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• W2904190029 abstract "To the Editor: We read with interest the review on neutrophilic dermatoses by Ashchyan et al1Ashchyan H.J. Nelson C.A. Stephen S. James W.D. Micheletti R.G. Rosenbach M. Neutrophilic dermatoses. Pyoderma gangrenosum and other bowel and arthritis associated neutrophilic dermatoses.J Am Acad Dermatol. 2018; 79: 1009-1022Abstract Full Text Full Text PDF Scopus (51) Google Scholar and believe that it will be of significant value to the dermatologic community. To supplement their review, there are 2 additional viewpoints that we would like to highlight, specifically, regarding the diagnosis and treatment of pyoderma gangrenosum (PG). Ashchyan et al1Ashchyan H.J. Nelson C.A. Stephen S. James W.D. Micheletti R.G. Rosenbach M. Neutrophilic dermatoses. Pyoderma gangrenosum and other bowel and arthritis associated neutrophilic dermatoses.J Am Acad Dermatol. 2018; 79: 1009-1022Abstract Full Text Full Text PDF Scopus (51) Google Scholar state that PG remains a “diagnosis of exclusion,”2Su W.P.D. Davis M.D.P. Weenig R.H. Powell F.C. Perry H.O. Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria.Int J Dermatol. 2004; 43: 790-800Crossref PubMed Scopus (411) Google Scholar which is a characterization that is difficult to justify, as it is impractical to have a medical diagnosis requiring that all other possible diagnoses be ruled out. In fact, the lack of clear diagnostic criteria for PG may be 1 reason why it has been reported that many cases initially diagnosed as PG can ultimately be reclassified as an alternative diagnosis.3Weenig R.H. Davis M.D.P. Dahl P.R. Su W.P.D. Skin ulcers misdiagnosed as pyoderma gangrenosum.N Engl J Med. 2002; 347: 1412-1418Crossref PubMed Scopus (302) Google Scholar Pertinent to this topic, 2 PG diagnostic criteria have been recently published.4Jockenhöfer F. Wollina U. Salva K.A. Benson S. Dissemond J. The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum.Br J Dermatol. 2018; (Accessed August 10, 2018)https://doi.org/10.1111/bjd.16401Crossref Scopus (71) Google Scholar, 5Maverakis E. Ma C. Shinkai K. et al.Diagnostic criteria of ulcerative pyoderma gangrenosum.JAMA Dermatol. 2018; 154: 461Crossref PubMed Scopus (211) Google Scholar The new criteria were independently developed in parallel by separate groups following different approaches.5Maverakis E. Ma C. Shinkai K. et al.Diagnostic criteria of ulcerative pyoderma gangrenosum.JAMA Dermatol. 2018; 154: 461Crossref PubMed Scopus (211) Google Scholar The first of the 2 studies utilized a score-based approach in which criteria weight was determined by observed prevalence among patients with PG.4Jockenhöfer F. Wollina U. Salva K.A. Benson S. Dissemond J. The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum.Br J Dermatol. 2018; (Accessed August 10, 2018)https://doi.org/10.1111/bjd.16401Crossref Scopus (71) Google Scholar The authors of the second study based their criteria on a Delphi exercise, which was then mathematically refined and validated.5Maverakis E. Ma C. Shinkai K. et al.Diagnostic criteria of ulcerative pyoderma gangrenosum.JAMA Dermatol. 2018; 154: 461Crossref PubMed Scopus (211) Google Scholar It is hoped that these diagnostic models will be of benefit in the clinical and research settings. Both models attempt to de-emphasize the need to exhaustively exclude other causes of ulceration and instead focus more on the pathologic features of PG. Of course, when PG is suspected, relevant causes of ulceration should still be excluded. Second, Ashchyan et al also highlighted as a “key point” the fact that the criterion standard therapy for PG is systemic corticosteroids. Although corticosteroids and cyclosporine have been the best characterized agents in the literature, we would caution against designating any PG therapy as a criterion standard.6Partridge A.C.R. Bai J.W. Rosen C.F. Walsh S.R. Gulliver W.P. Fleming P. Effectiveness of systemic treatments for pyoderma gangrenosum: a systematic review of observational studies and clinical trials.Br J Dermatol. 2018; 179: 290-295Google Scholar To date, there have been only 2 randomized controlled clinical trials in PG.7Ormerod A.D. Thomas K.S. Craig F.E. et al.Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial.BMJ. 2015; 350: h2958Crossref PubMed Scopus (146) Google Scholar, 8Brooklyn T.N. Dunnill M.G.S. Shetty A. et al.Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial.Gut. 2006; 55: 505-509Crossref PubMed Scopus (466) Google Scholar Although Ashchyan et al do describe the STOP-GAP trial in their discussion of treatments, the finding that the prednisolone and cyclosporine treatment arms had similar overall healing rates, namely, 47% at 6 months, was not addressed. In addition, the STOP-GAP study demonstrated that serious adverse reactions, such as infections, were more common in the prednisolone group.7Ormerod A.D. Thomas K.S. Craig F.E. et al.Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial.BMJ. 2015; 350: h2958Crossref PubMed Scopus (146) Google Scholar On the basis of the available data, selection of a systemic immunosuppressant should be tailored to each individual patient according to medication adverse event profiles, PG severity, and medical comorbidities, especially in light of the fact that approximately 55% of PG occurs in association with underlying systemic disease.9Binus A.M. Qureshi A.A. Li V.W. Winterfield L.S. Pyoderma gangrenosum: a retrospective review of patient characteristics, comorbidities and therapy in 103 patients.Br J Dermatol. 2011; 165: 1244-1250Crossref PubMed Scopus (236) Google Scholar Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatosesJournal of the American Academy of DermatologyVol. 79Issue 6PreviewNeutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. Full-Text PDF Reply to: “New validated diagnostic criteria for pyoderma gangrenosum”Journal of the American Academy of DermatologyVol. 80Issue 4PreviewTo the Editor: We would like to thank Maverakis et al for expressing interest in our article and for raising important discussion points.1 In particular, we applaud them for drawing attention to the new diagnostic criteria for pyoderma gangrenosum (PG) that were published this year.2,3 These criteria represent an important step forward in the diagnosis of PG. Full-Text PDF" @default.
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