Letter - Clinical
Hypertrophic scar mimicking peristomal pyoderma gangrenosum
Takashi Ito
, Toshiyuki Yamamoto
Autor para correspondência
Department of Dermatology, Fukushima Medical University, Hikarigaoka, Fukushima, Japan
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Clinical</span>" "titulo" => "Hypertrophic scar mimicking peristomal pyoderma gangrenosum" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "290" "paginaFinal" => "292" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Takashi Ito, Toshiyuki Yamamoto" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Takashi" "apellidos" => "Ito" "email" => array:1 [ 0 => "takashi1@fmu.ac.jp" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Toshiyuki" "apellidos" => "Yamamoto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Fukushima Medical University, Hikarigaoka, Fukushima, Japan" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1190 "Ancho" => 1508 "Tamanyo" => 151129 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0090" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic lesions presenting with well-circumscribed vegetating and keratotic appearances surrounding the stoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Peristomal Pyoderma Gangrenosum (PPG) is a subtype of pyoderma gangrenosum, arising around the stoma after surgical placement of an ileostomy or colostomy in patients with inflammatory bowel diseases.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Because there are a number of skin disorders involving the peristomal or parastomal areas, PPG may be overdiagnosed.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We herein describe an unusual case presenting with hyperkeratotic lesions around the stoma in a patient after colorectal cancer surgery.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 78-year-old male after colorectal cancer surgery was referred to us, complaining of hypertrophic lesions surrounding the stoma. He received a colostomy 6-months previously, and peristomal skin lesions gradually worsened in these 2-months. He suffered from exudate from the lesions and pain associated with skin infections. Physical examination showed relatively well-circumscribed vegetating and keratotic lesions around the lower left abdominal stoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No abnormalities were found in the blood test.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histological features showed irregular hypertrophy of the epidermis, with dilated blood vessels in the papillary dermis and edematous upper dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Neutrophil infiltration and histological malignancy were not observed. Immunohistochemistry showed dense staining for vimentin in the mesenchymal cells in the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). CD31 staining showed a number of vessels, and CD31-positive vascular endothelial cells were observed throughout the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). α-Smooth Muscle Actin (SMA)-positive myofibroblasts were proliferated (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A), which were partially positive for p16 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). A diagnosis of hypertrophic scar was made, and the patient received reoperation of the stoma including the surrounding skin lesions.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Peristomal pyoderma gangrenosum is a subtype of pyoderma gangrenosum, arising around the stoma in patients with inflammatory bowel diseases, and is observed in around 1% of patients with stoma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> By contrast, it is also suggested that PPG is overdiagnosed from its clinical features.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Currently, there are no standard diagnostic criteria, and there are several conditions that should be differentiated from PPG. Those conditions include irritant and contact dermatitis, infection, overgranulation, pseudo verrucous lesion, and squamous cell carcinoma.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In addition, other reports showed two cases of peristomal ulcerative conditions, which were eventually reclassified to be caused by irritant dermatitis;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> however, the hypertrophic scar was not included. The present case did not present with surrounding ulcers but hyperkeratotic lesions around the stoma. Histopathological examination did not reveal neutrophil infiltration in the dermis, but increased, thickened, and whorled collagen bundles, and a number of CD31-positive vessels throughout the dermis. Recent studies demonstrated strong expression of vimentin, α-SMA, and p16 in the hypertrophic/keloid scars, suggesting the proliferation of cellular senescence phase myofibroblasts.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We should keep in mind that a number of inflammatory conditions assume clinical appearance mimicking PPG, and careful differentiation from other disorders is necessary for accurate diagnosis of PPG.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Takashi Ito: Conducted the dermatological examination and treatment of the patient, and wrote a draft of the manuscript.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto: Substantial contribution for interpretation, revision, and final approval.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-03-10" "fechaAceptado" => "2022-07-16" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Department of Dermatology, Fukushima Medical University, Hikarigaoka, Fukushima, Japan.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1190 "Ancho" => 1508 "Tamanyo" => 151129 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0090" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic lesions presenting with well-circumscribed vegetating and keratotic appearances surrounding the stoma.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1958 "Ancho" => 1508 "Tamanyo" => 432070 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0095" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Histopathological features showing fibrosis of the thickened dermis. (B) Immunohistochemical examination using anti-vimentin antibody showed proliferation of mesenchymal cells. (C) The vessels in the dermis were increased in number, which were positive for CD31.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2567 "Ancho" => 1508 "Tamanyo" => 543312 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0100" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Myofibroblasts were increased in number, which were positively stained with α-SMA (A), and partially positive for p16 (B).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and management of peristomal pyoderma gangrenosum: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. 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| 2024 Setembro | 167 | 70 | 237 |
| 2024 Agosto | 185 | 117 | 302 |
| 2024 Julho | 147 | 102 | 249 |
| 2024 Junho | 132 | 55 | 187 |
| 2024 Maio | 109 | 75 | 184 |
| 2024 Abril | 254 | 114 | 368 |
| 2024 Março | 370 | 73 | 443 |
| 2024 Fevereiro | 99 | 86 | 185 |
| 2024 Janeiro | 59 | 72 | 131 |
| 2023 Dezembro | 57 | 52 | 109 |
