10.5826/dpc.1401a76
text/xml
2160-9381
3828
en
Pietro Rubegni
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
skin allograft
Successful Treatment of Pyoderma Gangrenosum With Composite Grafting of Acellular Dermal Matrix and Glycerolized Skin: A Preliminary Experience 
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Letter to the Editor
2024-01-31
2023-09-05
2024-01-31
2024-02-21
e2024076
Dermatol Pract Concept
Pietro Rubegni
2024/01/31
10.5826/dpc.1401a76
e2024076
Dermatology Unit, Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, Siena, Italy
2160-9381
skin allograft
en
e2024076
Successful Treatment of Pyoderma Gangrenosum With Composite Grafting of Acellular Dermal Matrix and Glycerolized Skin: A Preliminary Experience 
https://dpcj.org/index.php/dpc/article/download/3828/2539
 Successful Treatment of Pyoderma Gangrenosum
with Composite Grafting of Acellular Dermal Matrix
  and Glycerolized Skin: A Preliminary Experience
    Linda Tognetti,1 Laura Calabrese,1 Elisa Pianigiani,2 Francesca Ierardi,2 Pietro Rubegni1


1 Dermatology Unit, Department of Medical, Surgical and Neurological Science, Dermatology Section, University of Siena, Siena, Italy
2 Skin Bank Unit, S. Maria alle Scotte Hospital, Siena, Italy



Key words: pyoderma gangrenosum, skin allograft, acellular dermis, ulceration
Citation: Tognetti L, Calabrese L, Pianigiani E, Ierardi F, Rubegni P. Successful Treatment of Pyoderma Gangrenosum With Composite
Grafting of Acellular Dermal Matrix and Glycerolized Skin: A Preliminary Experience. Dermatol Pract Concept. 2024;14(1):e2024076.
DOI: https://doi.org/10.5826/dpc.1401a76
Accepted: September 19, 2023; Published: January 2024
Copyright: ©2024 Tognetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Acknowledgements: drs Filomena Russo, Azzurra Sirchio, Roberta Castellano, Maria Chiara Vecchio
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Linda Tognetti, MD,PhD, Department of Medical, Surgical and Neurological Science - Dermatology Section,
University of Siena, S. Maria alle Scotte Hospital, Viale Bracci 16, 53100 Siena, Italy. Tel: 0039-0577 585893. Fax: 0039 0577 585426
E-mail: linda.tognetti@dbm.unisi.it




Introduction                                                             wound therapy or hyperbaric oxygen therapy gave p
                                                                                                                         ­ romising
                                                                         results in immunosuppressed patients [2,3]; we previously
Pyoderma gangrenosum (PG) is a rare neutrophilic autoin-                 reported on positive outcome with glycerolized skin on a PG
flammatory skin disorder presenting as a painful and rap-                lesion [4]. Recently, grafting of an acellular dermal matrix
idly growing ulcer, with typical erythematous undermined                 for a deep PG wound was described [5].
edge, which can develop at injury sites due to pathergy phe-                  We here report our preliminary experience of two cases
nomenon. PG is usually associated with immuno-mediate                    successfully treated with a composite grafting technique
disorders such as inflammatory bowel diseases, rheumatoid                based on acellular dermal matrix and glycerolized skin pre-
arthritis and with neurological diseases. Given its unpre-               pared in the Skin Bank Unit of Siena Hospital [5,6].
dictable behavior, treatment must be tailored to the patient
status and comorbidities. Briefly, the use of immunosuppres-
                                                                         Cases Presentation
sive drugs (steroids and cyclosporin) or immunomodulating
(ie anti-TNFα inhibitors) proved to be effective in controlling          Case #1. A 52-year-old man with positive anamnesis for al-
inflammation. On the other hand, there is no consensus on                opecia universalis and an undetermined demyelinating dis-
which is the best topical treatment to stop the inflamma-                ease causing a right limb hemiplegia underwent orthopedic
tory loop and stimulate the ulcer healing [1]. Among them,               surgery for a hip titanium prosthesis implant, an ulcerative
a treatment protocol based on the grafting of autologous                 wound appeared after one week. Clinical appearance at
skin after adequate debridement through negative pressure                presentation time 6 weeks after surgery showed a fibrinous



