Postsurgical Pyoderma Gangrenosum Versus Necrotizing Fasciitis: Can We Spot the Difference?

Background: Pyoderma gangrenosum is a rare noninfectious cutaneous disease characterized by expanding areas of skin ulceration around necrotic centers with purulent debris. Exceptionally, it can be precipitated by surgery alone, and this entity has been described as postsurgical pyoderma gangrenosum (PSPG). Cases of PSPG in the literature are rare. Methods: We performed a retrospective review of the current literature on PSPG and highlight some observed differences between these conditions. We also present our experience of PSPG imitating an infectious process post reduction mammoplasty. Results: Although PSPG can demonstrate fever, malaise, systemic signs, and serology that mimic the sepsis of necrotizing fasciitis, we identify some features that can aid diagnosis of pyoderma gangrenosum in the absence of pathergy (which is pathognomonic). These include premorbid inflammatory bowel disease, hematological malignancy, or inflammatory polyarthritis; the exquisite and disproportionate pain associated (in particular within surrounding normal skin); symmetrical changes on both breasts; specific histopathological changes with absence of microorganisms; cutaneous wounds demonstrating an ulcerated, violaceous, and undermined edge; and, in this case, bilaterally spared nipple-areola complexes suggesting progression within continuous skin up to but not across incision lines. Conclusions: We hope that, in encouraging a higher index of suspicion, prompt diagnosis, and accurate treatment, a better outcome for both patient and surgeon can be achieved in future cases.

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