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Crohn's Disease Forum » Surgery » Stoma Subforum » Peristomal Pyoderma


04-09-2014, 09:19 AM   #1
glum chump
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Peristomal Pyoderma

Hi everyone:

I've been diagnosed with peristomal pyoderma, which sits just on the left side of my stoma. It's quite tender and makes changing the appliance a bit challenging. I'm also getting more than usual leaks and having to change more often. I've seen the ET nurse, and we're treating it with topical steroids and hydrofera blue. I'm waiting to see my gastroenterologist and a dermatologist. The ET nurse feels that we need to contain the pyoderma ASAP and for me to go back on Crohn's meds (I have a permanent ileostomy and have been in remission since 2011).

I'm wondering if any of you have had this and if you have any tips or suggestions regarding managing the stoma, appliance, skin area. Anything that's worked really well for you?

I have osteoporosis and I'm terrified that I'm going to have to go back on Prednisone. Have any of you been on any other medications? I want to be able to go to my gastroenterologist and dermatologist armed with some information and suggestions, and hoping some of you might be able to help me out!

Thanks for any information, knowledge and experience you can offer---I want to be a little bit less freaked out!

Kismet
04-09-2014, 12:30 PM   #2
bigtruck
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Are you using a convex appliance?
04-09-2014, 01:52 PM   #3
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I'm putting an excerpt from a openfile that is currently available. I am guessing you may have already read it as you have the right wording for your condition. I never had parastomal PG so I would not be able to testify for what seems best but if your condition is under control, I would maybe give a try to the topical approach before going to systemic but that is just me. On that matter I would focus mostly on the opinion of the dermatologist and what was proven effective in clearing the condition. Even though I just said I don't like the systemic approach too much, I also recognize that this condition need to be stop ASAP and avoid chance of having the lesion spreading. I guess it depends of the severity of your actual condition.

Here are the main management options. I hope this helps you and that your condition gets under control promptly!

Topical management
In mild cases, topical measures such as dressings, topical agents or intralesional injections may be sufficient to control the disease process (Table 1). Daily wound care should be performed through close liaison with a wound-care specialist. Moisture-retentive dressings appear to be superior to desiccative gauzes, in that they provide better pain control, induce collagen production, facilitate autolytic debridement and promote angiogenesis [58]. Furthermore, these occlusive dressings are useful as a means to avoid contaminating PPG with effluent. Cleansing of the wound with sterile saline is helpful, while the application of antibacterial agents—such as hydrogen peroxide or benzoyl peroxide—may also be useful [51, 59, 60]. Topical steroids and tacrolimus 0.3% preparations may be beneficial but care must be taken to exclude the possibility of concomitant infection [16, 61]. Patients whose diseases are in remission can try topical human platelet-derived growth factor if the process of re-epithelialization is slow [62, 63]. Intralesional injection of triamcinolone hexacetonide or cyclosporine has also been shown to be effective [64–66]. In general, the periphery of the lesion is injected, but the ulcer base may be injected too. Other topical therapies that may be used in controlling the inflammation and promoting wound healing include benzoyl peroxide, disodium cromoglycate, chlormethine, nicotine and 5-aminosalicylic acid [59, 62, 67–72].

Although PPG is a non-infectious disease in origin, the ulcer can harbor superimposed bacterial infection. If infection is suspected, swabs for bacterial and fungal smear and culture should be taken and empiric antibiotic treatment that covers coliforms should be given immediately [48]. Surgical intervention for PPG—such as debridement—should be avoided, as pathergy can coincide in 25–50% cases of PG. The risk of developing recurrent and more refractory PG may be high [5].

Systemic management
In patients who do not respond to topical or local therapies, who have a severe, rapid course, or who have active underlying disease (i.e. IBD), systemic management should be considered. Although there is no single therapy that can be efficacious in all cases, oral prednisone has been shown in the literature to be the most consistently successful agent for the treatment of PG [48]. Therapy with oral prednisone (1 mg/kg per day) is usually effective in controlling PG (Table 1) [73, 74]. The treatment should be continued until the lesions show evidence of healing and prolonged low-dose maintenance therapy is usually necessary in recurrent cases. Intravenous corticosteroid therapy (hydrocortisone 100 mg four times daily or methylprednisolone 1 g/day [pulse therapy]) for up to 5 days has also been reported to be successful (Table 1) [52, 75, 76]. Patients exposed to long-term use of prednisone are at risk of related side-effects: protecting agents, such as calcium, vitamin D and bisphosphonates can be used concomitantly [77]. Oral minocycline 100 mg twice daily may be of some benefit, usually as an adjunct to oral corticosteroid [2].

