PYODERMA VEGETANS

By Gary M. White, MD

Pyoderma vegetans


Pyoderma vegetans is an unusual inflammation of the skin that is believed to occur preferentially in immunosuppression states due to severe bacterial colonization or epithelial invasion.

The diagnosis of the disease depends on five criteria which were proposed by Su et al. [Arch Dermatol. 1979;115:170–173]:

  1. Large verrucous plaques with multiple pustules and elevated border
  2. Pseudoepitheliomatous hyperplasia with abscesses in tissue biopsy
  3. Growth of at least one pathogenic bacterium
  4. Negative culture for deep fungi, atypical mycobacteria or mycobacterium tuberculosis
  5. Normal bromide levels.

Differential Diagnosis

As noted above, fungal, AFB or other infection must be excluded. Halogenodermas should be considered. Pemphigus vegetans may show clinical and histopathological findings similar to PV, but lesions prefer the body folds. Two other entities also fall under the category of cutaneous, exuberant verrucous response to a chronic bacterial infection are: Botryomycosis and Blastomycosis Like Pyoderma. Some authors group these entities together as one disease. Botryomycosis is distinguished by lesions which contain granules resembling the sulphur granules of actinomycosis.

Clinical

An elevated, verrucous plaque studded with comedone-like areas, pits and/or pustules is seen.

Treatment

If there is any underlying disease, e.g. inflammatory bowel disease, it should be treated. Cultures should be performed and oral antibiotics give, but they alone are usually not sufficient. Systemic steroids, e.g. 0.5-1.0 mg/kg/day given in conjunction with oral antibiotics may be effective. Other therapies that have been used include dapsone, azathioprine, acitretin, and cyclosporine. This author has had good results with curettage and electrodessication of lesions although the resulting skin tends to scar (see image below). CO2 laser debridement has also been used with success. IV antibiotics combined with either intralesional steroids or radiation are alternatives.

References

Case Rep Dermatol. 2011 Jan-Apr; 3(1): 80–84.

Additional Pictures

Pyoderma vegetans

Pyoderma vegetans often heals with significant scarring.
Pyoderma vegetans

References

A case associated with SAPHO syndrome— Acta Dermato-Venereologica vol 90 (5) 531-2

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