pyoderma gangraenosum. In particular, since a surgical intervention can result in an uncontrolled exacerbation due to the pathergy phenomenon. Laboratory parameters and histology are not specific. Under a systemic immunomodulatory therapy, a sequential surgical wound management may accelerate wound healing.
坏疽性脓皮病（PG）是一种特发性溃疡性炎症性皮肤病，临床表现多样，估计发病率为0.3/10万，由于其组织学表现不具特异性，主要依靠临床排除诊断。坏疽性脓皮病进展迅速，手术干预后常出现致命的同形反应，这是一个治疗挑战。我们以一名47岁因坏疽性脓皮病接受双侧乳房重建游离腹壁下动脉穿支皮瓣（DIEP）的患者的复杂病程为例，希望引起人们对这种常被低估的疾病的关注。
一名47岁患者为进行双侧乳房重建接受了双侧游离DIEP皮瓣移植，右侧因多处动脉血栓形成而不得不切除。临床初步诊断为坏疽性脓皮病，并立即开始静脉注射类固醇治疗。13天后进行了进一步清创和网状植皮。此时，组织学检查首次符合坏疽性脓皮病的诊断。在开始的类固醇治疗下，伤口得以稳定，剩余缺损得以覆盖。住院6周后，患者最终伤口愈合出院，但美学效果不理想。
在手术干预中，如果出现不明原因的快速进展性溃疡，应始终考虑坏疽性脓皮病。特别是因为手术干预可能因同形反应导致病情失控加重。实验室检查参数和组织学检查均不具特异性。在全身免疫调节治疗下，序贯性手术伤口处理可能加速伤口愈合。