There are alternative ‘step-up’ therapies, the main purposes of which are twofold: (i) to reduce dependence on corticosteroids and (ii) to treat refractory disease. Dapsone and minocycline are the most frequently prescribed agents to provide a steroid-sparing effect [34, 54–56]. Oral dapsone 100–300 mg per day or minocycline 100 mg twice daily appear to be efficacious (Table 1). The mechanisms of action of these agents in the treatment of PG are not fully understood but they are related to its anti-microbial activity or anti-inflammatory effect. When corticosteroids fail, the most widely used alternative is cyclosporin [28, 74]. Several case reports and small case series demonstrate that most patients show clinical improvement within three weeks with a dose of 3–5 mg/kg per day and cyclosprin has been shown to be considerably more efficacious in the treatment of PG than azathioprine and methotrexate [26, 78, 79]. Other reported effective agents are tacrolimus, 6-mercaptopurine, cyclophosphamide, colchicine, clofazimine and chlorambucil [80–85].

Infliximab, an antibody against tumor necrosis factor α, has been shown to be efficacious in the management of PG. A randomized double blind, placebo-controlled trial by Brooklyn et al. compared 13 PG patients treated with infliximab with a group of 17 controls [3]. At 2 weeks, 46% of the infliximab group had responded, compared with 6% of the control group. Concerns about side-effects of infliximab, such as sepsis, have also been raised [48]. However, the benefits of infliximab outweigh the risks of its use and the agent has become the drug of choice in steroid-refractory PG. Although there are reports of refractory cases [86–88], adalimumab and etanercept are also thought to be effective biologic agents for PG[89–92]. Uses of plasma exchange, human immunoglobulin infusion and interferon-a therapy are also reported in more refractory PG (Table 1) [93–95].

General management
Because of the persistent and recurrent nature of PG, a long-term maintenance therapy may be required. As a general measure, pain relief, correction of anemia, nutrition and management of associated disease are important. Stoma care, including use of an appropriate stoma appliance and prevention of leaks, also deserves attention (Table 1) [5]. Relocation of stoma should be contra-indicated except for other indications, such as parastomal herniation or stoma dysfunction.
Source: Xian-rui Wu and Bo Shen Diagnosis and management of parastomal pyoderma gangrenosum Gastroenterol. Rep. 2013 1: 1-8.
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04-09-2014, 02:45 PM   #4
glum chump
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Are you using a convex appliance?
No. I'm using Coloplast SenSure 2-piece, sometimes with Eakin slims and other times with SecuPlast. I'm also using Brava tape around my flange for extra ammunition against leaks.

Kismet
04-09-2014, 03:21 PM   #5
bigtruck
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ImageUploadedByTapatalk1397074626.871029.jpg

This is my mess at the moment I cover mine with coloplast brava protective sheet 20x20 that you cut to size.
04-09-2014, 03:25 PM   #6
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Looks so much better Big Truck!
04-09-2014, 03:33 PM   #7
bigtruck
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Yes it's getting there but slowly
ImageUploadedByTapatalk1397075578.407362.jpg

I want it back to this lol
04-09-2014, 04:11 PM   #8
glum chump
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Geez, bigtruck, it looks painful. I've followed your trials through the forum, and I'm always amazed at your 'onward and upward' point of view. Wish I wasn't such a sissy about my stuff.

Is the Brava tape helping to protect your skin? The hydrofera blue covers the pyoderma...the pyoderma is a red and purple...it's continuing to grow, but at the moment, it hasn't opened, although there is some weeping.

I see the ET nurse on Friday -- I'm really hoping that I can control the pyoderma until we figure out what other treatment options I need to consider.

Cheers,

Kismet
04-10-2014, 04:21 AM   #9
bigtruck
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Geez, bigtruck, it looks painful. I've followed your trials through the forum, and I'm always amazed at your 'onward and upward' point of view. Wish I wasn't such a sissy about my stuff.



Is the Brava tape helping to protect your skin? The hydrofera blue covers the pyoderma...the pyoderma is a red and purple...it's continuing to grow, but at the moment, it hasn't opened, although there is some weeping.



I see the ET nurse on Friday -- I'm really hoping that I can control the pyoderma until we figure out what other treatment options I need to consider.



Cheers,



Kismet

If only you knew! I'm anything but onward and upward most days!!
Mind you what choice do we have.
04-10-2014, 08:37 AM   #10
glum chump
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If only you knew! I'm anything but onward and upward most days!!
Mind you what choice do we have.
Yep, that's what I figure, too. I'm here now...what can I do with what I have. I just wish our bodies didn't seriously take up the idea of "go big or go home"! I'd be happy with a quiet life with my stoma, thank you very much!

Kismet
04-10-2014, 08:40 AM   #11
bigtruck
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Yes I know what you mean it all seems so unfair and then when they give you a Stoma to improve things and it makes it worse doesn't help ones mental well being.
04-15-2014, 06:31 AM   #12
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Hi! I do have pyoderma too. For now it has healed (than god) but i remember how painful it was! We hit it hard with high dose of prednison orally, steroid cream and humira. I was on humira before my surgery but we started it again faster than originally discussed, cos it did helped pyoderma too. It was very painful but slowly it did healed with these medications. I was told that creams and stuff are not strong enough to hit pyoderma. It needs oral steroids too.

