(cache)Pyoderma Gangrenosum Differential Diagnoses

Sections

DDx

Diagnostic Considerations

Pyoderma gangrenosum is often misdiagnosed, and multiple attempts at grafting often occur before the diagnosis is made. The breakdown at the harvest site is a clue to the diagnosis and is an indicator of the pathergy often seen in active pyoderma gangrenosum patients.

In addition to the conditions listed in the differential diagnosis of pyoderma gangrenosum, the following should be considered:

Anthrax
Arterial insufficiency^[17]
Blastomycosis
Factitial disease (see the image below)
Traumatic ulceration
Tuberculosis gumma
PAPA (pyogenic arthritis, pyoderma gangrenosum, and acne) syndrome^[18]
Wegener granulomatosis
Atypical mycobacterial infections

Factitial ulceration on scalp from chronic manipulation, mimicking ulceration of pyoderma gangrenosum.

View Media Gallery

Differential Diagnoses

Workup

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González-Moreno J, Ruíz-Ruigomez M, Callejas Rubio JL, Ríos Fernández R, Ortego Centeno N. Pyoderma gangrenosum and systemic lupus erythematosus: a report of five cases and review of the literature. Lupus. 2015 Feb. 24 (2):130-7. [QxMD MEDLINE Link].
Callen JP, Jackson JM. Pyoderma gangrenosum: an update. Rheum Dis Clin North Am. 2007 Nov. 33 (4):787-802, vi. [QxMD MEDLINE Link].
Ashchyan HJ, Butler DC, Nelson CA, Noe MH, Tsiaras WG, Lockwood SJ, et al. The Association of Age With Clinical Presentation and Comorbidities of Pyoderma Gangrenosum. JAMA Dermatol. 2018 Apr 1. 154 (4):409-413. [QxMD MEDLINE Link].
Brown TS, Marshall GS, Callen JP. Cavitating pulmonary infiltrate in an adolescent with pyoderma gangrenosum: a rarely recognized extracutaneous manifestation of a neutrophilic dermatosis. J Am Acad Dermatol. 2000 Jul. 43 (1 Pt 1):108-12. [QxMD MEDLINE Link].
Belinchón-Romero I, Sánchez-Martínez V, Ramos-Belinchón C, Ramos-Rincón JM. Hospital admissions for pyoderma gangrenosum in Spain (1999-2021): Epidemiological and clinical characteristics, temporal trends, and factors associated with poor prognosis and higher cost. Health Sci Rep. 2024 Oct. 7 (10):e2286. [QxMD MEDLINE Link].[Full Text].
Ashchyan HJ, Nelson CA, Stephen S, James WD, Micheletti RG, Rosenbach M. Neutrophilic dermatoses: Pyoderma gangrenosum and other bowel- and arthritis-associated neutrophilic dermatoses. J Am Acad Dermatol. 2018 Dec. 79 (6):1009-1022. [QxMD MEDLINE Link].
Binus AM, Qureshi AA, Li VW, Winterfield LS. Pyoderma gangrenosum: a retrospective review of patient characteristics, comorbidities and therapy in 103 patients. Br J Dermatol. 2011 Dec. 165 (6):1244-50. [QxMD MEDLINE Link].
Schoemann MB, Zenn MR. Pyoderma gangrenosum following free transverse rectus abdominis myocutaneous breast reconstruction: a case report. Ann Plast Surg. 2010 Feb. 64 (2):151-4. [QxMD MEDLINE Link].
Rietjens M, Cuccia G, Brenelli F, Manconi A, Martella S, De Lorenzi F. A pyoderma gangrenosum following breast reconstruction: a rare cause of skin necrosis. Breast J. 2010 Mar-Apr. 16 (2):200-2. [QxMD MEDLINE Link].
Branagan NM, Higgins SP, Halim SA, Le TH. Systemic polyarteritis nodosa mimicking pyoderma gangrenosum in a rare association with small lymphocytic leukaemia/chronic lymphocytic leukaemia. Clin Exp Dermatol. 2009 Jul. 34 (5):e127-9. [QxMD MEDLINE Link].
Namazi MR, Kerchner KR, Pichardo RO. Essential type II mixed cryoglobulinemia causing pyoderma gangrenosum-like ulcers. ScientificWorldJournal. 2008 Feb 25. 8:228. [QxMD MEDLINE Link].[Full Text].
Ahmad K, Ramsay B. Pyoderma gangrenosum associated with subcorneal pustular dermatosis and IgA myeloma. Clin Exp Dermatol. 2009 Jan. 34 (1):46-8. [QxMD MEDLINE Link].
