eMedicine Specialties > Dermatology > Reactive & Inflammatory Dermatoses

Pyoderma Gangrenosum: Differential Diagnoses & Workup

Author: J Mark Jackson, MD, Clinical Professor of Medicine/Dermatology, Division of Dermatology, University of Louisville
Coauthor(s): Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Dec 8, 2009

Differential Diagnoses

Acute Febrile Neutrophilic Dermatosis
Hypersensitivity Vasculitis (Leukocytoclastic Vasculitis)
Aphthous Stomatitis
Impetigo
Behcet Disease
Insect Bites
Chancroid
Sporotrichosis
Churg-Strauss Syndrome (Allergic Granulomatosis)
Squamous Cell Carcinoma
Ecthyma
Venous Insufficiency
Ecthyma Gangrenosum
Verrucous Carcinoma
Herpes Simplex
Wegener Granulomatosis
hidradenitis suppurativa

Other Problems to Be Considered

Antiphospholipid antibody syndrome
Anthrax
Arterial insufficiency
Acute febrile neutrophilic dermatosis (Sweet syndrome)
Blastomycosis
Factitial disease
Traumatic ulceration
Tuberculosis gumma

Workup

Laboratory Studies

  • Routine blood work to evaluate for an underlying systemic illness in persons with pyoderma gangrenosum (PG) includes a CBC count; a comprehensive chemistry profile, including a liver function test; and a urinalysis.
  • A hepatitis profile should be performed to rule out hepatitis.
  • Serum and/or urine protein electrophoresis, peripheral smear, and bone marrow aspiration should be performed if indicated to evaluate for hematologic malignancies.
  • Other serum studies include a Venereal Disease Research Laboratory (VDRL) test, antineutrophil cytoplasmic antibody test, partial thromboplastin time test, and antiphospholipid antibody test to rule out Wegener granulomatosis, vasculitis, and antiphospholipid antibody syndrome. Serum protein electrophoresis is helpful to determine if a monoclonal gammopathy is present. If present, it is often of the IgA subtype.
  • Cultures of the ulcer/erosion for bacteria, fungi, atypical mycobacteria, and viruses are needed. The exact cultures to be performed depend on the individual situation. The cultures should be held for 6 weeks because some of the potential agents may take that long to grow in culture.

Imaging Studies

  • Chest radiography may be performed.
  • Colonoscopy or other tests to exclude associated inflammatory bowel disease or ulcerative colitis may be useful in patients with symptoms. The evaluation of patients with pyoderma gangrenosum and no symptoms of bowel disease is still uncertain.
  • Angiography or Doppler studies may be performed in patients suspected of having arterial or venous insufficiency.

Other Tests

  • The following tests may be performed:
    • Flexible sigmoidoscopy or colonoscopy in selected patients
    • Bone marrow aspiration or biopsy in selected patients
    • Culture of the ulceration and possibly of the biopsy material

Procedures

  • A skin biopsy should be performed.

Histologic Findings

The histopathologic findings in pyoderma gangrenosum are not specific. However, a biopsy is suggested in almost all instances because it is useful in the exclusion of other diseases. Microscopic features include massive neutrophilic infiltration, hemorrhage, and necrosis of the overlying epidermis. Histologically, this finding may simulate an abscess or cellulitis. Neutrophils are often around and within the vessel walls, but the full picture of vasculitis is generally absent. In early disease, a mixed cell infiltrate may be present. Late in the process, granulation tissue may be present, but granuloma formation is generally believed to be incompatible with the diagnosis of pyoderma gangrenosum.

More on Pyoderma Gangrenosum

Overview: Pyoderma Gangrenosum
Differential Diagnoses & Workup: Pyoderma Gangrenosum
Treatment & Medication: Pyoderma Gangrenosum
Follow-up: Pyoderma Gangrenosum
Multimedia: Pyoderma Gangrenosum
References
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References

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Further Reading

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Keywords

pyoderma gangrenosum, PG, classic PG, classic pyoderma gangrenosum, atypical PG, atypical pyoderma gangrenosum, pyostomatitis vegetans, vulvar pyoderma gangrenosum, penile pyoderma gangrenosum, peristomal pyoderma gangrenosum

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Contributor Information and Disclosures

Author

J Mark Jackson, MD, Clinical Professor of Medicine/Dermatology, Division of Dermatology, University of Louisville
J Mark Jackson, MD is a member of the following medical societies: American Academy of Dermatology, American Acne and Rosacea Society, American Medical Association, Kentucky Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Medicis Honoraria Consulting; Celgene Honoraria Consulting

Medical Editor

David P Fivenson, MD, Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan
David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology, Medical Dermatology Society, Michigan Dermatological Society, Michigan State Medical Society, Photomedicine Society, Society for Investigative Dermatology, and Wound Healing Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Warren R Heymann, MD, Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis  investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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