Inflammatory and vaso-oclusive ulcers (Dec 24) Flashcards
(22 cards)
What is an inflammatory ulcer?
An ulcer where the primary pathologic process is inflammation
e.g.
- Pyoderma Gangrenosum
- Vasculitis
- ulcerative panniculitis
- granulomatous conditions
- manifestation of AICTD
JAAD CME Dec 2024
What are the key clinical features of Pyoderma gangrenosum?
(6)
Severe pain
Pathergy
Violaceous borders
Undermined edge
Irregular shape
Cribiform scarring
JAAD CME Dec 2024
Does PG have any disease associations?
~ 50% have an underlying disease
Inflammatory bowel disease
Inflammatory arthritis
Haematological malignancy
JAAD CME Dec 2024
What is the role of biopsy in PG?
Only 7% of biopsies have characteristic features
More useful to exclude other aetiologies
JAAD CME Dec 2024
How is PG diagnosed?
No pathgnomonic histopathology findings or tests.
Relies on clinical diagnostic criteria:
- PARACELUSUS
- Delphi
- Su
Paracelusus has the highest sensitivity (JAAD CME Dec 2024)
- score > 10 for Dx
Major criteria (3 points each)
–> progressive disease course
–> red/ violaceous ulcer border
–> Assessment of ddx
Minor criteria (2 points each)
–> Amelioration by immunosuppressants
–> Characteristically irregular / bizarre ulcer shape
–> extreme pain
Additional (1 point)
–> ass with systemic disease
–> undermined ulcer border
–> histopath with suppurative inflammation
JAAD CME Dec 2024
How are vasculidities classified?
Small Vessel
1. Immune complex vasculitis
2. IgA Vasculitis
3. Cryoglobulinaemic vasculitis
4. ANCA associated Vaculitis
- Microscopic polyangitis
- Eosinophillic granulomatosis
- Granulomatosis with polyangitis
Medium Vessel
1. PAN
2. ANCA associated
- Microscopic polyangitis
- Eosinophillic granulomatosis
- Granulomatosis with polyangitis
Large Vessel
1. Giant cell arteritis
2. Takayasu arteritis
JAAD CME Dec 2024
What labratory investigations should be performed when vasculitis is suspected?
Biopsy:
1. for histopathology
2. Direct immunoflourescence
Bloods:
1. ANA
2. ANCA
3. HBV, HCV
4. HIV
5. strep (ASOT)
6. RF
7. CCP
8. C3 / C4
9. CH50, cryoglobulins
10. SPEP
11. Malignancy screen
To assess systemic involvement
1. Urinalysis
2. FBC, UEC, LFts
3. CXR
4. FOBT
JAAD CME Dec 2024
A 24 year old presents with retiform purpura. You suspect a medium vessel vasculitis. How would you biopsy this lesion?
Incisional biopsy
OR
> 6mm punch biopsy
OR
Telescoping biopsy
JAAD CME dec 2024
What are the subtypes of occlusive vasculopathy? (5)
Coagulopathic
* Livedoid coagulopathy
* Antiphospholipid antibody syndrome
* Systemic hypercoagulability
* Warfarin induced skin necrosis
Embolic
* Endocarditis
* Cholestrol emboli
* Skin metastasis
Thrombotic
* Heparin induced skin necrosis
* Myeloproliferative disease
* Type I cryoglobulinaemia
Calcium Depletion
* Calciphylaxis
* Hypertensice ichaemic leg ulcer
Other
* Cocaine
JAAD CME Dec 2024
What are the cutaneous manifestations of endocarditis?
Endocarditis
Petechiae
Oslers nodes (painful, eythematous lesions on the digits and toes)
Janeway lesions (painless haemorrhagic papules or macules on the palms and soles)
Splinter (linear, subungal) haemorrhages
JAAD CME Dec 2024
What is the diagnostic criteria for calciphylaxis?
Must meet 3 clinical features OR 2 clinical features and classic histopathology findings.
Clinical features:
* On haemodialysis (or GFR <15ml/min)
* > 2 painful cutaneous ulcers with purpura
* Painful ulcers on the trunk, extremitis or penis with purpura
Classic histopathological finding:
* Ulceration and necrosis
* Calcificaiton of the tunica media and intima of small to medium arterioles in the dermis and subcutaneous fat
* concentric stenosis of the arterioles
Hayashi et al
JAAD CME Dec 2024
What are the two (non infectious) categories of ulcer?
Inflammatory / vasculitic vs Vasooclusive
Management principles for ulcers
First-line pharmacological therapy for
pyoderma gangrenosum
JAAD CME 2024
Second line treatment in PG
methotrexate,
mycophenolate,
colchicine,
dapsone (topical or systemic),
azathioprine
biologics and small molecules
- etanercept,
- adalimumab,
- ustekinumab,
- guselkumab,
- risankizumab,
- tildrakizumab,
- anakinra,
- canakinumab,
- spesolimab,
- vilobelimab,
- apremilast,
- tofacitinib,
- upadicitinib
- baricitinib
JAAD CME 2024
Management of idiopathic cutaneous small vessel vasculitis
Rest
Elevation
Compression
Elimination or RX of triggers (medications, AI disease, infection)
Describe important aspects of local ulcer care
(1) Tissue debridement:
* remove the slough or debris and necrotic tissue that may impede ulcer healing while preserving well-vascularized granulation tissue
(2) infection control:
* Systemic antimicrobials should be reserved for ulcer infection (not just colonization), associated soft-tissue infection, or osteomyelitis and should be tailored based on culture results
(3) moisture imbalance (dressing selection and
edema and perfusion management)
* Non-adherant dressing
* Compression
(4) epithelial edge advancement
What are some of the epithelial edge advancement/Advanced and adjunctive therapies
reserved for chronic ulcers that do not improve by 50% after a minimum of 4 weeks of standard of care treatment
Topical timolol
- a b1/b2 antagonist
- proven promote re-epithelialization
- increase the rate of keratinocyte migration
- decreases the growth of Pseudomonas
aeruginosa
Types of compression
Types of debridement
autolytic debridement (with hydrogel or hydrocolloid dressings, concentrated surfactant gel such as Poloxamer 188 containing compounds which lead to the formation of a micelle matrix and allows wound debris to be loosened and washed away, honey),
enzymatic debridement (collagenase),
larval therapy,
mechanical debridement (pressurized wa-
ter jet, ultrasonic), and
surgical or sharp debridement.
Benefits of debridement
Debridement promotes keratinocyte
migration and increased debridement frequency is
associated with faster healing.7
Tissue debridement
helps to address biofilms, which are structured communities of adherent microbial cells enclosed in
a polymeric matrix that are typically resistant to
penetration by antimicrobials,