Hughes AP, Jackson JM, Callen JP. Clinical features and treatment of peristomal pyoderma gangrenosum. JAMA. 2000 Sep 27. 284 (12):1546-8. [QxMD MEDLINE Link].
Ho SA, Tan WP, Tan AW, Wong SN, Chua SH. Scrotal pyoderma gangrenosum associated with Crohn's disease. Singapore Med J. 2009 Dec. 50 (12):e397-400. [QxMD MEDLINE Link].
Vadillo M, Jucgla A, Podzamczer D, Rufi G, Domingo A. Pyoderma gangrenosum with liver, spleen and bone involvement in a patient with chronic myelomonocytic leukaemia. Br J Dermatol. 1999 Sep. 141 (3):541-3. [QxMD MEDLINE Link].
Weenig RH, Davis MD, Dahl PR, Su WP. Skin ulcers misdiagnosed as pyoderma gangrenosum. N Engl J Med. 2002 Oct 31. 347 (18):1412-8. [QxMD MEDLINE Link].
Fathalla BM, Al-Wahadneh AM, Al-Mutawa M, Kambouris M, El-Shanti H. A novel de novo PSTPIP1 mutation in a boy with pyogenic arthritis, pyoderma gangrenosum, acne (PAPA) syndrome. Clin Exp Rheumatol. 2014 Nov-Dec. 32 (6):956-8. [QxMD MEDLINE Link].
Nybaek H, Olsen AG, Karlsmark T, Jemec GB. Topical therapy for peristomal pyoderma gangrenosum. J Cutan Med Surg. 2004 Jul-Aug. 8 (4):220-3. [QxMD MEDLINE Link].
Jackson JM. TNF- alpha inhibitors. Dermatol Ther. 2007 Jul-Aug. 20 (4):251-64. [QxMD MEDLINE Link].
Kaur M, Kaffenberger BH. Topical corticosteroid powder for peristomal pyoderma gangrenosum: a systematic review. Wounds. 2024 Oct. 36 (10):331-337. [QxMD MEDLINE Link].[Full Text].
Wilson DM, John GR, Callen JP. Peripheral ulcerative keratitis--an extracutaneous neutrophilic disorder: report of a patient with rheumatoid arthritis, pustular vasculitis, pyoderma gangrenosum, and Sweet's syndrome with an excellent response to cyclosporine therapy. J Am Acad Dermatol. 1999 Feb. 40 (2 Pt 2):331-4. [QxMD MEDLINE Link].
Daniels NH, Callen JP. Mycophenolate mofetil is an effective treatment for peristomal pyoderma gangrenosum. Arch Dermatol. 2004 Dec. 140 (12):1427-9. [QxMD MEDLINE Link].
Eaton PA, Callen JP. Mycophenolate mofetil as therapy for pyoderma gangrenosum. Arch Dermatol. 2009 Jul. 145 (7):781-5. [QxMD MEDLINE Link].
Li J, Kelly R. Treatment of pyoderma gangrenosum with mycophenolate mofetil as a steroid-sparing agent. J Am Acad Dermatol. 2013 Oct. 69 (4):565-9. [QxMD MEDLINE Link].
Zaman M, Martinez R, Mayur O, Montoya M, Serwald G, McNichol MC, et al. Use of biologic therapies in the management of pyoderma gangrenosum: a systematic review. Arch Dermatol Res. 2024 Aug 19. 316 (8):539. [QxMD MEDLINE Link].
Yamamoto T, Yamanaka K, Yamasaki K, Isaji H, Matsubara N, Hozawa H, et al. Real-world safety and effectiveness of adalimumab in patients with pyoderma gangrenosum: Interim analysis of a post-marketing observational study in Japan. J Dermatol. 2024 Nov 13. [QxMD MEDLINE Link].
Campanati A, Brisigotti V, Ganzetti G, Molinelli E, Giuliodori K, Consales V, et al. Finally, recurrent pyoderma gangrenosum treated with Adalimumab: case report and review of the literature. J Eur Acad Dermatol Venereol. 2015 Jun. 29 (6):1245-7. [QxMD MEDLINE Link].
Cinotti E, Labeille B, Perrot JL, Pallot-Prades B, Cambazard F. Certolizumab for the treatment of refractory disseminated pyoderma gangrenosum associated with rheumatoid arthritis. Clin Exp Dermatol. 2014 Aug. 39 (6):750-1. [QxMD MEDLINE Link].
Brooklyn TN, Dunnill MG, Shetty A, Bowden JJ, Williams JD, Griffiths CE, et al. Infliximab for the treatment of pyoderma gangrenosum: a randomised, double blind, placebo controlled trial. Gut. 2006 Apr. 55 (4):505-9. [QxMD MEDLINE Link].
Kaur MR, Lewis HM. Severe recalcitrant pyoderma gangrenosum treated with infliximab. Br J Dermatol. 2005 Sep. 153 (3):689-91. [QxMD MEDLINE Link].