Hope you heal soon!
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Severe Crohn's since 2002. Tried every longterm medicine there is, Pentasa, Azamun, Remicade, Humira...
Temporary colostomy 2013 -> Parastomal hernia
Surgery, mesh, end colostomy 2014 -> deep wounds that didn't heal, three fistulas around stoma
Colon removal and ileostomy 2015 -> So far so good

And after every stoma surgery, nasty Pyoderma Gangrenosum around my stoma.
04-16-2014, 01:24 PM   #13
glum chump
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Thanks for the note, Jimena. Yes, it's painful and I dread every time when I have to change my appliance. I hate to go on Prednisone because I already have osteoporosis from previous use, but at the same time, the pyoderma will only become more tiresome.

Did you see a dermatologist or did you work only with your gastroenterologist?

Thanks again for your insights.

Kismet
04-17-2014, 03:46 AM   #14
Jimena
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Yeah, i know the feeling. I was just 5 weeks out of surgery and had to start prednison again. And surgery was made so i don't have to use steroids anymore. Lol. Didn't laugh at that time though.

Yep i did see dermatologist. He did the diagnosis (me and stomanurse were pretty sure it was pyoderma before dermatologist did the official diagnosis). Dermatologist ordered prednison and said that i should start humira again as soon as possiple. After second dose on humira pyoderma did start to heal faster and i think that humira really boosted the healing process. Dermatologist wanted me to start prednison for 80-100mg dose but i only agreed 60mg a day and luckily it was enough with humira.

The sooner you get pyomerma under control, the better it heals. I did see a photo from a women whos pyoderma was all over her stomach! Her diagnosis wasn't made soon enough and it spread all over. She was at the hospital for months under strong painkillers and had to be sedated everyother day when nurses clean the wounds and change appliances. It last almost 2 years to heal. It scared the hell out of me! It could be very dangerous if not treated aggressivily.

Didn't want to scary you!!! Hope you got it sorted out.
04-18-2014, 02:58 PM   #15
glum chump
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Okay, you have officially scared the pants right off me! Reading your post, if I had the ability to s--t my pants, I would have!!

That sucks that you had to start Prednisone right after surgery---how frustrating and demoralizing.

I'll see my GI on Tuesday and see what meds he thinks might work. He loves to prescribe Imuran, but I'm going to have to get him off the Imuran train since Imuran takes a while to work, and as you say Jimena, the pyoderma needs to be controlled ASAP. When I was doing research on pyoderma, the pictures look pretty awful.

Thanks for your support and the information!

Kismet.
04-19-2014, 10:10 AM   #16
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I am sorry, i really didn't mean to! but from what 7 heard from doctors, it is one serious disease which can make lot of damage if it gets bad. I think you should see dermalogist, they are experts. My stoma nurse said that she has been stoma nurse for over 30 years and i was her third pyoderma patient! It is so rare disease so mayby gi's haven't ever even saw it. At least that's the situation here in Finland.

Let me know how it goes! As you know, there aren't so much information from patients in the internet so i really would love to hear how it goes for you
04-20-2014, 11:01 AM   #17
glum chump
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You're right...the ET nurse I see is very concerned about the pyoderma. She said that they don't often see many cases of it, and that the GIs are not up to speed on treating pyoderma. My family doctor has put a referral through to a dermatologist, but according to the ET nurse, the dermatologist in the city where i live have experience with pyoderma, but not a lot with peristomal pyoderma. So the dermatologist here try to treat pyoderma with steroid injections in the stomach, which is 'okay' if you have pyoderma on your leg, but the nurse was saying that to inject in the stomach can cause 'trauma' to the stomach and risk the pyoderma spreading.

Funny, the nurse I'm working with said that I was also her second pyoderma patient in 25 years! And yes, it's something that the stoma nurse seems to be taking REALLY seriously. I know when I went to see my family doctor, he had to do a med search on pyoderma because he said he'd never come across it in his 15 years of practice.

So far, I'm using a topical steroid spray on the pyoderma when I change my flange. The spray is actually asthma medication (a puffer that people with asthma use called Flovent). Spraying the area with steroid rather than using a topical steroid cream means that you don't touch the pyoderma and cause it 'trauma.' The Flovent was actually the stoma nurse's recommendation and since my family doctor didn't know what exactly to do, he gave me the Flovent prescription and thought it was very smart of the nurse to use it.

I'll update you on my appointment with my GI and let you know where he goes with this.

Thanks so much for sticking with me, Jimena!

Kismet
04-29-2014, 12:45 AM   #18
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I have heard about those steroid injections too! Yuck! It must hurt so bad... I is very unknown disease.

I hope everything goes well on you and you get rid of it! How big are your pyoderma areas?
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