Research Letter | Dermatol Pract Concept. 2024;14(1):e2024076                                                                           1
lesion with undermined erythematous borders of 11x16 cm                  under Prednisone 5mg/die, Methotrexate 15 mg weekly with
                                                                         ­
(Figure 1A). After the diagnostic confirmation by histo-                 folic acid for Horton arteritis. After the diagnostic confir-
pathology, treatment with Prednisone 32 mg/die and was                   mation, prednisone was incremented to 25 mg/die. Once the
Cyclosporine 250 mg/die started, then tapered until suspen-              wound bed was chemically debrided Figure 2A), ­composite
sion after 3 months and 6 months respectively. Atraumatic                allografts was realized as previously described (Figure 2B);
debridement was realized with topical collagenase and hy-                after 1 month, the wound bed appeared reduced and filled
drocolloids, then composite grafts was prepared: patches                 with adequate granulation tissue (Figure 2C). The pa-
of   acellular   gamma-irradiated       de-epidermized       dermis      tient died after 2 months for complications due to bowel
(DED) were grafted into the deeper parts of the wound bed                perforation.
(Figure 1B), glycerol-preserved skin meshed 1:3 allografts
(Figure 1C) were positioned to cover the whole surface; the
                                                                         Conclusions
grafts were stabilized with steri-strip (stiches were not per-
formed to avoid pathergy phenomenon), double paraffin                    Skin allografts are well known to accelerate healing in
gauze layers were positioned (Figure 1D) and compressive                 hard-to-heal wounds [4,6]. Composite grafts are tailored ac-
dressing was performed. Epidermal allograft was replaced                 cording to wound specific features: the acellular DED, due
every 3 weeks for 2 times until intake (Figure 1E), then the             to its poor immunogenicity, acts as an ideal scaffold guid-
graft was resized and double paraffin gauzes replaced every              ing the host cells proliferation and preventing scarring while
week. At month 3.5, dressing with rigenase-polyhexanide                  the overlying epidermal grafts ensure the optimal wound
was applied every 3 days (Figure 1, F and G) until final clo-            humidity and consent the re-epithelization. In particular,
sure (­Figure 1H) after 5 months. The patient had no recur-              glycerolized skin allografts bring further advantages: being
rences at 8 months follow-up (Figure 1I).                                hypocellular, can be partially integrated into the PG wound
     Case #2. A 90-year-old woman affected by diverticuli-               bed, guiding re-epithelization; glycerol can significantly re-
tis developed a PG after trauma of the left thigh: she was               duce local pain, as reported by both patients.




Figure 1. (A) Clinical appearance at presentation time of patient 1: large ulcerative lesion with fibrinous bed and undermined erythematous
borders of 11x16cm; (B,C) Application of the acellular gamma-irradiated de-epidermized dermis patches into the deeper parts of the wound
bed (B) and of the glyceropreserved epidermis meshed 1:3 allografts (C); (D) Fixation with steri-strip and double paraffin gauze layers. (E-L)
Wound appearance 2 (E), 3 (F) and 4 (G) months after composite grafting. Final closure at month 5 (H) and follow-up at month 8 (I).



2                                                                            Research Letter | Dermatol Pract Concept. 2024;14(1):e2024076
Figure 2. (A) Wound appearance after chemical debridement; (B) Glycero-preserved epidermis meshed 1:3 allografts positioned to cover the
whole surface; (C) Lesion after 1 month: the wound bed appeared reduced and filled with adequate granulation tissue.


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Research Letter | Dermatol Pract Concept. 2024;14(1):e2024076                                                                                 3