Fernández A, Velasco A, Prieto V, Canueto J, Alvarez A, Rodríguez A. Response to infliximab in atypical pyoderma gangrenosum associated with ulcerative colitis. Am J Gastroenterol. 2008 Nov. 103 (11):2951-2. [QxMD MEDLINE Link].
Mooij JE, van Rappard DC, Mekkes JR. Six patients with pyoderma gangrenosum successfully treated with infliximab. Int J Dermatol. 2013 Nov. 52 (11):1418-20. [QxMD MEDLINE Link].
Ronicke M, Sollfrank L, Vitus MV, Walter LJ, Krieter M, Moelleken M, et al. Intravenous Immunoglobulin Therapy for Pyoderma Gangrenosum: A Multicenter Retrospective Analysis in 81 Patients. Am J Clin Dermatol. 2024 Nov 14. [QxMD MEDLINE Link].
Cummins DL, Anhalt GJ, Monahan T, Meyerle JH. Treatment of pyoderma gangrenosum with intravenous immunoglobulin. Br J Dermatol. 2007 Dec. 157 (6):1235-9. [QxMD MEDLINE Link].
Guenova E, Teske A, Fehrenbacher B, Hoerber S, Adamczyk A, Schaller M, et al. Interleukin 23 expression in pyoderma gangrenosum and targeted therapy with ustekinumab. Arch Dermatol. 2011 Oct. 147 (10):1203-5. [QxMD MEDLINE Link].
Vieira WA, Barbosa LR, Martin LM. Hyperbaric oxygen therapy as an adjuvant treatment for pyoderma gangrenosum. An Bras Dermatol. 2011 Nov-Dec. 86 (6):1193-6. [QxMD MEDLINE Link].
Jaeger T, Andres C, Grosber M, Zirbs M, Hein R, Ring J, et al. Pyoderma gangrenosum and concomitant hidradenitis suppurativa--rapid response to canakinumab (anti-IL-1β). Eur J Dermatol. 2013 May-Jun. 23 (3):408-10. [QxMD MEDLINE Link].
Flora A, Pham J, Woods JA, Radzeika M, Dickson H, Malone M, et al. The Clinical and Molecular Response of Pyoderma Gangrenosum to Interleukin 23 Blockade: Result from a proof-of-concept open-label clinical trial. J Invest Dermatol. 2024 Nov 13. [QxMD MEDLINE Link].
Bubna AK, Viplav V. Revisiting risankizumab: a newer biologic drug in dermatology. Ital J Dermatol Venerol. 2024 Oct. 159 (5):543-554. [QxMD MEDLINE Link].
Weigelt MA, Kirsner RS. Peristomal Pyoderma Gangrenosum Responding to Risankizumab. Adv Skin Wound Care. 2021 Jun 1. 34 (6):327-329. [QxMD MEDLINE Link].
Burgdorf B, Schlott S, Ivanov IH, Dissemond J. Successful treatment of a refractory pyoderma gangrenosum with risankizumab. Int Wound J. 2020 Aug. 17 (4):1086-1088. [QxMD MEDLINE Link].[Full Text].
Botvid S, Zachariae C, Skov L, Schwensen JF. Successful treatment of pyoderma gangrenosum with guselkumab. JEADV Clin Pract. 2024. 1-5. [Full Text].
Laird ME, Tong LX, Lo Sicco KI, Kim RH, Meehan SA, Franks AG Jr. Novel use of apremilast for adjunctive treatment of recalcitrant pyoderma gangrenosum. JAAD Case Rep. 2017 May. 3 (3):228-229. [QxMD MEDLINE Link].
Kochar B, Herfarth N, Mamie C, Navarini AA, Scharl M, Herfarth HH. Tofacitinib for the Treatment of Pyoderma Gangrenosum. Clin Gastroenterol Hepatol. 2019 Apr. 17 (5):991-993. [QxMD MEDLINE Link].
Prieto Jimenez PM, Tabib S, Abbott B, Melmed G. Successful Outcome Treating Pyoderma Gangrenosum and Pouchitis With Upadacitinib. ACG Case Rep J. 2024 Aug. 11 (8):e01442. [QxMD MEDLINE Link].[Full Text].
Song H, Lahood N, Mostaghimi A. Intravenous immunoglobulin as adjunct therapy for refractory pyoderma gangrenosum: systematic review of cases and case series. Br J Dermatol. 2018 Feb. 178 (2):363-368. [QxMD MEDLINE Link].
Barańska-Rybak W, Kakol M, Naesstrom M, Komorowska O, Sokołowska-Wojdyło M, Roszkiewicz J. A retrospective study of 12 cases of pyoderma gangrenosum: why we should avoid surgical intervention and what therapy to apply. Am Surg. 2011 Dec. 77 (12):1644-9. [QxMD MEDLINE Link].
Haag CK, Bacik L, Latour E, Morse DC, Fett NM, Ortega-Loayza AG. Perioperative management of pyoderma gangrenosum. J Am Acad Dermatol. 2020 Aug. 83 (2):369-374. [QxMD MEDLINE Link].

