Early and Multiple Modality Approach to Pyoderma Gangrenosum - Case Report

治療壞疽性膿皮症的臨床經驗－病例報告

劉虹慧(Hung-Hui Liu) ； 喬浩禹(Hao-Yu Chio) ； 陳錫根(Shyi-Gen Chen) ； 戴念梓(Niann-Tzyy Dai) ； 曾元生(Yuan-Sheng Tzeng)

《臺灣整形外科醫學會雜誌》 28卷2期 (2019/06) Pp. 167-177

摘要

Background: Because of the rarity of pyoderma gangrenosum (PG), a destructive and painful cutaneous disease, there is no standardized treatment, with a combination of systemic immunosuppressive medications and local wound care being the most common management strategy. Aim and objective: To report a case of PG with multiple expanding necrotic ulcers that was successfully treated by early surgical intervention as an adjunct to systemic immunosuppressive therapy. Materials and methods: We report a case of PG associated with Crohn's disease that was treated with immunosuppression followed by multimodal surgery including early and weekly surgical debridement and direct closure of gluteal, axillary, and pubic ulcers. Vacuum-assisted closure was used to treat a sternal ulcer with exposed bone, and temporary cadaveric skin coverage was utilized for more superficial wounds. Results: The combined approach to the management of actively progressing PG, which, to our knowledge, has not been reported previously, led to an excellent outcome, including a short hospital stay, rapid wound healing without recurrence, efficient pain control, absence of secondary infection, and acceptable cosmetic appearance. Conclusion: We suggest that a multimodal surgical approach should be considered for patients with PG to improve the wound healing as soon as medical treatment is started.

關鍵字

cadaveric skin graft ； pyoderma gangrenosum ； vacuum-assisted closure ； inflammatory bowel disease ； pathergy

並列摘要

背景：壞疽性膿皮症屬於一種很罕見的的自體免疫疾病，在臨床上的表現大多為非感染性的疼痛皮膚潰瘍，診斷主要是根據臨床症狀及病史，再安排病灶切片去排除其他可能疾病。目前並無治療上的準則，但在過去多偏向藥物合併局部傷口照顧的保守治療方式，認為侵犯性的手術治療會使病程惡化並引發新病灶。但近年來，有不少病例在接受適當的手術搭配藥物治療，顯示出良好的結果被發表出來。目的及目標：報告我們成功以早期手術介入輔助藥物治療一個嚴重壞疽性膿皮症的案例。材料及方法：一名43歲女性，在被診斷出壞疽性膿皮症後，我們除了給予適當的藥物治療外，立即根據其傷口狀況給予早期的手術介入治療，包含定期的清創、直接縫合、暫時性屍皮的覆蓋及負壓傷口治療。結果：得到極好的成效，不只縮短了整個病程的時間，減少了病患的住院天數，最後的疤痕也呈現較佳的外觀。病人出院後追蹤6個月，均無任何局部或廣泛性復發。結論：根據我們治療這位案例的極佳成效和過去近幾年來陸續發表手術介入成功治療的一些案例及研究，在治療壞疽性膿皮症時，除適當的免疫抑制藥物外，根據傷口狀況提供適當的手術介入及負壓治療是有幫助的。