Media Gallery

Classic, or typical, pyoderma gangrenosum. No associated disease was present, and condition responded well to cyclosporine.
Peristomal pyoderma gangrenosum.
Factitial ulceration on scalp from chronic manipulation, mimicking ulceration of pyoderma gangrenosum.

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Author

J Mark Jackson, MD Clinical Professor of Medicine/Dermatology, Division of Dermatology, University of Louisville School of Medicine

J Mark Jackson, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Kentucky Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey P Callen, MD Professor of Medicine (Dermatology), 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, American College of Rheumatology

Disclosure: Received income in an amount equal to or greater than $250 from: Biogen US (Adjudicator for study entry cutaneous lupus erythematosus); Priovant (Adjudicator for entry into a dermatomyositis study); IQVIA (Serono - adjudicator for a study of cutaneous LE) <br/>Received honoraria from UpToDate for author/editor; Received royalty from Elsevier for book author/editor; Received dividends from trust accounts, but I do not control these accounts, and have directed our managers to divest pharmaceutical stocks as is fiscally prudent from Stock holdings in various trust accounts include some pharmaceutical companies and device makers for these trust accounts for: Stocks held in various trust accounts: Allergen; Amgen; Pfizer; 3M; Johnson and Johnson; Merck; Abbott Laboratories; AbbVie; Procter and Gamble;; Celgene; Gilead; CVS; Walgreens; Bristol-Myers Squibb.

Chief Editor

William D James, MD Emeritus Professor, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, American Contact Dermatitis Society, Association of Military Dermatologists, Association of Professors of Dermatology, American Dermatological Association, Women's Dermatologic Society, Medical Dermatology Society, Dermatology Foundation, Society for Investigative Dermatology, Pennsylvania Academy of Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Acknowledgements

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.

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.

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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